Reviewer for AbPsych

Schizophrenia

  • Schizophrenia is characterized by major disturbances in thought, emotion, and behavior.
    • Disordered thinking: Ideas are not logically related.
    • Faulty perception and attention.
    • Lack of emotional expressiveness or inappropriate emotions.
    • Disturbances in movement or behavior, such as a disheveled appearance.
  • It can disrupt interpersonal relationships and diminish the capacity to work or live independently.
  • Significantly increased rates of suicide and death are associated with schizophrenia.

DSM-5 Criteria for Schizophrenia

  • Two or more of the following symptoms for at least 6 months, with one symptom being either delusions, hallucinations, or disorganized speech:
    1. Delusions
    2. Hallucinations
    3. Disorganized speech
    4. Disorganized (catatonic) behavior
    5. Negative symptoms (diminished motivation or emotional expression)
  • Functioning in work, relationships, or self-care has declined since onset.
  • Signs of the disorder must persist for at least 6 months.
    • If during a prodromal or residual phase, negative symptoms or two or more of symptoms 1-4 are present in a less severe form.

Clinical Description of Schizophrenia

Three major clusters of symptoms:

  • Positive
    • Delusions
    • Hallucinations
  • Negative
    • Avolition
    • Alogia
    • Anhedonia
    • Blunted affect
    • Asociality
  • Disorganized
    • Disorganized behavior
    • Disorganized speech

Positive Symptoms: Behavioral Excesses and Distortions

  • Delusions:
    • Firmly held beliefs contrary to reality and resistant to disconfirming evidence.
    • Types:
      • Persecutory delusions (65% of patients): "The CIA planted a listening device in my head."
      • Thought insertion
      • Thought broadcasting
      • Outside control
      • Grandiose delusions
      • Ideas of reference
  • Hallucinations:
    • Sensory experiences in the absence of sensory stimulation.
    • Types:
      • Auditory (74% of patients)
      • Visual
      • Hearing voices is associated with increased activity in Broca’s area.

Negative Symptoms: Behavioral Deficits

  • Avolition:
    • Lack of interest; apathy.
  • Asociality:
    • Inability to form close personal relationships.
  • Anhedonia:
    • Inability to experience pleasure.
    • Consummatory pleasure (pleasure experienced in the moment).
    • Anticipatory pleasure (pleasure expected in the future).
  • Blunted affect:
    • Exhibits little or no affect in face or voice.
  • Alogia:
    • Reduction in speech.
  • Two domains:
    • Experience domain:
      • Motivation
      • Emotional experience
      • Sociality
    • Expression domain:
      • Outward expression of emotion
      • Vocalization

Disorganized Symptoms

  • Disorganized speech (formal thought disorder):
    • Incoherence: Inability to organize ideas.
    • Loose associations (derailment): Rambles, difficulty sticking to one topic.
  • Disorganized behavior:
    • Odd or peculiar behavior; silliness, agitation, unusual dress.
    • Example: wearing several heavy coats in hot weather.

Example of Loosening of Associations

  • An "announcement" posted by a person with schizophrenia:
    • "Things that relate, the town of Antelope, Oregon, Jonestown, Charlie Manson, the Hillside Strangler, the Zodiac Killer, Watergate, King’s trial in L.A., and many more. In the last 7 years alone, over 23 Starwars scientists committed suicide for no apparent reason."
    • "The AIDS coverup, the conference in South America in 87 had over 1,000 doctors claim that insects can transmit it. To be able to read one’s thoughts and place thoughts in one’s mind without the person knowing it’s being done. Realization is a reality of bioelectromagnetic control, which is thought transfer and emotional control, recording individual brain-wave frequencies of thought, sensation, and emotions."

Movement Symptoms

  • Catatonia:
    • Motor abnormalities.
    • Repetitive, complex gestures (usually of the fingers or hands).
    • Excitable, wild flailing of limbs.
  • Catatonic immobility:
    • Maintain unusual posture for long periods of time (e.g., stand on one leg).
  • Waxy flexibility:
    • Limbs can be manipulated and posed by another.

