HD 3700 Adult Psychopathology Prelim 3

Body Dysmorphic Disorder Symptoms

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

• At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.

• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

• The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Body preoccupations

• Usually more than one region of the body is seen as flawed

• Common areas are nose, face, skin, hair, stomach

  • Can include scars

• Concerns may involve size (too large or too small), texture, symmetry, color, shape

• Concerns very specific (and consistent with diagnostic criteria) not perceived by others or not viewed as significant as they are to the person

• Like obsessions, they are unwanted, distressing, and difficult to dismiss

• Time consuming

  • Most people spend 3+ hours a day thinking about their body

  • ¼ spend over 8 hours a day

• People REALLY believe them

Delusion

strong persistent conviction that does not change even if there is significant evidence that it is not true

Body preoccupations in BDD are often considered delusional

Unlike in OCD where response behaviors alleviate distress in BDD they often worsen the distress associated with the perceived flaws

Body Dysmorphic Disorder onset

4 - 5, emerge slowly within 4-5 years, recurrent

Body Dysmorphic Disorder prevalence

2-3 % of population

Is Body Dysmorphic Disorder an eating disorder?

No because the focus is not on body weight

muscle dysmorphia

belief that body is too lean and muscles are not sufficiently developed

Body Dysmorphic Disorder Treatment 

Hard to treat: only 25 - 50% reach remission though more improvement - largely because the delusions are hard to shake

SSRIs

EX/RP: exposure to situations that usually bring on thoughts of bodily flaws (looking at a picture or changing clothes to induce obsessions)

Mirror retraining

Trichotillomania Symptoms

• Recurrent pulling out of one’s hair, resulting in hair loss.

•  Repeated attempts to decrease or stop hair-pulling.

• The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Shame or embarrassment

• The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).

• The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder)

Automatic pulling

tendency to pull hair unintentionally, almost without any awareness of the action

Focused hair pulling

intentional hair pulling; occurs either in reaction to stress or distress or people search for a hair that feels different or wrong in some way and remove it

Trichotillomania prevalence

2 - 3% of population

Trichotillomania stats

Adolescent onset, No significant gender disparities in prevalence, though women seem to develop at young age — women report more distress

Trichotillomania treatment

• 25% of people experience natural recovery and stop pulling without any interactions 

  • Age is a strong predictor

  • Older people are the more likely to stop pulling on their own and without trying to do so

Excoriation disorder symptoms

• Recurrent skin picking resulting in skin lesions.

• Repeated attempts to decrease or stop skin picking.

•  The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).

• The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

Excoriation disorder sleep

25% pick when asleep

Excoriation disorder extreme

• Can result in antibiotics, hospitalizations, or surgery

• Repetitive strain injuries in the hand are common

• Many find picking pleasurable but later experience intense shame about their picking 

Types of picking in Excoriation disorder

automatic (trancelike state) and focused picking

Habit reversal training

1. Awareness training helps people figure out WHEN they are most likely to pick or pull and what sensations or urges precede picking or pulling

2. Identify a competing response that can be done instead

3. Identify social supports to help transition to using competing response 

Form of CBT that is effective for both trichotillomania and Excoriation disorder

Habit reversal training

Habit Reversal Training success

Works well for functional/intentional hair pulling or picking

Identify a competing response

• Work best when there are some benefits 

• Can mimic picking or pulling 

  • Pulling threads of a tassel

• Can be a pleasurable substitute 

  • Fidget toy or a treat 

Acceptance and Commitment Therapy

3rd wave CBT

Helps people observe and accept urges to pull or pick

Recognize that the urge to pull or pick may always be present

Develop comfort with the urge to pull or pick without engaging in the behavior

 trichotillomania and Excoriation disorder other treatment

Acceptance and Commitment Therapy

Hoarding disorder symptoms

• Persistent difficulty discarding or parting with possessions regardless of their actual value 

• The difficulty is due to a perceived need to save the items and to distress associated with discarding them 

• Difficult discarding possessions result in the accumulation of possessions that congested and clutter active living areas and substantially compromises their intended use

