PSYCH 257 (Psychopathology) Exam 2

What are mood disorders? (Unipolar vs Bipolar)

Mood disorders involve experiences of depression and/or mania

• Unipolar mood disorders have only lows (depression)

• Bipolar mood disorders have highs and lows (Mania and Depression)

Is bipolar 1 unipolar or bipolar

Bipolar 1 would only be mania but still classified under bipolar; they should experience depression at some point. 

• Most people with Bipolar I will eventually experience depressive episodes at some point in their life — it's just not required for the diagnosis.

Mood Spectrum

goes from left/blue/low to right/red/high

Blue - Depression, dysthymia (longer less severe depression)

Red - Hypomania (less intense mania), mania

Major Depressive Episode

2 week period with depressed mood every day and/or diminished interest in almost all activities. 

Symptoms: (must have 1 or 2)

1. Depressed mood most of the day, nearly everyday
2. Diminished interest or pleasure in all, or almost all, activities

• Changes in sleep patterns/insomnia 

• Fatigue/reduced psychomotor 

• Concentration difficulty 

• Irritability 

• Changes in appetite and weight

• Recurrent thoughts of death/suicide, guilt and worthlessness 

*1 episode means 50% chance of another episode which would then be considered MDD recurrent 2 = 70%, 3 = 90% 

Dysthymic disorder aka persistent depressive disorder

Depressed mood most of the day, more days than not for at least 2 years with consistent symptoms that don’t stop for more than 2 months. 

(less severe but lasts longer)

2 or more symptoms: 

• Poor appetite/overeating 

• Sleep issues 

• Low energy 

• Poor self-esteem/hopelessness 

• Poor concentration/decision-making skills 

During 2-year period, person has never been without symptoms for > 2 months at a time

Double Depression

a combination of persistent depression and major depressive episode; like someone with dysthymia experiencing a depressive episode

• patient already has persistent depression and has a triggering incident pushing them into major depression. 

Manic Episode

Distinct period of abnormally and persistently elevated, expansive or irritable mood; increased goal-directed activity or energy.

3+ symptoms or 4+ if mood is only irritable: 

• Big self-esteem/grandiosity 

• Less need for sleep 

• Lots of talking and racing thoughts 

• Distractibility 

• Increased goal-directed activity 

• Excessive involvement in pleasurable activities with potential for negative consequences 

• Marked impairment in social and occupational functioning 

When is an episode considered manic?

Considered a manic episode when it goes on for a week or longer or the person is hospitalized

Hypomanic episode

a distinct period (4 days) of abnormally and persistently elevated, expansive or irritable mood; abnormally and persistently increased activity or energy. 

How do you know it is hypomania?

a distinct period (4 days) of abnormally and persistently elevated, expansive or irritable mood; absnormally and persistently increased activity or energy. 

1. 4 days and not hospitalized 

2. 3+ symptoms or 4+ if mood is only irritable: 

• Big self-esteem/grandiosity 

• Less need for sleep 

• Lots of talking and racing thoughts 

• Distractability 

• Increased goal-directed activity 

• Excessive involvement in pleasurable activities with potential for negative consequences 

• No marked impairment 

Mania

Mania:

• Impairment of functioning and hospitalization

• Abnormally and persistently elevated, expansive, or irritable mood

• Abnormally and persistently increased goal-directed activity or energy

• Week+

During mood disturbance, 3 (+) symptoms have persisted, or 4 (+) if mood only irritable:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual, or pressure to keep talking
4. Racing thoughts (“flight of ideas”)
5. Distractibility
6. Increase in goal-directed activity
7. Excessive involvement in pleasurable activities with potential for negative consequences

• Work Examples: Take on unrealistic projects, quit job

• Sleep Examples: Not sleeping days at a time  

• Marked impairment in social & occupational

Hypomania

Hypomania:

• 4+days

• No marked impairment and no hospitalization

• Work example: Working long hours, take on a new project

• Sleep examples: sleep less than usual but still functioning normal  

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood and Abnormally and persistently increased activity or energy

During mood disturbance, 3 (+) symptoms have persisted, or 4 (+) if mood only irritable:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual, or pressure to
keep talking
4. Racing thoughts (“flight of ideas”)
5. Distractibility
6. Increase in goal-directed activity
7. Excessive involvement in pleasurable activities with potential for negative consequences

