Clinical Psych

Specific Phobia

Criteria

Additional Notes

1. Fear or Anxiety about a specific object or situation

Example: flying, height, animals, needle, blood

Note; children – fear or anxiety may be expressed by crying, tantrums, freezing, or clinging

1. Phobic object or situation almost always provokes immediate fear or anxiety

• Fear or anxiety may take form of a full or limited symptoms of a panic attack
• Fear or anxiety is triggered almost every time encountering the phobic stimulus

1. Phobic object or situation is actively avoided or endured with intense fear or anxiety

Example: refuses to go out in the garden - phobia of bugs

1. Fear or anxiety is disproportionate to the actual danger posed by the specific object or situation and to the sociocultural context

Example: feeling immense anxiety to drive or to go to a cultural event

1. fear, anxiety, or avoidance is persistent — (typically) lasting for 6 months or more

Subtype – based on phobic stimulus

• Animal:
• Spider
• Insects
• Dogs
• Natural environment
• Heights
• Storms
• Water
• Blood-injection-injury
• Needles
• Invasive medical procedure
• Situation
• Airplanes (flying)
• Elevators
• Enclosed spaces (claustrophobia)
• Other
• Children: situations that may lead to vomiting or choking

Example: loud sounds or costumed characters (clowns, mimes)

Social Anxiety Disorder

Criteria

Additional Notes

1. Fear or anxiety about one or more social situations — individual is exposed to possible scrutiny by others (judgment)

Example:

• Social interaction: conversation, meeting unfamiliar people
• Being observed: eating or drinking
• Performing: giving a speech, stage fright

Notes: children – anxiety must occur in peer settings and not just during interactions with adults

1. Fears acting in a way or displaying anxiety symptoms that will be judged negatively.

Example: humiliation, embarrassment, rejection, offensive to others

1. Social situation almost always provokes fear or anxiety

Notes: children – fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations

1. Social situations are avoided or endures with intense fear or anxiety
2. Fear or anxiety is disproportionate to the actual threat posed by the social situation and to the sociocultural context
3. Fear, anxiety, or avoidance is persistent — lasting for 6 months or more

Panic Disorder

Criteria

Additional Notes

1. Recurrent unexpected panic attacks
2. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

• Persistent concern or worry about additional panic attacks or their consequences

Example: losing control, having a heart attacks, ‘going crazy’

• Significant maladaptive change in behaviour related to the attacks

Example: behaviours designed to avoid having panic attacks: avoidance of exercise or unfamiliar situations

Panic attacks: abrupt surge of intense fear or intense discomfort that reaches a peak within minutes – can occur from a calm state or an anxious state

• Physiological and psychological symptoms - 4 or more:
• palpitations, pounding heart, accelerated heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath or something
• feelings of choking
• chest pain or discomfort
• nausea or abdominal distress
• dizziness, unsteadiness, light-headedness or fainting
• chills or heat sensations
• Paresthesias: numbness or tingling sensation
• derealisation: feelings of unreality
• depersonalisation: detached from oneself
• fear of losing control or ‘going crazy’
• fear of dying

Agoraphobia

1. Fear or anxiety about two (or more) of the following five situations:

• Using public transportation: cars, buses, trains, ships, planes
• Open spaces: parking lots, markets, bridges
• Enclosed spaces: shops, lifts, theatres, cinemas
• Queueing or being in a crowd
• Being outside of the home alone

1. Worry it might be hard to escape or get help if start develop panic symptoms/embarassing symptoms → avoidance of situations

Example: fear of falling on the elderly, fear of peeing in public

1. Agoraphobic situations almost always provoke fear or anxiety
2. Agoraphobic situations:

• actively avoided
• require the presence of a companion
• endured with intense fear of anxiety

1. Fear or anxiety is disproportionate to actual danger posed by the situations and to the sociocultural context
2. fear, anxiety, or avoidance is persistent, typically lasting 6 months or more
3. If another medical condition is present — fear, anxiety, or avoidance is clearly excessive

• Agoraphobia os diagnosed irrespective of the presence of panic attacks
• If presentation criteria both meet panic disorder and agoraphobia = both diagnoses should be assigned

Generalised Anxiety Disorder

1. Excessive anxiety and worry (apprehensive expectation), occurring most days for at least 6 months — in regards to a number of events

Example: work or school performance

1. Difficulty in controlling the worry

Anxiety and worry are associated with 3 or more of the following:

1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank
4. Irritability.
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restlessness, unsatisfying sleep

Noted: children – only 1/6 is required for children

Disorder

Important clinical features

Specific phobia

Fear and avoidance of a specific object or situation.

Social Anxiety disorder

Fear about social situations in which the individual is exposed to possible scrutiny by others.

Panic attacks

Recurrent unexpected panic attacks and worry about panic attacks.

Agoraphobia

Fear of the situation because they worry it might be hard to escape or get help if something happens to them.

Generalised anxiety disorder

Excessive anxiety and worry with difficulty to control the worry.