  • If living areas are uncluttered it is only because of the interventions of third parties

• Cause clinically distress or impairment in social, occupational or other important areas of functioning (maintaining a safe environment for self and others)

  • Usually obvious to other people

• The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome)

• The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism

• spectrum disorder)

Hoarding disorder prevalence

2-6 % of population

Hoarding disorder other

• No significant gender differences in prevalence

• Highly comorbid with MDD – about 50% of people

Psychotic disorders 5 domains

Delusions, Hallucinations, Disorganized Speech and Thought, Grossly Disorganized or Abnormal Motor Behavior, Negative Symptoms

Delusions

Intense intractable beliefs that do not waver even with evidence that conflicts or disconfirms them

Delusions content

• Persecutory: being harassed or harmed by an individual, group, or organization

• Referential

  • Gestures, comments, and environmental cues are directed towards oneself 

• Grandiose

  • Belief in having exceptional abilities, fame, or wealth

• Erotomaniac

  • False belief that another person is in love with you

• Somatic

  • Related to health or organ function 

Delusion categories 

Bizarre (implausible - Outside force has removed one’s internal organs and replaced them with the organs of another person, without leaving a mark or scar) or non-bizarre  (plausible - Text messages are being monitored by the government)

Hallucination

Vivid, clear, perceptual-like experiences that occur without an external stimulus

Hallucination types

Auditory (most common), visual, tactile, olfactory

of the general population reports hearing a voice at some point

10-25%

of the general population reports hearing multiple voices 

1%

of people who hear voices recurrently hear more than one voice

66%

of voices have a different accent than the voice hearer’s accent

71%

of voices are “crowds” of talking

57%

of voices are middle aged men talking

34%

of voices are young women talking

10%

hear the same voice recurrently

68%

hear abusive voices

68%

hear approving or gentle voices

25%

of people begin hearing voices after a significant emotional event

70%

Where do auditory hallucinations occur?

Perception is that the voice is inside the head, not transmitted through the ears

fMRI studies confirm that different neural regions are activated by stimuli

Disorganized speech and thought

• Loose associations or frequently switching from topic to topic

• Tangentiality: providing unrelated responses to conversational prompts

• incoherence: sometimes referred to as “word salad”; words in a string are disconnected from each other

  • Purple sky drink balloons elephant crackers

• Mildly disorganized speech is common; in psychosis, this disorganization must be severe enough to impair effective communication 

Grossly disorganized or abnormal motor behavior

Silliness, agitation, mutism or lack of verbal responses, staring, echoing, grimacing, catatonia

Negative symptoms

• Negative symptoms are symptoms that are marked by the absence or diminishing of what we would expect to see in someone

  • Flat affect (diminished emotional expression)

  • Avolition (decrease in self-motivated or pleasure)

  • Anhedonia (lack of interest or pleasure)

  • Asociality (social withdrawal)

Hallucinations and delusions are referred to ____ symptoms

positive

disorganized symptoms

describe illogical speech, erratic behavior, and affect that does not match the situation

Brief psychotic disorder symptoms

• Presence of 1+ of the following symptoms. At least 1 must be 1, 2, or 3:

  • 1. Delusions

  • 2. Hallucinations

  • 3. Disorganized speech

  • 4. Grossly disorganized or catatonic behavior

  • Don't include behavior if it's culturally normal

• Duration of an episode of the disturbance is at least 1 day but less than 1 month with eventual full return to the premorbid level of functioning

• The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Brief psychotic disorder specifiers

• With peripartum onset

• With marked stressor

Schizophreniform disorder symptoms 

• 2 or more of the following each present for a significant portion of time during a 1 month period (or less if successfully treated). At least one must be 1, 2, or 3

  • 1. Delusions

  • 2. Hallucinations

  • 3. Disorganized speech

  • 4. Grossly disoriented or catatonic behavior

  • 5. Negative symptoms 

• The duration of an episode of the disturbance is at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.