Examples of hypomanic and manic behavior

Hypomanic:

• Spending extra money on clothes and gadgets (still within budget)

• More talkative

• Feeling confident and believing that you can accomplish a lot

Manic:

• Talking non-stop, interrupting conversations, nonsensical speech

• Invincible and famous

• Driving recklessly

• Starting multiple creative projects but not finishing any or writing nonsensical works

Bipolar 1

Bipolar 1: At least 1 manic episode lasting 7+ days (or requiring hospitalization) 

• Diagnosed based on mania alone

• Can be only mania (we assume they will eventually have a depressive episode but it is not mandatory) and ranges to major depression

• More focus on mania - if they have ever had one full episode

• Bipolar 1 = Mania + Maybe Depression

Bipolar 2

Bipolar 2: At least 1 hypomanic episode (4+ days) AND 1 major depressive episode 

• Depression is required for this one  

• ranges from major depression to hypomania, requires a presence or history of major depressive episode and a hypomanic episode.

• hypomania alone is not generally impairing 

• Often misdiagnosed as depression - hypomanic episodes can go unrecognized “feeling better”

• More focus on depression

• Bipolar 2 = Depression + Hypomania

Cyclothymic Disorder

milder, long-term version of bipolar disorder

hypomanic and depressive symptoms with patterns that last at least 2 years (1 year for children). 

• Frequent hypomanic & depressive symptoms, but not severe enough for Bipolar I/II or MDD

• Combination of persistent depressive disorder and hypomania 

Cyclothymic disorder vs Bipolar 2

Cyclothymia is not full blown depression, going back and forth between hypomania and depression quickly. Generally bipolar 1 or 2 does not go between the episodes as quickly. 

Biological causes of mood disorders

1. Genetic predisposition 

2. Neurotransmitter imbalances (seratonin, norepinephrine, dopamine)

   • Too much = mania

   • Too little = depression

3.  Endocrine system; cortisol 

4. Sleep disruptions

Amygdala and Hippocampus

 Amygdala; mood 

Hippocampus; causing memory loss (some people claim to have no memory of their depressive episode) 

Genetic predispositions for Bipolar vs MDD

Higher genetic influence in Bipolar (70-80)

Lower in MDD (unipolar) (30-40)

Neurotransmitter imbalances in Bipolar and MDD (cortisol, dopamine and norepinephrine)

Bipolar: Excess dopamine and norepinephrine (fight or flight) in mania with deficit in depression

MDD (unipolar): Chronically elevated cortisol (stress hormone)

Endocrine System in Bipolar and MDD (cortisol)

Bipolar: Fluctuating cortisol levels between episodes (lower in depressive)

MDD (unipolar): Chronically elevated

Sleep Disruptions in Bipolar and MDD

Bipolar: Poor sleep = disruptions in hormones = manic episodes

Sleep deprivation increases dopamine activity, which fuels manic symptoms

MDD: Poor sleep = hormonal imbalances = poor mood regulation = low mood

Stressful life events and learned helplessness in Bipolar and MDD (MD)

Bipolar

• Stressful life events can trigger depressive and manic episodes. High stress = less mood stability, impulsive coping, sleep disruption

• Learned helplessness can contribute to depressive episodes

MDD (Unipolar)

• Major stressors can trigger depressive episodes, chronic stress mantains depression by increaseing negative thought patterns and hopelessness

• Learned helplessness = persistant failures or uncontrolable negitive thoughts leading to lack of motivation, powerlessness, often the cause of short-term episodes

Major Depressive Disorder

Depressed mood or loss of interest for at least 2 weeks and 5 total symptoms the list

• No history of mania/hypomania

• 1 Depressive Episode = MDD single episode

• Greater than 1 = MDD Recurrent

Pessimism vs Neuroticism

Pessimism is a way of thinking: expect the worst outcome / negative viewpoint

• "Things will probably go wrong"

• Persistent in depressive phases of bipolar

• Fuels hopelessness and depression through negative thinking patterns (e.g., “Nobody likes me” 

Neuroticism is a personality trait that influences emotional regulation (experience a lot of negative things)