Statistics (WHO)

• ~4% of the global population currently experience an anxiety disorder
• 2019: 301 million people in the world had an anxiety disorder → most common mental disorder

Gender Difference

• Women > men: 1.66 times more likely to be affected by anxiety disorders than men

Onset (symptoms)

During childhood or adolescece

Genetic Risk Factors

• Family & Twin studies: heritability of 30-67%
• Candidate genes: genes related to
• monoaminergic neurotransmitter systems
• hypothalamic-pituitary-adrenal (HPA) axis function.
• 5-HT1A, 5-HTT, MAO-A, COMT, CCK-B, ADORA2A, CRHR1, FKBP5, ACE, RGS2/7 and NPSR1

Neurobiological

Brain Structures

• Amygdala: Dysregulation – hyperactivity or abnormal structural changes
• Prefrontal Cortex: alterations in the volume, density, or connectivity of PFC
• Hypothalamic-Pituitary-Adrenal (HPA) Axis: dysregulation → heightened cortisol levels or abnormal response patterns

Neurotransmitter Imbalance

• Serotonin: involved in regulating mood and anxiety.
• dysfunction — anxiety disorders
• Gamma-Aminobutyric Acid (GABA): primary inhibitory neurotransmitter in the brain.
• crucial role in regulating anxiety and stress response
• reduced GABA activity or GABA receptor dysfunction → development anxiety disorders
• Other: Imbalances of other neurotransmitters like Glutamate, norepinephrine and dopamine.

Personality Risk Factors

influences an individual’s susceptibility to developing anxiety disorders

High Neuroticism

• tendencies towards negative emotions — anxiety, depression, vulnerability to stress
• more likely to experience chronic worry, rumination and emotional instability → more susceptible to developing anxiety disorders

*Widiger, 2009: trait disposition to experience negative effect such as anxiety

Trait Anxiety

• refers to stable individual differences in the tendency to experience anxiety across various situations and contexts
• High trait anxiety: more likely to
• interpret ambiguous situations → threatening → heightened vigilance, arousal, and susceptibility to anxiety disorder

Low self-esteem

• negative self-evaluations and feelings of inadequacy or worthlessness
• associated with increased vulnerability to anxiety disorders
• More prone to:
• experiencing social anxiety
• performance anxiety
• excessive worry about rejection or disapproval from others

Developmental Risk Factors

Early Life Stress and Adversity

• exposure → significantly increase the risk of developing anxiety disorders

Example: trauma, abuse, neglect, parental separation, or family conflict

• Adverse childhood experience can:
• disrupts normal development processes
• contribute to dysregulation of stress response systems
• shape maladaptive coping strategies that persists into adulthood

Parenting styles and Family environment

• linked to the development of anxiety disorders in children.

Example: overprotection, excessive control, or lack of warmth and responsiveness

• Overly anxious/overprotective parenting style may prevent development of effective coping skills and independence → increasing vulnerability to anxiety-related symptoms

Theory

Elaboration

Classical Conditioning

Learned via paired association

Example: an individual may develop a fear of spiders after experiencing a traumatic event involving spiders

• Little Albert experiment

Operant Conditioning

anxiety disorders: avoidance behaviours → reducing or avoiding anxiety-provoking stimuli or situation

• engaging in avoidance behaviour + successfully avoid the feared stimulus → relief from anxiety
• relief → negative reinforcement → increasing likelihood of repeating avoidance behaviour

Social Learning Theory

learned to be anxious through observing other people who had anxiety

Example: observing anxious mother

• mother has social anxiety → child vies social situations — dangerous or importance of external approval
• child → avoids objects/situations feared by the mother (e.g., arachnophobia)

*Burnstein & Ginsburg (2010): parental modelling significantly increased children’s anxiety compared to control condition

Catastrophising

Magnifying the likelihood or severity of potential threats or negative outcomes.

Selective Attention

Focusing disproportionately on threatening or anxiety-provoking stimuli while ignoring neutral or positive information.

Overgeneralisation

Drawing sweeping conclusions about oneself, others, or the world based on isolated negative experiences

Selective Memory

Recalling past experiences in a way that reinforces negative beliefs or expectations.

Black-and-white Thinking

Viewing situations in extreme terms (e.g., all-or-nothing thinking), leading to rigid and dichotomous perceptions.

Medication

characteristics

SSRIS & SNRIS

• increases the levels of serotonin and/or norepinephrine in the brain.
• Helps regulate mood and reduce anxiety symptoms.

Benzodiazepines

• Enhances GABA, has calming, sedative effects.
• Highly addictive and can lead to abuse.

Beta-Blockers:

• block the effects of adrenaline
• reducing physical symptoms – rapid heart rate, trembling, and sweating.

Buspirone

• balance the levels of dopamine and serotonin.
• Regulates mood.