• When a diagnosis must be made without waiting for recovery, it is qualified as provisional

• Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

• The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Schizophrenia

• 2 or more of the following each present for a significant portion of time during a 1 month period or less if successfully treated least one must be 1, 2, 3

  • 1. Delusions

  • 2. Hallucinations

  • 3. Disorganized speech

  • 4. Grossly disoriented or catatonic behavior

  • 5. Negative symptoms 

• For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

• Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Schizophrenia rule outs

• Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

•  The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

• If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Schizophrenia prognosis

• Chronic disorder, full recovery is rare; once it develops, people have symptoms for the rest of their lives.

• Remission is defined by symptoms no longer impairing daily life and functioning 

• About 50-80% of people who are hospitalized for severe symptoms of schizophrenia will be rehospitalized at some point in their lives

Schizophrenia prevalence

Equal prevalence across men and women but earlier onset in men, 1% prevalence

Schizophrenia early indicators

People who go on to develop schizophrenia show mild motor problems, physical abnormalities, or neurological “soft signs” and mild social problems even in childhood.

Often non-specific and appear in many different types of neurological conditions

Mild social problems early on

Schizophrenia prodrome (1 - 2 years prior to the onset of schizophrenia)

Positive symptom indicators: magical thinking or feeling like someone else is present when they are not

Negative symptoms early indicators: social isolation, anhedonia

Delusional disorder

presence of one or more delusions with a duration of more than one month, but no disorganized speech. Hallucinations may be present but are not severe and are related to the theme of the delusion

Functioning is not impaired and behavior is not unusual in Schizophrenia

Some studies show about ½ of people marry and work

Schizoaffective disorder

• a psychotic disorder with symptoms of both schizophrenia and a major mood disorder (e.g., bipolar disorder or major depressive disorder)

• Unlike psychotic symptoms that only occur during a mood disorder, people with schizoaffective disorder show delusions and hallucinations for at least two weeks not during mood disruptions

• And they show major mood disruptions for the majority of the time as they experience psychosis

Schizophrenia Genetics

polygenic, heritable, Adoption studies show that likelihood of schizophrenia is more strongly related to where a biological parent has schizophrenia than an adoptive parent

Psychosocial Antecedents of Schizophrenia

Prenatal exposure to viruses, infections, birth complications (especially those involving loss of oxygen at birth), Childhood stress, adversity, poverty, homelessness, immigration

Regular cannabis use during adolescence is associated with a

four-fold increase in likelihood of a diagnosis of schizophrenia

Cannabis can temporarily induce hallucinations

people with Cannabis-induced psychosis show elevated rates of later diagnoses of schizophrenia

Cannabis use during adolescence is associated with thinning of

cerebral cortex that does not rebound or recover

Dopamine Hypothesis of Schizophrenia

hallucinations and delusions are correlated with excessive dopamine activity in the mesolimbic pathway. Negative symptoms seem to result from less dopamine in the mesocortical pathway

main pathways in the brain that transmit dopamine

mesolimbic, mesocortical, nigrostriatal, and tuberoinfundibulnar

Antipsychotic medications

First line treatment for psychosis

Older (or typical) antipsychotics block dopamine, in order to reduce positive symptoms—> harsh side effects as dopamine is depleted in other pathways - reduction in nigrostriatal pathway often led to Parkinson like

symptoms (tremors, rigidity, slow movement), tardive dyskinesia: involuntary lip smacking, grimacing, tongue thrusting, reduction in the tuberoinfundibular pathway can involve weight gain, lactation, sexual dysfunction

Atypical Antipsychotics - second generation 

Work on both dopamine and serotonin, less parkinson’s side effects

How Well Do Antipsychotics Work?

45% of people = remission of symptoms in 18months after starting treatment. Of these, 12% maintained remission for 6 months

Better at reducing positive symptoms than improving negative ones

Psychosis treatment

Antipsychotics + hospitalization (80% of young adults with schizophrenia will be hospitalized

involuntary, generally in the first 2 years of onset)

Review of 22 countries show higher rates of involuntary hospitalization in

Blacks, South Asians, males, immigrants

15%

of people experience a coercive measure – such as seclusion, physical restraint, or forced pharmacological treatment during hospitalization

Does Hospitalization Help?