Other Psychotic Disorders

  • Schizophreniform Disorder
    • Same symptoms as schizophrenia but with a symptom duration greater than 1 month but less than 6 months.
    • Symptoms must include either hallucinations, delusions, or disorganized speech.
  • Brief Psychotic Disorder
    • Symptom duration of 1 day to 1 month, often triggered by extreme stress.
    • Symptoms must include either hallucinations, delusions, or disorganized speech.
  • Schizoaffective Disorder
    • Symptoms of both schizophrenia and either a depressive or manic episode.
    • Symptoms of a major mood episode are present for a majority of the duration of the illness.
  • Delusional Disorder
    • Delusions may include persecution, jealousy, being followed, erotomania (loved by a famous person), or somatic delusions.
    • No other symptoms of schizophrenia.

PHASES OF SCHIZOPHRENIA

  1. Prodromal Phase
  2. Acute (Active) Phase
  3. Recovery (Residual) Phase

Prodromal Phase

  • The earliest stage of schizophrenia.
  • Symptoms are often mild and hard to notice, making diagnosis difficult.
  • Accurate diagnosis and treatment in this stage may improve the person's quality of life and even slow the progression of the condition.
  • Symptoms include:
    • Self-isolation
    • Loss of interest in activities
    • Clumsiness
    • Difficulty expressing emotions
    • Disrupted sleep
    • Anxiety
    • Odd beliefs
    • Changes in appetite
  • Not everyone with schizophrenia will experience these symptoms, and symptoms will vary from person to person.

Acute (Active) Phase

  • Also known as the active phase, where a person actively experiences psychosis symptoms.
  • Positive symptoms are most predominant during this phase.

Recovery (Residual) Phase

  • Sometimes referred to as the residual phase.
  • Often requires proper treatment in the acute phase to reach this stage.
  • Positive symptoms typically subside, and negative symptoms become more prominent.
  • Negative symptoms detract from a person’s functioning and may include:
    • Social isolation
    • Lethargy
    • Lack of interest in social activities
    • Difficulty concentrating
    • Poor hygiene
    • Difficulty making decisions
    • Forgetfulness

Risk Factors for Schizophrenia

  • Genetics
    • Schizophrenia sometimes runs in families, but it does not mean that other members of the family will have it.
    • Many genes may increase the chances of developing schizophrenia, but no single gene causes it by itself.
  • Environment
    • A combination of genetic factors and aspects of a person’s environment and life experiences may play a role.
    • These environmental factors may include living in poverty, stressful surroundings, and exposure to viruses or nutritional problems before birth.
  • Brain structure and function
    • Differences in the size of certain brain areas and in connections between brain areas.
    • Some of these brain differences may develop before birth.

Etiology of Schizophrenia: Genetic Factors

  • Genetically heterogeneous: not caused by a single gene.
  • Family studies: relatives at increased risk; negative symptoms have a stronger genetic component.
  • Twin studies:
    • 44\% risk for MZ twins vs. 12\% risk for DZ twins.
    • Children of non-schizophrenic MZ twins were more likely to develop schizophrenia (9.4\% vs. 1\% in the general population).
  • Adoption studies: increased likelihood of developing psychotic disorders.
  • Familial high-risk studies: differing negative vs. positive symptomatology.
  • Association studies:
    • Two genes associated with schizophrenia:
      • DTNGP1 (dystrobrevin-binding protein 1)
      • NGR1 (growth factor neuregulin; risk factor for schizotypal traits)
    • Two genes associated with cognitive deficits:
      • COMT (Catechol-O-Methyltransferase)
      • BDNF (brain-derived neurotrophic factor)
  • Genome-wide scans: identification of gene mutations; several identified but results need replication.

Etiology of Schizophrenia: Neurotransmitters

  • Dopamine Theory
    • Disorder due to excess levels of dopamine.
    • Drugs that alleviate symptoms reduce dopamine activity.
    • Amphetamines, which increase dopamine levels, can induce psychosis.
    • Theory revised:
      • Excess numbers of dopamine receptors or oversensitive dopamine receptors.
      • Localized mainly in the mesolimbic pathway.
      • Mesolimbic dopamine abnormalities mainly related to positive symptoms.
      • Underactive dopamine activity in the mesocortical pathway mainly related to negative symptoms.

