Lecture 10: Psychological Disorders and their Treatment

1. How do we define a psychological disorder?

General criteria for a disorder • Statistical rarity • Uncommon • Subjective distress • Associated with low quality of life, poor mental well-being • Impairment • Cognition, emotion regulation and attention • Biological dysfunction • Significant abnormalities in the nervous system

2. Discuss the idea of heterogeneity. 

n. the quality of having very different characteristics or values. For example, heterogeneity of variance is present in an analysis of variance when the average squared distance of each score from the mean differs for each group in the study (e.g., control group vs. treatment group).

3. Compare the traditional disease model of illness with the more recent network (dynamical system) model.

Theoretical models • Interpersonal model proposed by Coyne • If you feel down, you look to others for assurance • Others respond negatively to your need (hostility + rejection) • Poor interactions increasing need for reassurance • Behavioral models proposed by Lewinsohn • Low rate of reinforcement: try many things w/no success • Learned helplessness is a related concept (Seligman) • Cognitive model popularized by Beck • Cognitive distortions affect the ability to acknowledge reality or interpret it properly (always negative) • Best describes people with serious depression 

4. Give several major misconceptions about diagnosis.

Controversies

1. Diagnosis is categorizing people (pigeon-holing)

• A person does not lose their individuality with diagnosis

• Better to use the term “people with XXX”

2. Diagnoses are unreliable (experts disagree)

• Clinicians generally agree (inter-rater reliability ~ 0.8)

3. Diagnoses are invalid

• Diagnoses can predict outcomes

4. Diagnoses negatively impact a person’s life

• In the right context (supportive environment), an effective

diagnosis generally improves quality of life

5. Discuss the features, strengths and weaknesses of the DSM-5.

 DSM-5 Features • Provides a set of criteria for guiding diagnosis, includes some 300+ disorders • Uses a biopsychosocial approach • Biological factors, psychological factors (thinking patterns) and societal factors (culture) • Criticisms • Not all disorders meet validity criteria • Vagueness may lead to “pathologization” of normal behavior • Categorical (binary; either/or) rather than dimensional • Concerns raised about lack of transparency, pace of preparation and conflicts of uninterest

6. For the disorders of anxiety, depression, bipolar disorder, schizophrenia and autism:

   1. Give main features (symptoms)

   2. Give epidemiological characteristics (prevalence, groups most vulnerable)

   3. Identify potential genetic and environmental factors

   4. Highlight a role of culture (if any) 

Anxiety disorders • Generalized Anxiety Disorder (GAD) • Panic Disorder • Phobias • ~4% of people may suffer from these conditions • Related to anxiety disorders, but now considered independent, are obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) 

1 – GAD • Exaggerated worry/tension in day-to-day situations (generalized and not specific) • May later lead to the emergence of other disorders • More common in females than males

2 – Panic Disorders • Characterized by episodes of intensive fear (w/sweating, dizziness, light headaches, breathing difficulty, heart irregularities) • Many people might report a single panic attack each year (e.g. 20% of students an attack once a year) • In panic disorder, however, the attacks are repeated and unexpected • Emerges early in adulthood

3 – Phobias • Intense, irrational fear of a specific thing • May be outgrowth of panic disorder • A popular example is agoraphobia (fear of marketplaces or crowded environments) • By far the most common of all anxiety disorders • Most phobias are not highly distressing, do not impair quality of life or require treatment 

4 – OCD • Obsessions are persistent thoughts that are unwanted and/or cause stress • Centered around topics such as sex, contamination, aggression and religion • Compulsions are repetitive behaviors undertaken to reduce distress and relieve shame/guilt • Washing hands • Re-reading sentences

What is depression? • Loss of interest or pleasure in activities normally enjoyed (e.g. anhedonia) • Decreased energy (e.g. fatigue) • Feelings of guilt or low self-worth • Disturbed sleep, appetite and activity • Inability to concentrate • Thoughts of suicide

Types of Depression • Unipolar depressive disorder • Major Depressive Disorder (MDD; chronic) • Major Depressive Episodes (MDE; acute but often recurrent) • Post-partum depression • Dysthymia • Seasonal affective disorder Depressive episodes also occur in bipolar disorder, but bipolar disorder is considered separately

Bipolar Disorder • Episodes of depression and elevated mood (previously called manic depression) • During periods of elevated mood (mania/hypomania) the individual feels extremely energetic, happy and/or irritable • They may experience reduced need for sleep and make poor decisions with little regard for consequences

Bipolar Disorder • ~1% of the global population • One of the most costly disorders worldwide (top 10) • Economic costs estimated to be $45 billion in the US • Frequently results in absenteeism • Risk of suicide and self-harm is high • Related to a number of other traits (particularly creativity), and over-represented in certain parts of the population (creative professionals/artists)

7. Discuss key traits in effective therapists. Just how important is a good therapist? 

The therapist is critical • “Good therapists” are viewed as warm, respectful, caring, engaged, empathetic and authentic • Ability to instill hope/positivity is another valued trait • No clear relationship between experience + outcomes • Trait matching with therapist (female-female, ethnicityethnicity) is often preferred, but benefits are unclear