Can provide short-term benefits in stabilizing symptoms or

accessing new or different treatments

• Minimal evidence that it provides long-term changes in functioning

or symptoms

• Minimal evidence that it is associated with the prevention of relapse

Tara Peris’s story

• Her mother experienced significant delusions AND was brilliant 

  • FBI, fear of neighbors

  • Boarded up the windows 

• House was filthy

• Gets job in Japan

  • Before her psychosis, she was good at working

  • Comes with housing

  • Lucky to get this job

  • Disappears for a decade  

    • Maybe go to Holland?

    • Claimed she was royalty from Holland

• She had disorganized speech

• Tara experiences lots of frustration 

  • Mother isn't getting treatment

  • What IF someone intervened

    • Lots of stigma so ignored

    • When she lived with her dad she had rules, and a bed time

• Her mom had hard time at birth

  • Experienced somatic symptoms 

  • Odd neurological symptoms

Expressed Emotion

Pattern of family interaction associated with high rates of relapse, rehospitalization, more severe delusional thinking, and longer episodes of severe symptoms in people with schizophrenia 

Risk of rehospitalization following discharge in high EE families is ____ than that in low EE families

more than double

Components of Expressed Emotion

Criticism: negative comments about a person and their behavior

Hostility: family members believe symptoms are within the person’s control and the patient could choose to be less affected

Emotional overinvolvement: family members blame themselves for illness; any problems or setbacks are perceived as their fault and not due to schizophrenia itself

What fosters EE?

More conscientions, have higher internal locus of control, and feel more burdened and distressed in their caregiver roles

People with schizophrenia from high EE families tended to have high premorbid functioning

EE may not just worsen symptoms – but emerge in family members as a response to their loved one’s symptoms

even in the absence of intervention, EE declines as people with schizophrenia show improvement in symptoms.

Psychosis CBT

• CBTp: goal is not to reduce of re-evaluate hallucinations or delusions – but to adjust their thoughts

  • Examine behaviors and feelings that are linked with hallucinations and delusions

  • Targets negative symptoms

  • Structured, goal-driven, time-limited

  • Reduces distress and effects of symptoms by 20-65%, depending on the study 

  • Improves reasoning skills, daily functioning, and beliefs about self and others

Therapeutic Relationship in CBTp

Therapist avoids confronting patient about reality, conveys that a delusion is a reasonable reaction to a puzzling or threatening experience, such as hearing a voice or panic, Works to change the response to psychotic symptoms

Hearing Voices Movement

Movement to shift public and professional perceptions of psychosis, Challenges assumption that hearing voices are a severe mental illness, emphasizes that many people hear voices

Voice cessation is not

considered a sign of success or progress

Personality

Traits and characteristics that psychologically distinguish one person from another, Relatively consistent across situations and across time

The Big 5

Openness to experience, Conscientiousness, Extraversion, Agreeableness, Neuroticism

Openness to experience

Curiosity, creativity, willingness to try new thing

Conscientiousness

Diligence, dependability

Extraversion

Social interactiveness, talkative

Agreeableness

Willingness to cooperate, kindness, trusting

Neuroticism

Trait negative emotion

Dog Personaility

Owner’s evaluation of dog’s personality consistent with the stranger’s evaluation of same dog’s personality

Personality Disorder

An enduring pattern of inner experience and behavior that deviates

markedly from the norms and expectations of the individual’s

culture, is pervasive and inflexible, has an onset in adolescence or

early adulthood, is stable over time, and leads to distress or

impairment.

Tend to involve a remarkable amount of impairment, particularly

interpersonally

may or may not be associated with distress in the person who has one

Personality disorder prevalence

10% in US, massive comorbidity

Why are Some People Prone to Personality Disorders?

associated with impaired family relationships in childhood

Personality disorders and stigma

public stigma, even within healthcare, is high

Cluster A personality disorders

Paranoid, Schizoid, Schizotypal