Behaviour Therapy

• widely used and highly effective approach for treating anxiety disorders
• based on principles of learning theory:
• Focuses on identifying and modifying maladaptive behaviours that contribute to anxiety.
• intervention: principles of extinction or reinforcement

Exposure Therapy

• cornerstone of behaviour therapy for anxiety disorders.
• used for specific phobias, social anxiety disorder, and panic disorders
• Conducted in vivo or imaginal — depending on the nature of the fear

GOAL: gradually expose individuals to feared object or situations in a controlled and systematic manner.

• allows them to confront their fears and learn that the feared outcomes are unlikely to occur
• experience habituation: anxiety decreases over time → desensitised to fear stimuli

Cognitive Behavioural Therapy

• most widely used and empirically supported treatments for anxiety disorders
• Premise: maladaptive thoughts, beliefs and behaviours contribute to the development and maintenance of anxiety

AIM: helps individuals identify and change patterns → reduce anxiety and improve functioning

Psychoeducation

First step in CBT – 2 or 3 sessions

• Therapist: provides information about anxiety disorders — causes, symptoms, and maintenance factors
• helps individuals understand the nature and increases their motivation to engage in treatment

Cognitive Restructuring

• involves identifying and challenging irrational or distorted thought and beliefs
• learn to recognise negative thinking patterns — catastrophising, overgeneralisation, and all-or-nothing thinking.
• replace them with more realistic and balanced thoughts — changing interpretation of situations → reduce anxiety and improve coping skills

Exposure Therapy

Core component of CBT

• allows them to learn that their feared outcomes are unlikely to occur
• through repeated exposure → habituation

Relaxation Technique

Example: deep breathing, progressive muscle relaxation, and mindfulness meditation → incorporated into CBT

• helps individuals reduce physiological arousal and manage anxiety symptoms
• can be used in conjunction with exposure therapy to facilitate relaxation during exposure sessions

Homework Assignment and Between-Session Practice:

• homework assignment – practice skills learned in therapy
• helps reinforce learning and allows generalisation of skills to real-life situations

Skills Training

people with anxiety disorders → skills deficit

• Can involve roleplaying, modelling or group based skills training.
• Start by identifying the skills that the patient lacks that is contributing to the disorder.

Group Therapy
Structured form of treatment

• Conducted under guidance of a trained therapist
• involves:
• sharing experiences
• learning coping skills
• provide mutual support

Normalisation

• group therapy: helps normalise anxiety-related experiences and symptoms
• demonstrates anxiety = common and understandable response to stressors
• individuals learn:
• anxiety is a normal part of human experience
• possible to manage and overcome anxiety-related difficulties with right support skills

Social Support

• group therapy: supportive and validating environment – can connect with others who understand their struggles.
• involves:
• haring experiences,
• offering encouragement
• providing feedback
• valuable social support and validation.

– reduce feelings of loneliness and increase feelings of belongingness.

Mindfulness-based Intervention

have gained attention and empirical support for their effectiveness in alleviating symptoms of anxiety disorders.

• involve paying attention to the present moment without judgement
• Uses CBT elements

Intervention:

• Mindfulness-Based Stress Reduction
• Mindfulness-Based Cognitive Therapy
• Acceptance and Commitment Therapy
• Dialectical Behavior Therapy

Major Depressive Disorder

Criteria

Notes

1. 4 or more of the following symptoms have been present during the same 2-week period + represent a change from previous functioning
2. Significant weight loss: change or more than 5% of body weight in a month
3. Insomnia or hypersomnia: nearly every day
4. Feeling of worthlessness or excessive/inappropriate guilt: nearly every day

• Cognition
• Suicide ideation

1. fatigue/loss of energy: nearly every day
2. Diminished ability to think/concentrate/indecisiveness: nearly every day

• Cognition
• Affects performance

1. Recurrent thought of death, suicidal ideation without a specific plan/suicide attempt/specific plan for commiting suicide
2. Psychomotor agitation/retardation nearly every day
3. symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The episode is not attributable to the physiological effects of a substance or another medical condition.

Symptoms:

• Depressed Mood
• Nearly every day: indicated by either subjected report or observations made by others
• Loss of Interest
• Nearly every day – diminished interest or pleasure in all/almost all activities most of the day: indicated by either subjective account or observation

Severity

Based on number of symptoms and dysfunction

• Mild: does not experience much dysfunction
• Moderate: considerable difficulty but is able to function in at least some areas.
• Severe: unable to function in personal, family, social, educational, occupational, or other important domains, except to a very limited degree.

Rating Scale:

• Beck Depression Inventory
• Cut off scores

Persistent Depressive Disorder/Dysthymic Disorder

Criteria

Notes

1. Depressed Mood – most days for at least 2 years

• Indication: subjective account or observation by others
• Duration: 2 years (difference with MDD) – never been without symptoms for more than 2 months at a time

1. Presence of 2 or more of the following:

• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

Premenstrual Dysphoric Disorder

Criteria

Notes

1. Majority of menstrual cycle

• depressive symptoms must be present in the final week before the onset of menses
• start to improve within a few days after the onset of menses
• become minimal or absent in the week post menses.