Etiology of Schizophrenia: Brain Structure and Function

  • Enlarged ventricles:
    • Implies loss of brain cells.
    • Correlates with:
      • Poor performance on cognitive tests
      • Poor premorbid adjustment
      • Poor response to treatment
  • Prefrontal Cortex
    • Behaviors disrupted by schizophrenia (e.g., speech, decision making) are governed by the prefrontal cortex.
    • Individuals with schizophrenia show impairments on neuropsychological tests of the prefrontal cortex (e.g., memory).
    • Individuals with schizophrenia show low metabolic rates in the prefrontal cortex and a failure to show frontal activity related to negative symptoms.
    • Disrupted communication among neurons due to loss of dendritic spines, known as Disconnection Syndrome.
  • Structural and functional abnormalities in the temporal cortex:
    • Temporal gyrus
    • Hippocampus
    • Amygdala
    • Anterior cingulate
    • Reduced gray matter and volume are evident, with disrupted connectivity in the brain.
  • Environmental Factors
    • Damage during gestation or birth with high rates of obstetrical complications in patients with schizophrenia.
    • Reduced supply of oxygen during delivery may result in loss of cortical matter.
    • Viral damage to the fetal brain.
    • Presence of parasite, toxoplasma gondii, associated with 2.5x greater risk of developing schizophrenia.
    • Higher rates of schizophrenia when the mother had the flu in the second trimester of pregnancy.
  • Developmental factors
    • The prefrontal cortex matures in adolescence or early adulthood, and dopamine activity also peaks in adolescence.
    • Stress activates the HPA system, which triggers cortisol secretion that increases dopamine activity.
    • Excessive pruning of synaptic connections.
    • The use of cannabis during adolescence is associated with increased risk, which may explain why symptoms appear in late adolescence but brain damage occurs early in life.

Etiology of Schizophrenia: Psychological Stress

  • Reaction to stress
    • Individuals with schizophrenia and their first-degree relatives are more reactive to stress with greater decreases in positive mood and increases in negative mood.
  • Socioeconomic status
    • Highest rates of schizophrenia are among the urban poor.
    • Sociogenic hypothesis:
      • Stress of poverty causes disorder.
    • Social selection theory:
      • Downward drift in socioeconomic status.
      • Research supports social selection.

Etiology of Schizophrenia: Family Factors

  • Schizophrenogenic mother
    • Cold, domineering, conflict-inducing, but no support for this theory.
  • Communication deviance (CD)
    • Hostility and poor communication; inconclusive at this time.

Etiology of Schizophrenia: Families and Relapse

  • Family environment impacts relapse.
  • Expressed Emotion (EE)
    • Hostility, critical comments, emotional overinvolvement.
    • Bidirectional association with unusual patient thoughts leading to increased critical comments, and increased critical comments leading to unusual patient thoughts.

Etiology of Schizophrenia: Developmental Studies

  • Use of retrospective or “follow-back” studies.
  • Developmental histories of children who later developed schizophrenia showed lower IQ and were more often delinquent (boys) and withdrawn (girls).
  • Coding of home movies showed poorer motor skills and more expression of negative emotion.

How is Schizophrenia Treated?

  • Current treatments focus on helping people manage their symptoms, improve day-to-day functioning, and achieve personal life goals.

Treatment of Schizophrenia: Medications

  • First-generation antipsychotic medications (neuroleptics; 1950s):
    • Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes (Navane).
    • Reduce agitation and violent behavior.
    • Block dopamine receptors.
    • Little effect on negative symptoms.
    • Extrapyramidal side effects, such as tardive dyskinesia and neuroleptic malignant syndrome.
    • Maintenance dosages to prevent relapse.
  • Second-generation antipsychotics:
    • Clozapine (Clozaril) impacts serotonin receptors.
    • Fewer motor side effects and less treatment noncompliance, reducing relapse.
    • Side effects include impaired immune symptom functioning, seizures, dizziness, fatigue, drooling, and weight gain.
    • Newer medications may improve cognitive function, including Olanzapine (Zyprexa) and Risperidone (Risperdal).
  • Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study
    • Second-generation drugs were not more effective than older, first-generation drugs.
    • Second-generation drugs did not produce fewer unpleasant side effects.
    • Nearly three-quarters stopped taking the medications before the study ended.
    • Second-generation antipsychotics have serious side effects, like weight gain, diabetes, and pancreatitis.