• Neuroticism makes individuals emotionally reactive and prone to anxiety, depression, and mood swings - "I feel anxious or upset a lot"

• Individuals with high neuroticism tend to ruminate and experience

Medicating Depressive Disorders and Bipolar disorders

Depressive Disorders:

Meds generally inhibit reuptake of neurotransmitters (helps keep serotonin, dopamine and norepinephrine available)

• Trycyclic Antidepressants

• Monoamine Oxidase Inhibitors (stop an enzyme called monoamine oxidase from breaking down certain neurotransmitters in the brain)

• Selective Serotonin Reuptake Inhibitors

Bipolar disorders

• Lithium: regulates rate of nurostransmission

• Valproate: Increases GABA, a calming neurotransmitter

Cognitive Targets

• Cognitive Targets: Negative bias thinking

  • Looking at how people interpret things (if they always think of the bad side balance with evidence and using all of the information)  

Behavioral Activation

Behavioral Targets: often people don’t feel motivated to do anything and therefore don’t receive the dopamine from doing something making them feel more down – you need to get them up and moving (have to start really small)  

• Often you would start with mastery (something they can accomplish easily – listening to a song or lighting a candle)  

Medical Adherence and regularity

• Medication Adherence: Especially important for bipolar

  • Not taking them can cause bad side effects that can cause difficulty

  • Staying on them even if the side effects are bad  

• Regularity: sleeping, routines and medication even if it doesn’t feel good it helps a lot – even sleeping in can cause you to not sleep well the next night spiriling, etc.  

  • Really important for bipolar as well as avoiding stressors  

Suicide and heightened risk factors

Risk of suicide is significantly increased among those with mood disorders

• Bipolar is especially at risk (feeling depressed but often too down to do it – then become manic and can follow through with plans)  

Heightened Risk Factors:

• Male gender

• History of previous suicide attempts

• Combined substance use

• Periods of severe depression or mania

• Feelings of hopelessness or worthlessness

• Lack of social support (wouldn't leave children)  

With the right support and treatment, individuals with mood disorders can find relief and live fulfilling lives (most people who have mood disorders do not die by suicide)  

Over the last 3 months, Jay has not felt like their usual self. They are no longer interested in socializing and they take little pleasure from activities they used to enjoy. They have difficulty sleeping and eating. Jay appears to meet criteria for:

MDD

For the last week, Chandra has been irritable and on edge. She has not been sleeping more than two hours per night and has been flying into fits of rage when anyone suggests she sleep. She says she’s working on a project that will change the course of human history. Chandra’s symptoms are most consistent with

Bipolar 1

Anorexia Nervosa

1. Dietary Restrictions that lead to low body weight - severity is based on weight

2. Intense fear of weight gain, becoming fat or behaviors that interfere with weight gain

3. Disturbed perception of body

   • or undue influence of body in self-evaluation

   • or denial of seriousness of low weight

Restrictive vs binge purge type

Subtypes of Anorexia Nervosa

Restrictive: (AN-R)

• Restrictive eating as a hallmark

• Absence of regular bingeing or purging

• Compulsive exercise is common

Binge-purge type (AN-BP)

• Recurrent bingeing AND OR recurrent purging

Issues with BMI Criteria

• Weight/BMI is an important factor as very low weight is medically dangerous, BUT this is only one factor in severity 

• Rapid weight loss can be very unhealthy, even if BMI is still in "normal” 
  range 

• Using weight as the primary measure of severity can delay diagnosis, discourage treatment, and overlook serious cases 

• Many individuals with eating disorders do not receive help because they “don’t look sick/thin enough” 

• Those in larger bodies may even be praised for weight loss, reinforcing disordered behaviors 
   

What are better approaches to only using BMI criteria

• Assessing physical symptoms (heart rate, electrolytes)

• Asses psychological distress

• Asses behaviors

binge/purge frequency should be considered as ________ can cause cardiac failure and death 

electrolyte imbalances

Bulimia Nervosa

1. Recurrent binge eating (1 time or more a week for three months)  

2. Recurrent inappropriate compensation: laxitives, fasting, vomiting, excessive exercise after a binge  

3. Overevaluation of shape and weight – self-image is connnected to weight  

4. AN criteria not met (weight) - difference is the weight category, typically heavier than AN bc of binging  

   • Often restrited eating outside of binging  

Clinical binge and three essential parts of a binge

Clinical binge: eating a unusually large amount of food within a two hour period (at least two or more meals in a very short period of time – high fat or calories)