1. 1 or more of the following:

• Marked affective lability: mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection.
• Marked irritability or anger or increased interpersonal conflicts.
• Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension, and/or feelings of being keyed up or on edge.
• Decreased interest in usual activities: work, school, friends, hobbies
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating; or specific food cravings
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms: breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.

Bipolar Disorder

Criteria

Notes

Manic Episodes: a distinct period of abnormally and persistently elevated, expansive, or irritable mood – lasting at least 1 week

• 3 or more of the following are present:

1. Inflated self-esteem or grandiosity
2. Decreases need for sleep (feels rested after only 3 hours of)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility: i.e., attention too easily drawn to unimportant or irrelevant external stimuli
6. Increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal- directed activity)
7. Excessive involvement in activities — high potential for bad consequences: e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments

extreme highs (”manic” episodes) — extreme lows (depressive episodes)

Mood Disturbance: sufficiently severe

• to cause marked impairment in social occupational functioning
• to necessitate hospitalisation to prevent harm to self or others
• presence of psychotic features

Hypomania: similar manic symptoms but milder – 4 consecutive days

• Episode: not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalisation

Types of Bipolar Disorder

• Type 1: Criteria have been met for at least one manic episode.
• Type 2: Criteria have been met for at least one hypomanic episode + never been a manic episode.

Cyclothymic Disorder

Criteria

Notes

1. For at least 2 years there have been:

• Numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode

E.g: euphoria, irritability, or expansiveness, psychomotor activation, etc.

1. Symptoms have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
2. Criteria for a major depressive, manic, or hypomanic episode have never been met.

Statistics (WHO)

• 3.8% of the population experience depression,
• 5% of adults (4% among men and 6% among women), 5.7% of adults older than 60 years.
• 7000, 000+ deaths due to suicide every year
• Suicide: 4th leading cause of death — 15 - 29 year olds

Gender Difference

• Women > men: twice as common

Justification: gender difference in coping with stressors

• women: internalise problems → affecting self-esteem, suicide ideation
• men: cope with external behaviours → substance abuse

Epidemiological studies

*(Rowland and Marwaha, 2018)

• lifetime prevalence of around 1% for bipolar type 1 in the general population

Onset

• Mean age: early twenties

Gender difference

• Equal distribution

*(Rowland and Marwaha, 2018)

• appears to have a roughly equal distribution across sex and ethnicity.

*some studies

• males > females: higher prevalence of manic ep + bipolar type 1
• females > males: higher prevalence of bipolar type 2

Genetic Risk Factors

• Twin studies
• 1/3 risk of MDD in adults are due to genetic differences between individuals
• concordance rate for depression: 60% (MZ) & 30% (DZ)
• Risk increases ~2.5-3 times for those who have a first-degree relative with depression
• Genes: Serotonin system (5-TH) genes
• Neurotransmitter serotonin effects: emotions, sleep, circadian rhythm, appetite, aggression, sexual behaviour, etc.

Biological Causes

Neurotransmitter Imbalance

depression → insufficient chemicals — serotonin, norepinephrine, or dopamine

• Serotonin is the neurotransmitter most commonly associated with depression.

Endocrine Dysfunction

associated with alteration in level and activity of various endocrine glands — adrenal and thyroid gland

• dysregulation of the body’s response to stress
• elevated cortisol and related neurohormones
• Hypercortilosm → damages stress system — death of cells (hippocampus) + generalised effects on the circuits underlying emotion regulation

Environmental stressor

depression → more stress + dysfunction → worsen life situation and depression

• Acute life events
• Chronic stress
• Childhood exposure to adversity: Bereavement, divorce, illness, unemployment, money worries, traumatic experiences, etc.

History of childhood trauma: (have)

• lower rates of remission and recovery
• longer depression episodes
• more chronic disease discourse
• earlier onset of symptoms

Psychological Risk Factors

• Thought, inference, attitudes, and interpretation
• direct relationship between amount and severity of someone’s negative thoughts & severity of their depressive symptoms
• increased negative thoughts = increased depressed

CBT

depressive people think differently than non-depressed

Example: depressed ppl tend to view themselves, environment and the future → negative, pessimistic light

Result: misinterpretation of facts in a negative ways and blame ways themselves for any misfortune that occurs

Genetic Risk Factors

• Runs in families – higher frequency of occurrence → relatives of bipolar probands > unipolar probands
• The concordance rate of monozygotic twins lies between 43% and 75%.