8. Describe the concept of insight, behavioral, cognitive, acceptance and mindfulness therapies. For each therapy listed, give:

   1. The central philosophy

   2. The structure of the therapeutic interaction (activities/exercises involved)

   3. Efficacy

Insight therapies Focus on understanding how a person’s thoughts, beliefs, actions and prior history influence their current behavior

Psychoanalytic therapies • Abnormal behaviors in mental health disorders may stem from early and/or traumatic experiences • Emphasis on the unconscious and the analysis of: • thoughts and feelings that patients avoid (repressed) • wishes and fantasies • recurring themes and patterns • therapeutic interaction • Belief that insight into unconscious material is required for meaningful changes in behavior • Bring unconscious processing into conscious awareness

Procedures in psychoanalysis • Free association and Interpretation • “What’s the first thing that comes to mind when I mention X?” • First answers given, or answers given repeatedly, may be meaningful in ways the person does not realize • Therapist may propose explanations • Dream analysis • Dreams may represent subconscious desires that contribute to the current mental state • Wish fulfilment theory of dreaming • Debate over role of insight in therapy efficacy

2 – Humanistic Therapies • Related to perspectives of Rogers and Maslow • Often called client-centered (older term) or personcentered (newer term) therapy • Emphasis on insight, positivity and achieving selfactualization through choice (free will) • Therapist should be authentic, unconditionally positive and empathic (three critically important traits) • Less structured (client decides how time is spent)

Behavioral Therapies

Behavioral therapies • Whereas insight therapies focus on general awareness, behavioral therapies focus specifically on current behaviors the client sees as problematic • Strategies to treat the behavior often included • More data-driven, comprehensive assessments sometimes included (e.g. psychological/physiological tests and interviews given) • Emphasis on principles of learning and reinforcement (see L05) 

Examples • Systemic desensitization • Fears may result from conditioning (CS + unpleasant stimulus, CS becomes cue for unpleasant stimulus) • Treatment involves re-pairing CS with positive stimulus (e.g. one that causes relaxation) • Aversion therapies • Reduce a bad behavior by paring it with a bad outcome (e.g. Disulfiram/Antabuse in the treatment of alcoholism) • Extinction Therapy/Flooding (L05) • Token economies (L05)

Cognitive behavioral therapy (CBT) • May be used to treat depression and anxiety

• Very popular, used by ~40% of clinical psychologists 

Acceptance-based therapies

Acceptance-based therapies • “Third wave” of therapy • Behavioral therapies are considered the first wave, cognitive therapies the second wave • Focuses on embracing thoughts and feelings, without feeling ashamed about them • Though this seems similar to the humanistic therapies mentioned earlier, acceptance-based therapies are different in that acceptance is the primary focus • Growing in popularity

Acceptance-based therapies • Promise in treating anxiety, depression and addiction1 • Acceptance and Commitment Therapy (ACT), Mindfulness-Based approaches and Dialectic Behavioral Therapy arguably all fall into this category

1. When looking at all psychotherapies, be able to answer the following questions:

1. Which therapies are most effective?

2. Why might we still believe in effective therapies?

Summary • Evidence supports that many therapies work better no treatment (true control) or placebo treatment • Most therapies are comparable in their effects; individual differences mean its vital to find the “best therapy” for you • Certain therapeutic approaches, though well-intended, can be ineffective or even harmful to certain people • Crisis debriefing, Scared Straight, Youth interrogation, Books (bibliotherapy) and other examples • The popularity of a therapy is not proof it works; research is key moving forward

1. Describe the typical biomedical treatments used for depression, anxiety, bipolar disorder and schizophrenia. Highlight preferred approaches and approaches reserved for treatment-resistant cases.

Biomedical treatments • Includes drugs, brain stimulation and surgery (anything that directly affects biology) • May be more effective for certain individuals, but risk for side effects is generally greater • Not always intended to be used alone, usually should be paired with other psychotherapy methods • Today, we will discuss biomedical treatments for depression, anxiety, bipolar disorder and schizophrenia

BMT for depression • Drugs (moderate/severe cases) • SSRIs (Selective Serotonin Reuptake Inhibitors) • Concerns of over-prescription + withdrawal • Transcranial magnetic stimulation (TMS) • More accessible (though not more effective) • Ketamine • Rapid effect (for those whom it works) • Newer (c. 2019), side effects unclear • Electroconvulsive therapy • Psychosurgery (removal of cingulate)

BMT for other disorders • Anxiety • Drugs increasing GABAA receptor activity are anxiolytic (e.g. benzodiazepines) • However, SSRIs are most commonly used • Bipolar disorder • Lithium, valproate, anticonvulsants and antipsychotics • Schizophrenia • First generation/conventional antipsychotics (block D2 receptors) • Second generation antipsychotics have multiple actions (e.g. block 5-HT2 receptors)

Concerns about BMT • Side effects generally more significant than for therapy • Some treatments non-reversible (e.g. psychosurgery) • Though some treatments are more convenient than psychotherapy, they are also more costly (e.g. drugs) • Common misconception that all disorders are a ‘simple chemical imbalance’ may lead people to prefer drugs and avoid other treatments that could be beneficial • Most effective approach likely involves biomedical treatments and psychotherapy together