Psychological Treatments

  • Patient Outcomes Research Team (PORT) treatment recommendation:
    • Medication PLUS psychosocial intervention.
  • Social skills training
    • Teach skills for managing interpersonal situations, such as completing a job application, reading bus schedules, and making appointments.
    • Involves role-playing and other practice exercises, both in group and in vivo.
  • Family therapy to reduce expressed emotion
    • Educate family about causes, symptoms, and signs of relapse.
    • Stress the importance of medication.
    • Help family to avoid blaming the patient.
    • Improve family communication and problem-solving.
    • Encourage expanded support networks.
    • Instill hope.
  • Cognitive behavioral therapy
    • Recognize and challenge delusional beliefs.
    • Recognize and challenge expectations associated with negative symptoms (e.g., “Nothing will make me feel better so why bother?”).
  • Cognitive remediation training or cognitive enhancement therapy (CET)
    • Improve attention, memory, problem-solving, and other cognitive-based symptoms.
  • Case management
    • Multidisciplinary team to provide comprehensive services.
  • Residential treatment and vocational rehabilitation.

How is Schizophrenia Treated?

  • Current treatments for schizophrenia focus on helping people manage their symptoms, improve day-to-day functioning, and achieve personal life goals, such as completing education, pursuing a career, and having fulfilling relationships.

Personality Disorders

Key Features

  • Longstanding, pervasive, inflexible, extreme, and persistent patterns of behavior and inner experience.
    • Unstable positive sense of self.
    • Unable to sustain close relationships.
  • DSM-5 retains 3-cluster format of the DSM-IV-TR.
  • Alternative DSM-5 Model for Personality Disorders included in the appendix of the DSM-5. This is due to
    • Half who met diagnostic criteria for one DSM-IV-TR personality disorder met diagnostic criteria for another personality disorder.
    • Some of the DSM-IV-TR personality diagnoses are rare (< 2%).
    • Many people who seem to have serious personality problems do not fit any of the personality disorder diagnoses.
    • Individuals with a personality disorder can vary a good deal from one another in the nature of their personality traits and the severity of their condition.
    • To capture subsyndromal symptoms better

Personality Disorder Clusters

Three clusters with clinical similarity:

  • Odd/Eccentric (Cluster A)
  • Dramatic/Erratic (Cluster B)
  • Anxious/Fearful (Cluster C)
Cluster A (odd/eccentric)
  • Paranoid
  • Schizoid
  • Schizotypal
Cluster B (dramatic/erratic)
  • Antisocial
  • Borderline
  • Histrionic
  • Narcissistic
Cluster C (anxious/fearful)
  • Avoidant
  • Dependent
  • Obsessive-compulsive

Common Risk Factors Across the Personality Disorders

  • Children in the Community Study
    • Findings suggest disorders are related to early adversity (abuse or neglect increase risk).
    • Unaffected or aversive parenting styles were linked to increased rates of personality disorders.
  • Twin studies suggest moderately high heritability with personality disorders.

Odd/Eccentric Cluster

  • Some similarity to, but less severe than, schizophrenia.
  • Paranoid Personality Disorder
  • Schizotypal Personality Disorder
  • Schizoid Personality Disorder

Paranoid Personality Disorder

  • Presence of four or more of the following signs of distrust and suspiciousness, beginning in early adulthood and shown in many contexts:
    • Unjustified suspiciousness of being harmed, deceived, or exploited.
    • Unwarranted doubts about the loyalty or trustworthiness of friends or associates.
    • Reluctance to confide in others because of suspiciousness.
    • The tendency to read hidden meanings into the benign actions of others.
    • Bears grudges for perceived wrongs.
    • Angry reactions to perceived attacks on character or reputation.
    • Unwarranted suspiciousness of the fidelity of partner.

Schizoid Personality Disorder

  • Presence of four or more of the following signs of aloofness and flat affect from early adulthood across many contexts:
    • Lack of desire for or enjoyment of close relationships.
    • Almost always prefers solitude to companionship.
    • Little interest in sex.
    • Few or no pleasurable activities.
    • Lack of friends.
    • Indifference to praise or criticism.
    • Flat affect, emotional detachment.