*(Angst, 1996): number incidences that have been reported among first-degree relatives are approximately 12-22%

Biological Risk

Neurotransmitter Imbalance

associated with chemical imbalances in the brain

• (suspected) dopamine, norepinephrine, serotonin, GABA, glutamate, and acetylcholine.
• Mania → due to excess neurotransmitters – fluctuation between excess and deficiency

Endocrine Imbalance: regulates various bodily functions through the release of hormones

endocrine and nervous system are linked by the hypothalamus

• Via glands: thyroid, adrenal, and reproductive glands
• Disruption → affect mood and behaviour
• evidence: certain endocrine factors may contribute to development of exacerbation of bipolar disorder

Neuroanatomy

Neuroimaging studies: bipolar associated with structural brain abnormalities

• predominantly observed in PFC and Temporal Cortex
• Cingulate Gyrus
• Subcortical regions
• enlarged ventricles
• subcortical abnormalities → amygdala, hippocampus, and thalamus

Circadian Rhythm

depressive + manic phase → significant alteration in circadian rhythm in bipolar patients

• shortening of circadian period in bipolar patients
• sleep deprivation → provocation of hypomanic and manic phases — 2-25% in bipolar patients

Psychosocial Risk Factors

Recent stressful life events

• recent marriage, divorce, disability or unemployment
• period of high stress — death of loved on or other traumatic

Substance abuse

• frequently comorbid with substance abuse — cannabis, opioids, cocaine, sedatives, and alcohol

Cognitive Models of mania

• mood → positive or more irritable → increase self-esteem → increase activities
• Cognitive errors → mood

Example: overgeneralization, global and stable attributions as a result of anticipated or current positive experiences

Medication

Characteristics/Specific Medication

Antidepressants

stabilise neurotransmitters

SSRIS

Sertraline, fluvoxamine, fluoxetine, citalopram, escitalopram, and paroxetine.

SNRI

venlafaxine, desvenlafaxine, duloxetine, milnacipran, and levomilnacipran

Type of Therapy

Notes

CBT

most extensively studies therapy for depression

• Improves dysfunctional cognitions and attitudes
• identify, challenge and modify cognitive distortions

Interpersonal psychotherapy

recognises interpersonal problems and role transitions

Mindfulness based Intervention

Mindfulness-based cognitive therapy (MBCT), Acceptance and commitment therapy (ACT)

• includes CBT techniques and mindfulness
• beneficial in improving mood symptoms and in curbing relapse

Dialectic Behavioural Therapy

form of CBT

• involves mindfulness, distress tolerance and emotional regulation

Supportive Psychotherapy

• just provide supportive or a listening ear
• patients would come to the solution themselves

Lifestyle aspect

Notes

Smoking

• Reduced smoking is related to increased optimistic mood and quality of life
• decreases likelihood of getting anxious and depressed compared with regular smoking

Alcohol consumption

• Alcohol: a depressant and alters balance of chemicals — serotonin and dopamine

Diet and mental health

healthy diet → decreased risk of mood disorders

• gut microbiome → regulating mood and mental health
• high fibre, fruits, vegetables, and fermented food supports a healthy gut microbiome
• Nutrients deficiency → increased risk of depression
• omega-3 fatty acids, vitamins B6 and B12, folate, and magnesium → mental health

Exercise and Yoga

• Increased release of β-endorphins
• related to positive moods and overall enhances sense of well-being
• protective against the development of mood disorders
• decreased physical activity → greater risk of developing depressive disorder

Type of Therapy

Notes

CBT

GOAL:

• improving compliance
• Recognition of early symptoms of relapse
• adherence — “make peace” with medication
• measurement: attitudes and beliefs about medication

Activities:

• self-monitoring of moods and cognitions
• addressing dysfunctional beliefs
• implementing healthier thinking patterns.

Interpersonal psychotherapy

• focused on enhancing routine and structure of day-to-day events

disruption is social rhythms (interpersonal conflicts) → destabilised bipolar illness + timing of daily activities

AIM: stabilise and build predictable routine

• individualised, involves education about bipolar disorder, and tracking and stabilising daily events
• Medication adherence: education about bipolar disorder.
• routinization of daily life also may include taking medications at structured times of the day
• social rhythm component:
• monitoring daily routines (wake up time)
• targeting stability in the timing of routines

Family-focused therapy

developed out of research

• interpersonal conflict + hostility → disruptors (stress)

GOALS:

• Enhance communication skills among family members
• Increase supportive behaviours
• Increase problem-solving behaviours

Obsessive Compulsive Disorder

characterised by the presence of persistent obsessions or compulsions, or most commonly both

Criteria + Symptoms

Notes

• Obsessions or compulsions are time-consuming
• cause clinically significant distress/impairment in social, occupational, or other important areas of functioning
• symptoms are not attributable to the physiological effects of a substance or other medical conditions
• May avoid certain people, places, or situations that cause them distress and trigger obsessions and/or compulsions – confines people to their homes for fear they may not be able to perform their rituals or manage their symptoms on other ways
• Avoidance may further impair ability to function in life

Subtypes:

Content of obsessions & compulsions are typically thematically related

(OCD symptom dimensions)

• Cleaning: Contamination + cleaning compulsion
• Doubts & checking: Checking locks, lights, gas after getting doubts about them
• Symmetry: symmetry obsessions and repeating, ordering, and counting compulsion
• Forbidden or Taboo thought: aggressive, sexual, and religious obsessions and related compulsions
• Harm: fear of harm to self or others and related checking compulsion