• often start when you try and eat a small amount of a cheat food and then physically cannot stop (sometimes people schedule their binges

• I've had a hard day I am going to go home and binge)

1. Time Frame

2. Quantities

3. Loss of Control

Binge Eating Disorder

Just the binge part of Bulimia Nervosa

1. Recurrent binge eating episodes – at least once a week for three months  

2. Marked distress about binge eating  

3. No recurrent inappropriate compensation 

Associated Risks with Eating Disorders

• Mortality – Highest of all psych disorders 

• Suicide is the most common cause of death, followed by cardiac arrest 

• Cardiac problems – Electrolyte imbalances, prolapse, reduced muscle mass, slowed heart rate 

• Dental problems 

• Anemia 

• Comorbid psych disorders

Prevalence of eating disorders in men

• Around 25% of individuals with eating disorders are men, though under diagnosis is common 

• Men are less likely to seek treatment due to stigma and misconceptions 

Differences in presentation of Eating Disorders in Genders

• More likely to focus on muscle gain, leanness, and control over physique – fine line in athletics  

• Especially true in gay community and athletes 

• Gay and bisexual men: 7x more likely to develop an ED 

• Body Dysmorphic Disorder with Muscle Dysmorphia Specifier (obsession with muscularity) is more common in men 

• May engage in excessive exercise, supplement use, and rigid dieting 

Barriers to treatment

• Social stigma-eating disorders are seen as a "female issue" 

• Medical professionals may overlook symptoms in men 

• Less research and targeted treatment approaches for men with EDs 

Sociological factors and diet culture

Idealization of a slim body type as the epitome of beauty, particularly among North American white women* 

Fat-phobia

• People with larger bodies are frequently depicted in a negative light, if represented at all in the media

• employment discriminations

• Healthcare Bias: Individuals with higher body weight face discrimination from medical professionals 

•  Media and Advertising

• Health and fitness culture - emphasis on aesthetics rather than health

• Nutrition and exercise goals often based off of staying slim and lean

• Cultural and social rewards

Why does dieting have a counter effect on the dieter

(they aim to lose weight and then the opposite effect occurs) 

• Food restriction can lead to subsequent food obsession, binge eating, and rapid weight gain

• Restraint of eating increases the risk of loss of control overeating, thereby undermining dieting efforts (Polivy and Herman, 1985) 

• Dieting can impair cognitive functioning, which makes effective decision-making regarding food choices more challenging

Adolescent girls who diet have 18 times the chances of developing an ED within:

6 months

Language that disguises eating and dieting as health or wellness related

• Intermittent Fasting 

• Clean Eating – there aren't acc clean vs dirty just different kinds  

• Detoxes and Cleanses - “toxins” what are these toxins  

• Keto, Paleo, Low-Carb  

• “Mindful Eating” Apps – contains a lot of diet culture  

Biological factors of ED

• Twin studies on AN and BN provide strong evidence for a genetic component in eating disorders 

• Key Findings from Twin Studies: 

  • Anorexia Nervosa: ~50-80% heritable. 

  • Bulimia Nervosa: ~50-60% heritable. 

• Higher Concordance in Monozygotic (Identical) Twins than in Dizygotic (Fraternal) Twins 

• Genetic factors contribute to personality traits linked to EDs (e.g., perfectionism, impulsivity, anxiety) 

Developmental contributions to ED

• Parental attitudes and modelling around food, weight, and body image 

  • High control or enmeshed family relationships may contribute to restrictive eating 

  • Criticism or pressure regarding weight/appearance increases risk 
     

• Trauma and Abuse: Trauma survivors may develop eating disorders due to shame, negative body image, and/or as a way to cope 

  • Restriction may create a sense of control or emotional numbness 

  • Bingeing may provide temporary emotional relief 

  • Some may try to manipulate their body size to feel safer or avoid 
    attention 

• Peer pressure and comparison culture, especially during adolescence 

Emotional and personality factors of an ED

Personality: 