Schizotypal Personality Disorder

  • Unusual and eccentric thoughts and behaviors (psychoticism), interpersonal detachment, and suspiciousness.
  • Odd beliefs or magical thinking:
    • Telepathic, clairvoyant, ideas of reference.
  • Illusions: Feels the presence of a force or person not actually present.
  • Odd/eccentric behavior or appearance
    • Wears strange clothes
    • Talks to self
  • Affect is flat; aloof from others
  • Presence of five or more of the following signs of unusual thinking, eccentric behavior, and interpersonal deficits from early adulthood across many contexts:
    • Ideas of reference.
    • Peculiar beliefs or magical thinking, e.g., belief in extrasensory perception.
    • Unusual perceptions, e.g., distorted feelings about one’s body.
    • Peculiar patterns of thought and speech.
    • Suspiciousness or paranoia.
    • Inappropriate or restricted affect.
    • Odd or eccentric behavior or appearance.
    • Lack of close friends.
    • Anxiety around other people that does not diminish with familiarity.
  • Similar to schizophrenia:
    • Individuals with schizotypal PD show problems similar to those found in schizophrenia.
    • Highly heritable (~60%).
    • Cognitive and neuropsychological deficits.
    • Enlarged ventricles.
    • Less temporal gray matter.

Dramatic/Erratic Cluster

  • Antisocial Personality Disorder
  • Borderline Personality Disorder
  • Histrionic Personality Disorder
  • Narcissistic Personality Disorder

Antisocial Personality Disorder

  • Pervasive disregard for the rights of others.

  • Pattern of irresponsible behaviors:

    • Poor work record, breaking laws, being irritable and physically aggressive, defaulting on debts, being reckless and impulsive, neglecting to plan ahead, little regard for truth, and little remorse for misdeeds.

  • Evidence of conduct disorder before age 15.

  • Much more common in men than women.

  • Comorbid substance use is very common.

  • Age at least 18

  • Evidence of conduct disorder before age 15

  • Pervasive pattern of disregard for the rights of others since the age of 15 as shown by at least three of the following:

    • Repeated law breaking
    • Deceitfulness, lying
    • Impulsivity
    • Irritability and aggressiveness
    • Reckless disregard for own safety and that of others
    • Irresponsibility as seen in unreliable employment or financial history
    • Lack of remorse

Antisocial Personality Disorder (Psychopathy or Sociopathy)

  • Focuses on internal thoughts and feelings.
  • Poverty of emotion:
    • Negative emotions: Lacks shame, remorse and anxiety; does not learn from mistakes.
    • Positive emotions: Merely an act used to manipulate others; superficially charming.
  • Impulsivity: Behave irresponsibly for thrills.
  • Psychopathy Checklist – revised (Hare) Scale.

Etiology of Antisocial Personality Disorder

  • Problems with research that is conducted mostly with criminals and different measurements (APD vs. psychopathy).
  • Genetics: Antisocial behavior heritable (40-50%), with genetic risk for APD, psychopathy, conduct disorder, and substance abuse related.
  • Family environment: Lack of warmth, high negativity, and parental inconsistency predict APD, and also poverty, exposure to violence, and with interaction with genetics.
  • Fearlessness:
    • Lack of fear or anxiety
    • Low baseline levels of skin conductance; less reactive to aversive stimuli.
  • Impulsivity: Lack of response to threat when pursuing rewards.
  • Deficits in empathy: Not in tune with the emotional reactions of others.

Borderline Personality Disorder (BPD)

  • Impulsive, self-damaging behaviors.

  • Unstable, stormy, intense relationships.

  • Emotional reactivity:

    • Feelings towards others can change drastically and inexplicably very quickly.
    • Emotions are intense, erratic, shift abruptly—often from passionate idealization to contemptuous anger.

  • Frantic efforts to avoid abandonment.

  • Unstable sense of self.

  • Anger-control problems

  • Chronic feelings of emptiness.

  • Recurrent suicidal gestures.

  • Transient psychotic or dissociative symptoms.

  • Later in life, most no longer meet diagnostic criteria.

  • Cormorbidity high with PTSD, MDD, substance-related, eating disorders, and schizotypal PD that predicts less chance of symptom remission.

  • Presence of five or more of the following in many contexts beginning in early adulthood:

    • Frantic efforts to avoid abandonment.
    • Unstable interpersonal relationships in which others are either idealized or devalued.
    • Unstable sense of self.
    • Self-damaging, impulsive behaviors in at least two areas, such as spending, sex, substance abuse, reckless driving, binge eating.
    • Recurrent suicidal behavior, gestures, or self-injurious behavior (e.g., cutting self).
    • Chronic feelings of emptiness.
    • Recurrent bouts of intense or poorly controlled anger.
    • During stress, a tendency to experience transient paranoid thoughts and dissociative symptoms.