Prevalence

• OCD affects ~1.2% of the world’s population including children and adults, regardless of gender, social or cultural background
• Malaysia: affects ~1 - 2 % of nation’s population

Body Dysmorphic Disorder

persistent preoccupation with one or more perceived defects/flaws in appearance – either unnoticeable/only slightly noticeable to others

Engaged Behaviours

Notes

response to the preoccupation — individuals engage:

• Repeated examination of appearance/severity of perceived defect/flaw
• excessive attempts to camouflage or alter the perceived defect
• marked avoidance of social situations/triggers that increase distress or impairment in personal, family, social, educational, occupational or other important areas of functioning

• Experience self-consciousness, often with ideas or reference

i.e., conviction that people are taking notice, judging, or talking about the perceived defect or flaw

• Ashamed of their appearance and their excessive focus on how they look → may be reluctant to reveal their concerns to others
• Respond poorly to such cosmetic treatment and sometimes become worse

Hoarding Disorder

• accumulation of possessions – to excessive acquisition of or difficulty discarding possessions, regardless of their actual value
• accumulation = living spaces becoming cluttered to the point that their use or safety is compromised

– symptoms result in significant distress or impairment in important areas of functioning

Engaged Behaviours

Notes

Excessive Acquisition: items that are not needed or for which there is no available space

• ~ 80-90% of individuals with hoarding disorder display of excessive acquisition
• most frequent form: excessive buying, followed by acquisition of free items (leaflets, items discarded by others)

Difficulty in Discardine

• perceived need to save items and distress associated with discarding them

Trichotillomania Disorder

recurrent pulling of one’s hair → significant hair loss, unsuccessful attempts to decrease or stop behaviour

– symptoms results in significant distress or significant impairment in important areas of functioning

Engaged Behaviours

Notes

Hair pulling

• May occur from any region in the body: (most common) scalp, eyebrows, and, eyelids
• Accompanied by a range of behaviours/rituals
• searching for a particular kind of hair to pull (e.g., hairs with a specific texture or colour)
• may try to pull out hair in a specific way (e.g., so that the root comes out intact)
• visually examine or tactilely manipulate the hair after it has been pulled
• rolling the hair between fingers
• pulling the strand between the teeth
• biting the hair into pieces
• Preceded or accompanied by various emotional states
• triggered by feelings of anxiety or boredom
• preceded by an increasing sense of tension — immediately before pulling out the hair or when attempting to resist the urge to pull
• lead to gratification, pleasure, or a sense of relied when the hair is pulled out

• individuals experience an ‘itch-like’ or tingling sensation in the scalp that is alleviated by the act of pulling hair
• pain does not usually accompany hair pulling
• some individuals may pull hairs from pets, dolls, and other fibrous materials (e.g., sweaters or carpets) or other people

Excoriation Disorder

• recurrent picking of one’s own skin leading to skin lesions
• unsuccessful attempts to decrease or stop the behaviours

– symptoms result in significant distress or impairment in important areas of functioning

Engaged Behaviours

Notes

Skin picking

• most commonly picked sites: face, arms and hands, but many individuals pick from multiple body regions
• pain is not routinely reported to accompany skin picking
• behaviours/rituals:
• search for a particular kind of scab to pull
• examine, play with, or swallow the skin after it has been pulled
• Preceded by various emotional states:
• triggered by feelings of anxiety or boredom
• increasing sense of tension — immediately before picking the skin or when attempting to resist the urge to pick
• lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked

Genetic Predisposition

• Family & Twin studies
• OCD → familial disease

*Krebs and Heyman, 2015: 45 — 65% of the variance of OCD is attributable to genetic factors

*Carey and Gottesman (1981): 87% concordance rate of obsessive symptoms and features between MZ twins (47% in DZ twins) from the Maudsley Twin Register.

• Mice & human experiments:
• mutated NMDA → increase in OCD-like behaviour

*Sheshachala and Narayanaswamy, 2019: mutations in the NMDA subunit “NR2” have been linked to fears of contamination and compulsive cleaning

*Hanna et al. (2007): genome-wide linkage scan

• suggestive evidence for linkage on chromosome 10p15
• association with 3 SNPs in a gene in this linkage region ADAR3

Biological Risk Factors

Brain region

• fMRI → model for pathophysiology of OCD
• involves hyperactivity in certain subcortical and cortical regions
• Excessive activity in frontal regions of the brain — OFC + Anterior Cingulate Cortex
• explain intrusive thought and high levels of anxiety, respectively in OCD patients

Neurotransmitter

• Problem with serotonin → OCD came from observation about a drug called clomipramine
• affects both serotonin and another neurotransmitter called norepinephrine, and helped with symptoms.
• drugs that only affect norepinephrine didn’t help as much
• unique efficacy of clomipramine and the SSRIs remains the strongest support for this hypothesis
• individuals with OCD — disrupted balance of chemicals called glutamate and GABA in certain parts of their brain — anterior cingulate cortex + supplementary motor area (Frontal lobe)