• Perfectionism – High self-expectations, fear of failure/criticism/rejection 

• Anxiety sensitivity – Avoiding risk, strong need for control, obsessiveness 

• Impulsivity - more common in bulimia/binge-eating disorder 

Emotional Regulation Difficulties: 

• Difficulty coping with distress 

• Restriction = emotional numbing; bingeing = emotional escape 

Cognitive patterns in ED

• Black-and-white thinking about food, weight, and self-worth 

• Distorted perception of body image 

• Low self-esteem and identity struggles 

Barriers to help in ED

• Functions being served by the eating disorder may deter help-seeking EG; emotion regulation, trauma avoidance, social reward  

• Shame and denial common deterrents  

• Barriers related to access  

Using CBT to treat ED

• Phobias, OCD have similar treatments  

• Exposure is necessary  

• Weight restoration  

• Eating fear-foods  

• Regular eating schedule  

• Moderate exercise  

• Mindfulness/DBT (DBT has skill building components like emotion regulation skills) 

Other factors to consider - The development of: 

• New ways of coping with emotional distress 

• Identity outside of the eating disorder 

• More compassionate ways of relating to one’s feelings and body 

• Social circles with positive culture around food and body image 

Sleep occurs in repeating cycles, progressing through different ______ and ____ stages 

REM and non-REM

What is a sleep cycle and what are the stages

Each cycle lasts approximately 90 minutes, with multiple cycles per night 

• Stage 1 and 2: You first fall asleep, but are not yet in a deep sleep

• Stage 3 and 4: You are in a deep, restful sleep your heart rate and breathing slow and your body is still

  1-4 = nonREM

• Stage 5: Your brain is active and your dreaming, your eyes move under your eyelids in REM

The first half of the night has what

More deep sleep (stages 3 and 4)

• REM becomes longer and more frequent in later cycles

What is different about stage 4

Stage 4 disappears after the first few cycles, while REM dominates toward morning 

• If you go to bed late (~12pm) your body will prioritize REM sleep and you won’t get as much deep sleep which is important for physical recovery 

• Why if you go to bed late you have crazy dreams  

• Your body physically restores itself in the first half  

Why is REM sleep important

crucial for memory consolidation and emotional processing

• You are filing away emotions and experiences which is often why you have nightmares  

Why do we sleep - restoration theory

Suggests sleep is essential for repairing and rejuvenating the body and brain. It helps in muscle growth, tissue repair, and protein synthesis. 

Evolution theory

Proposes sleep evolved as a survival mechanism:

• It conserves energy (don’t need to eat or drink or stress) and protects individuals from predators during parts of the day when there's little value or danger in being awake.

• It preserves energy so we don’t need to eat as much as well. Exposed to more risks (conservation)  

Information conservation theory

Sleep plays a crucial role in processing and consolidating memories from the day.

• It strengthens neural connections and supports learning and memory formation. 

Waste Clearance theory

• (Glymphatic System)

• Sleep facilitates the clearance of waste products from the brain, including toxins associated with neurodegenerative diseases (e.g., dementia), through the glymphatic system. 

• We deal with our fears and phobias in different contexts through dreams  

What are some of the effects of Sleep Deprivation

• Impaired Immune System

• Severe yawning

• Hallucinations

• Symptoms similar to ADHD

• Risk of Diabetes type 2

• Increased heart and risk of heart issues

• Decreased time reaction

• Tremors

• Aches

• Growth Suppression

• Obesity

• Decreased temp

What happens when you loose sleep for even one night

lead to deficits equivalent to having a blood alcohol concentration of 0.1%, which is above the legal limit for driving in many jurisdictions 

What are the three main factors of sleep disturbance

• Biological Vulnerability to sleep disturbance

• Sleep stress (poor sleep hygiene, cultural demands)

• Maladaptive reactions (someone reacting to stress making it worse): Naps, sleep schedule changes, parental reactions, self-medication)

Sleep-Wake disorders

1. Dyssomnias – difficulties getting enough sleep, problems in the timing of sleep, and complaints about the quality of sleep

   • Insomnia Disorder

   • Hypersomnolence Disorder - being too sleepy

   • Narcolepsy - falling asleep during the day

   • Breathing-Related Sleep Disorders (apnea)