  • Genetic component:

    • Highly heritable (60%)
    • May play a role in impulsivity and emotional dysregulation.

  • Decreased functioning of the serotonin system and increased activation of the amygdala.

  • Social Environmental Factors

    • Parental separation, verbal and emotional abuse during childhood.

Etiology of Borderline Personality Disorder (BPD):

  • Linehan’s Diathesis-Stress Theory
    • Individuals with BPD have difficulty controlling their emotions (emotional dysregulation) due to a possible biological diathesis.
    • Family invalidates or discounts emotional experiences and expression.
    • Interaction between extreme emotional reactivity and invalidating family → BPD.

Histrionic Personality Disorder

  • Presence of five or more of the following signs of excessive emotionality and attention-seeking shown in many contexts by early adulthood:
    • Strong need to be the center of attention
    • Inappropriate sexually seductive behavior
    • Rapidly shifting expression of emotions
    • Use of physical appearance to draw attention to self
    • Speech that is excessively impressionistic and lacking in detail
    • Exaggerated, theatrical emotional expression
    • Overly suggestible
    • Misreads relationships as more intimate than they are

Narcissistic Personality Disorder

  • Grandiose view of self and is preoccupied with fantasies of success.

  • Self-centered-ness

    • Demands constant attention and adulation
    • Lack of empathy
    • Feelings of arrogance, envy, entitlement

  • Sensitive to criticism and is enraged when not admired.

  • Seeks out high-status partners

  • Presence of five or more of the following shown by early adulthood in many contexts:

    • Grandiose view of one’s importance
    • Preoccupation with one’s success, brilliance, beauty
    • Belief that one is special and can be understood only by other high-status people
    • Extreme need for admiration
    • Tendency to exploit others
    • Lack of empathy
    • Envious of others
    • Arrogant behavior or attitudes

Etiology of Narcissistic Personality Disorder

  • Kohut’s Self-Psychology Model
    • Characteristics mask low self-esteem in childhood, and narcissist valued as a means to increase parent’s own self-esteem.
    • Not valued for his or her own competency and self-worth; parental emotional coldness and overemphasis on the child’s achievements reported by narcissists.
  • Social cognitive model: narcissist has low self-esteem, and interpersonal relationships are a way to bolster sagging self-esteem rather than increase closeness to others. Lab studies reveal cognitive biases that maintain narcissism.

Anxious/Fearful Cluster

  • Avoidant Personality Disorder
  • Dependent Personality Disorder
  • Obsessive-Compulsive Personality Disorder

Avoidant Personality Disorder

  • Fears criticism, rejection, or disapproval.

  • Avoids interpersonal situations.

  • Restrained and inhibited in interpersonal situations due to feelings of inadequacy, inferiority.

  • Avoids taking risks or trying new activities as they do not want to risk embarrassment.

  • High comorbidity with social anxiety disorder and related to Japanese syndrome called taijin kyofusho (taijin means “interpersonal” and kyofusho means “fear”).

  • High comorbidity with major depression.

  • A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as shown by four or more of the following starting in early adulthood in many contexts:

    • Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval.
    • Unwilling to get involved with people unless certain of being liked.
    • Restrained in intimate relationships because of the fear of being shamed or ridiculed.
    • Preoccupation with being criticized or rejected.
    • Inhibited in new interpersonal situations because of feelings of inadequacy.
    • Views self as socially inept or inferior.
    • Unusually reluctant to try new activities because they may prove embarrassing.

Dependent Personality Disorder

  • An excessive need to be taken care of, as shown by the presence of at least five of the following beginning in early adulthood and shown in many contexts:
    • Difficulty making decisions without excessive advice and reassurance from others.
    • Need for others to take responsibility for most major areas of life.
    • Difficulty disagreeing with others for fear of losing their support.
    • Difficulty doing things on own because of lack of self-confidence.
    • Doing unpleasant things as a way to obtain the approval and support of others.
    • Feelings of helplessness when alone because of lack of confidence in the ability to handle things without others.
    • Urgently seeking a new relationship when one ends.
    • Preoccupation with fears of having to take care of self.