*(Biria et al., 2023): higher glutamate levels in the supplementary motor area, is associated with severity of OCD symptoms

Psychosocial theories

Brain region

• fear acquired and generalised through classical conditioning and maintained through avoidance and escape behaviours (negatively reinforced)
• key to behavioural model → functional connection between obsessions and compulsions:
• obsessions provoke distress (anxiety, disgust, and discomfort)
• subsequently reduced by compulsion
• Compulsive behaviours typically performed:
• may lead to short-term relief
• results in behavioural tendency for compulsions to increase over time
• engaging in compulsions prevents the habituation of the brain distress associated with obsessions

Cognitive Behavioural Model

• Interpret content of intrusion as:
• meaning something bad about them and/or that something bad will happen
• Believing that they are personally responsible for preventing harm to themselves and/or other
• Cognitive Distortions
• catastrophic thinking
• all-or-nothing thinking
• overestimation of threat

Paul Salkovskis’ Cognitive Model of OCD

→ everyone gets intrusive thought occasionally

• People with OCD: mistakenly believe
• just thinking about something = actually doing it (thought-action fusion)
• not stopping harm = causing harm
• external factors don’t reduce their responsibility for harm
• not performing rituals after thinking about harm = intending harm
• should have complete control over their thought

Environmental Risk Factors

Environmental factors that can trigger an onset/exacerbate OCD symptoms:

• life events
• trauma
• stress
• maladaptive parenting
• pregnancy and postpartum
• other mental disorders: depression, anxiety, or a tic disorder

Medication

• 5 compounds have FDA approval for treatment of OCD:
• clomipramine (a tricyclic antidepressant)
• four SSRIs (fluoxetine, fluvoxamine, paroxetine, and sertraline).
• Studies: Efficiency of SSRIs for OCD
• no response to initial SSRIS treatment (less than 25% reduction in Y-BOCS score) or exhibits partial response → may benefit from augmentation of the SSRI + antipsychotic medication
• Antipsychotic drugs that have evidence for their use include haloperidol, risperidone, and aripiprazole.

Medical

Radio/Neurosurgical Procedures

extremely severe cases — not responding to multiple therapeutic interventions, gamma knife radiosurgery and deep brain stimulation have been used

• Gamma Knife Radiosurgery: used in OCD prior to deep brain stimulation
• not FDA-approved and consists of anterior capsulotomy, limbic leucotomy, and cingulotomy.
• Deep brain stimulation: has received a “Humanitarian Device Exemption” from the FDA for severe, intractable OCD.
• relatively small number of patients have had the procedure, and the targets and programming paradigms are not standardized

Transcranial Magnetic Stimulation

– has mixed data — additional questions of efficacy + which sites to target

• (some) suggest that targeting the pre-supplementary motor area with low-frequency (1 Hz) TMS can be useful.
• Targeting the anterior cingulate cortex with high-frequency (20 Hz) stimulation with deep TMS may be effective in resistant OCD
• But further controlled studies are required to establish the efficacy of this approach.

Behaviour Therapy

Exposure and Response Therapy

effectiveness of ERP → clearly demonstrated in OCD

→ first step:

• providing psychoeducation about the illness and ERP process
• parents are encouraged to complete 24-hour obsession and compulsion symptom log after the Y-BOCS is administered
• data will be used in the construction of a hierarchy of symptom triggers
• symptom triggers — rated on a scale of 0 - 100 (10-point intervals)

Example: a patient with contamination symptoms might consider touching a House doorknob less anxiety-provoking (rated a lower number) than touching a public toilet seat.

• patients: work on doing “exposures” by moving up their hierarchies

Example: holding on to a “contaminated” doorknob – encouraged to continue holding onto the doorknob until his or her anxiety decreases substantially.

Cognitive Behaviour Therapy

Cognitive Behavioural Therapy

First line of treatment for OCD

CBT → extends behaviour therapy by adding the component of cognitive restructuring

• Sessions: consists of
• Therapeutic alliance
• Psychoeducation
• Cognitive restructuring
• Exposure and response prevention
• Relaxation techniques
• Homework assignments
• typically conducted over a structured course of sessions — 12 -20 sessions → vary depending on individual needs and severity of symptoms

Psychoeducation

• therapist educates individuals about OCD, its symptoms, and its underlying mechanisms.
• helps understand that their thoughts and behaviours are a result of the disorder rather than personal weakness or failure.
• helps the individual identify their specific obsessions (intrusive, unwanted thoughts, images, or urges) and compulsions (repetitive behaviours or mental acts performed in response to obsessions).