   • Circadian Rhythm Disorders

2. Parasomnias – abnormal events that occur during sleep

   • Nightmare disorder, sleep terrors, sleep-walking

Dyssomnias

Any type of sleep disturbance: Difficulties getting good quality sleep - people often develop maladaptive reactions  

• Insomnia disorder 

• Hypersomnolence disorders 

• Narcolepsy 

• Breathing-related sleep disorders 

• Sleep apnea 

• Circadian rhythm sleep-wake disorders 

Insomnias

Dissatisfaction with sleep quantity/quality associated with at least one of the following difficulties: 

1.  Initiating sleep; or 

2. Maintaining sleep (frequent awakenings); and/or 

3. Early morning awakenings with inability to return to sleep 

   • Clinically significant distress/impairment 

   • Occurs at least 3 nights/week for at least 3 months 

   • Occurs despite adequate opportunity for sleep

• Insomnia doesn’t mean not sleeping at all. Problem is experince of chronically unsatisfying sleep  

CBT for sleep disorders

Individualized treatment outlining triggers and thought processes. Without needing medication. It focuses on changing negative thoughts, emotions, and behaviors that keep people from sleeping well.

• Keeping journal

• Improve sleep hygiene

• Changing ideas about sleep

Medications for sleep disorders

Sedative and or benzodiazepines

• Can cause dependance

Rebound insomnia

Temporary worsening of sleep problems that happens after stopping sleep medication or certain substances like alcohol or drugs.

Is melatonin good?

Only if you only need help getting to sleep initially (doesnt help sustained sleep)

People with insomnia are more likely to

• Have distorted perception of sleep length and sleep quality

• Experience increased intrusive worries when they try to sleep

• Endorse unhelpful, negative beliefs about sleep:

  • Unrealistic expectations

  • Catastrophizing

• Endorse positive meta-beliefs about benefits of worrying in bed

• Try to conserve energy during waking hours (e.g., cancel appointments, avoid exercise, avoid social events, etc.)

Things that help sleep hygiene:

1. Stick to the same bedtime and wake up time, even on the weekends.

2. Practice a relaxing bedtime ritual.

3. Avoid naps, especially in the afternoon.

4. Exercise daily.

5. Design your sleep environment to be conducive to sleeping.

6. Sleep on a comfortable mattress and pillows.

7. Use bright light to help manage your circadian rhythms.

8. Avoid alcohol, cigarettes, and heavy meals in the evening.

9. Wind down. Your body needs time to shift into sleep mode, so spend the last hour before bed doing a calming activity such as reading.

10. If you can't sleep, go into another room and do something relaxing until you feel tired.

Disorders that develop after a stressful or traumatic life event includes:

• Post-traumatic stress disorder (PTSD)

• Acute stress disorder

• Adjustment Disorder

• NEW Complex PTSD

PTSD

• Emotional disorder one month after a traumatic incident:

  • War

  • physical/sexual assault, particularly rape

  • Car accidents

  • Natural catastrophes

  • And more

Criterion A stressors

• Exposure to actual or threatened death, serious injury, or sexual violence through:

  • Direct exposure

  • Witnessing the trauma

  • Learning that the trauma happened to a close relative or close friend

  • Indirect exposure to aversive details of the trauma, usua;;y in the course of professional duties (eg. therapists, first responders)

PTSD - Re-experiencing

• nightmares, intrusive memories, flashbacks

  • A car accident survivor hears a car horn and suddenly feel as though they are back in the crash

  • A sexual assault survivor experiences sudden distressing memories when seeing someone who resembles the assailant

Avoidance - PTSD

• Avoidance of the intense feelings or reminders of the event through emotional numbing, avoiding people/places/circumstances

  • A domestic violence survivor avoids dating or forming close relationships because intimacy reminds them of past abuse

  • A first responder who witnessed a tragic event at work starts avoiding certain parts of town where it occurred

Negative changes to mood/cognition and reactivity in PTSD

• Negative changes to mood/cognition: these symptoms affect thoughts, emotions, and beliefs about oneself, others, and the world

  • A police officer feels emotionally detached and unable to feel joy, even in positive situations