Obsessive-Compulsive Personality Disorder

  • A perfectionist and preoccupied with rules, details, schedules, and organization.
  • Overly focused on work with little time for leisure, family, and friends.
  • Reluctant to make decisions or delegate and is rigid and inflexible, especially about morality.
  • “Control freaks”.
  • OCPD is different from OCD as it does not have the obsessions/compulsions of OCD.
  • Most frequently comorbid with avoidant PD and very little research into etiology.
  • Intense need for order and control, as shown by the presence of at least four of the following beginning by early adulthood and evidenced in many contexts:
    • Preoccupation with rules, details, and organization to the extent that the point of an activity is lost.
    • Extreme perfectionism interferes with task completion.
    • Excessive devotion to work to the exclusion of leisure and friendships.
    • Inflexibility about morals and values.
    • Difficulty discarding worthless items.
    • Reluctance to delegate unless others conform to one’s standards.
    • Miserliness.
    • Rigidity and stubbornness.

Treatment of Borderline PD

  • Difficult to treat; interpersonal problems play out in therapy, and attempts to manipulate therapist
  • Medications: Antidepressants & Mood stabilizers
  • Dialectical Behavioral Therapy (Linehan, 1987)
    • Acceptance and empathy plus CBT
    • Emotion-regulation techniques and social skills training
  • Mentalization-based therapy: Fail to think about their own and other’s feelings
  • Schema-focused cognitive therapy: Identify maladaptive assumptions that underlie cognitions

Treatment of Schizotypal Personality Disorder, Avoidant Personality Disorder, and Psychopathy

  • Schizotypal PD: Antipsychotic and antidepressant medications
  • Avoidant PD: Same treatments as social anxiety disorder, for example, antidepressant medications and social skills training
    Psychopathy: psychotherapy: either CBT or psychodynamic

Dissociative Disorders

Key Features

  • Alteration in the experience of the self and reality.
  • Lack of conscious access to memory, typically of a stressful experience. The fugue subtype involves traveling or wandering coupled with loss of memory for one's identity or past.
  • At least two distinct personalities that act independently of each other.

Dissociative Disorders and Memory

  • Dissociation is when some aspect of cognition or experience becomes inaccessible to consciousness as an avoidance response, though some types of dissociation are harmless and common (e.g., losing track of time).
  • Sudden disruption in the continuity of:
    • Consciousness
    • Emotions
    • Motivation
    • Memory
    • Identity
  • How does memory work under stress?
    • Psychodynamic: Traumatic events are repressed.
    • Cognitive: Extreme stress usually enhances rather than impairs memory, known as interference memory formation, which is not accessible to awareness later.
  • Memory Deficits and Dissociation
    • Memory deficits in explicit but not implicit memory.
    • Explicit memory involves conscious recall of experiences (e.g., graduation, mother’s birthday party).
    • Implicit memory underlies behaviors based on experiences that cannot be consciously recalled (e.g., playing basketball, writing a check).
  • Distinguishing other causes of memory loss from dissociation:
    • Dementia: Memory fails slowly over time, is not linked to stress, and is accompanied by other cognitive deficits, including the inability to learn new information.
    • Memory loss after a brain injury and substance abuse.

Depersonalization/Derealization Disorder

  • The perception of self is altered, triggered by stress or traumatic event, with no disturbance in memory.

  • No psychosis or loss of memory.

  • Often comorbid with anxiety and depression, with typical onset in adolescence and a chronic course.

  • Symptoms are not explained by substances, another dissociative disorder, another psychological disorder, or a medical condition.

  • Experiences of depersonalization or detachment from one’s mental processes as if one is in a dream

    • Unusual sensory experiences with limbs feel deformed or enlarged and voice sounds different or distant
    • Feelings of detachment or disconnection: Watching self from outside; Floating above one’s body

  • Or experiences of derealization with world has become unreal

    • World appears strange, peculiar, foreign, dream-like
    • Objects appear at times strangely diminished in size, at times flat
    • Incapable of experiencing emotions. Feeling as if they were dead, lifeless, mere automatons Experiences of unreality of surroundings

  • Symptoms are persistent or recurrent

  • Reality testing remains intact

  • Symptoms are not explained by substances, another dissociative disorder

Dissociative Amnesia

  • Inability to remember important personal information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness
  • The amnesia is not explained by substances, or by other medical or psychological conditions, so need to rule out other possible causes of memory loss
  • Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently purposeful wandering and usually remits spontaneously

Dissociative Amn