• Reactivity: disturbed sleep, hypervigilance, increased startle response

  • A shooting survivor jumps or panics when hearing fireworks or loud noises

  • A first responder entering room and surveilling the whole thing, or not allowing their kids to do the whole thing

Specifiers in PTSD: Delayed expression

Additional information added to the diagnosis

• Delayed expression: PTSD symptoms do not fully appear until at least 6 months after the event

  • WHY? Some individuals suppress or disconnect from the trauma until a trigger (eg. life stress, new trauma) brings symptoms to the surface

  • Trigger onset may be a lack of distraction (eg. retirement)

Dissociative, Depersonalization, Derealization

Not a single disorder but a symptom that may appear in various disorders:

• Dissociation: a disconnection between thoughts, memories, identity, emotions, and perception of reality

  • Dissociation is a coping mechanism that helps survivors manage extreme distress or overwhelming emotions

  • Ranges from normative (eg. daydreaming, zoning out) to disordered

• Depersonalization: feeling detached from oneself (“I feel like I’m watching myself from the outside”)

• Derealization: Feeling like the world isn’t real (“everything looks foggy or dreamlike”)

PTSD Causes:

Anxious predisposition (makes it more likely)

• Intensity and severity of trauma

  • Resnick et al. (1993) found that likelihood of developing PTSD increased as a function of the severity of the trauma

Most likely to get PTSD

both life threat and injury, then injury only

• Least likely to get PTSD: no life threat of injury, life threat only

Stress changes in the brain from PTSD

• Overactive amygdala: excessive fear responses, hypervigilance, and emotional dysregulation

• Shrinking in hippocampus: flashbacks, memory gaps, difficulty separating past/present

• These brain changes explain why PTSD patients feel “stuck” in their trauma and react strongly to reminders

Lack of social support with PTSD

Talking about traumatic events help file them away

Neuroplasticity in PTSD

• Trauma causes the brain to:

  • Strengthen fear pathways in the amygdala

  • Weaken memory regulation in the hippocampus
    ➔ This can help or harm us, depending on the situation

• Repeated stress keeps fear circuits active, making emotional regulation harder

• Avoidance behaviours reinforce these brain changes by:

  • Preventing the brain from reprocessing traumatic memories

  • Confirming that the fear is justified and as scary as we believe

Imaginal Exposure with Relaxation Training

• Clients mentally revisit traumatic events in a safe setting while practicing relaxation techniques (eg. deep breathing)

• Helps reduce avoidance, desensitize emotional distress, and reprocess trauma

Eye movement desensitization and reprocessing (EMDR)

• Dont know why it helps but it does

• Clients recall traumatic memories while following bilateral stimulation (eye movements, tapping)

Helps the brain reprocess trauma and reduce emotional intensity

Biological Treatments in PTSD

• SSRIs: regulate brain’s overactive fear response and mood alterations

• Repetitive Transcranial Magnetic simulation

Repetitive Transcranial Magnetic Stimulation

• (RTMS): magnetic pulses stimulate underactive brain regions associated with PTSD symptoms

  • Strengthens connections between the prefrontal cortex (thinking brain) and the amygdala (fear center) to improve emotional regulation and reduce hyperarousal

Acute Stress Disorder

•  occurs up to 1 month after a traumatic even

  • Can be short-term PTSD precursor

  • May resolve and not lead to PTSD, but is a significant risk factor (40-80%)

Adjustment disorder

• emotional and/or behavioural reactions to life stress (divorce, job loss, move) that is out of proportion to the stressor

  • May include depression, anxiety, and conduct problems (eg. aggression, rule breaking)

Complex PTSD

• NOT currently recognized in DSM-5-TR, but IS in the ICD-11

• Caused by prolonged exposure to traumatic events, often interpersonal in nature, such as long term abuse

• Includes the symptoms of PTSD plus:

  • Emotion dysregulation

  • Interpersonal problems

  • Complex changes in self-concept (eg. feeling “othered”, lacking identity)

• Impact on relationships: problems with trust, intimacy, and a tendency to avoid relationships or to seek out unhealthy relationships

Treatment for Complex PTSD

• may require longer-term psychotherapy that focuses not only on coping with traumatic memories but also on improving emotional regulation, self-concept, and relationship skills (eg. DBT)