Cognitive Restructuring

• Ppl with OCD tend to hold maladaptive beliefs and cognitive distortions — catastrophic thinking or overestimation of threat
• a therapist helps them identify and challenge these distortions by examining the evidence for and against their beliefs.
• learn to replace irrational thoughts with more realistic ones
• normalise intrusive thoughts and urges

Exposure and Response Theory

• most important component of CBT along with belief
• involves gradually exposing the individual to situations that trigger their obsessions while preventing the usual compulsive response.
• over time — repeated exposure without engaging in compulsions → habituation → anxiety diminishes

Developing Coping Strategies

• manage anxiety and distress when facing obsessions without resorting to compulsions
• include relaxation techniques, mindfulness, stress management and cognitive restructuring

Family Inclusive Treat

• AIM:
• include the family members in the treatment
• improve the family functioning, facilitate behavioural therapy
• family members may be encouraged to participate in CBT — family accommodation of symptoms is associated with poorer treatment outcomes.

Habit Reversal Training

→ trichotillomania/excoriation disorder

GOAL: develops both an internal and external awareness of their behaviours so appropriate action may be taken.

Awareness Training: first component of HRT

• The therapist and client work together to uncover the warning signs that precede a habit.
• encouraged to monitor when, where, and under what circumstances they engage in hair pulling.
• include specific thoughts, emotions, and behaviours.
• Situations in which the habit typically occurs are explored.

Competing Response Training

• Therapist assists the individual in developing alternative behaviours that are physically incompatible with hair pulling
• behaviours: competing response

Example: individuals might clench their fists, squeeze a stress ball, or engage in activities that keep their hands occupied and away from their hair.

Relaxation Training

→ Tricotillomania tends to manifest most frequently when a person is under stress.

• various relaxation strategies are utilised to help minimise one’s stress levels.
• Mindfulness
• Meditation
• Deep breathing
• Visualisation
• Progressive muscle relaxation
• Exercise
• Reading
• Writing
• Listening to music
• self-care activities vary from person to person — treatment is highly individualised

Post-Traumatic Stress Disorder

Criteria

Prevalence

General Criteria

• duration of the disturbance is more than 1 month
• disturbance causes clinically significant distress or impairment in important areas of functioning
• disturbance is not attributable to substance or another medical condition

Specific Criteria

1. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

• directly experiencing the traumatic event
• Witnessing the event as it happens to other
• Learning the event occurred to a close family member/close friend
• Experiencing repeated or extreme exposure to aversive details of the traumatic events.

Example: first responders collecting human remains; police officers repeatedly exposed to details of child abuse.

1. After going through a traumatic event, people might experience intrusive symptoms, like:

• Repeated and involuntary distressing memories of the event.
• Distressing nightmares about the event.
• Dissociative reaction (flashbacks): Individual feels or acts as if the event is happening again.
• Feeling intense psychological distress when they encounter things that remind them of the event or resemble an aspect of the traumatic event.
• Having strong physiological reactions when they encounter things that remind them of the event.

1. After a traumatic event, the individual might try to avoid things that remind them of it, like:

• avoid thinking or talking about anything that reminds them of the event.
• avoid external reminders (people, places, conversations, activities, objects, situations) that bring back upsetting memories or feelings about the event.

1. Post, traumatic event, a person might have negative alterations in cognitions and mood associated with the traumatic event: (2)

• Persistent thoughts that distort the cause or consequences of the event, leading to self-blame or blaming others.
• Persistent negative emotional state: fear, horror, anger, guilt, or shame.
• Trouble remembering important parts of the event, often due to dissociative amnesia.
• Not due to other factors such as head injury, alcohol, or drugs.
• Strong and persistent negative beliefs about themselves, others or the world: “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”
• Losing interest in activities they used to enjoy.
• Feeling disconnected or estranged from others.
• Difficulty experiencing positive emotions: inability to experience happiness, satisfaction, or loving feelings.

1. After experiencing a traumatic event, a person might show marked alterations in arousal and reactivity associated with the traumatic events, like: (2)

• Irritable behaviour and angry outbursts (with little or no provocation): Expressed as verbal or physical aggression toward people or objects.
• Engaging in risky behaviours or actions that could harm themselves.
• Hypervigilance: Being overly alert or watchful, always on the lookout for danger
• Exaggerated startle response: Reacting strongly to sudden noises or surprises.
• Problems with concentration.
• Sleep disturbance: difficulty falling or staying asleep or restless sleep.

• can occur in all people of any ethnicity, nationality or culture, and at any age
• 1 year prevalence of PTSD → range from 1-6% in the general adult population samples across the world
• women > men: greater likelihood of exposure to events that carry the highest risk for development of PTSD.
• childhood sexual abuse
• sexual assault, and other forms of interpersonal violence.
• veterans > civilian: rates are higher — increases the risk of traumatic exposure (e.g., police, firefighters, emergency medical personnel).

Adjustment Disorder

excessive reactions to stress that involve negative thoughts, strong emotions and changes in behaviour

– symptoms: occur because the individual is having a hard time coping

Criteria

Prevalence

1. The person develops emotional or behavioural symptoms within 3 months of a stressful event
2. Symptoms or behaviours are clinically significant and can be seen in one or both of these ways:
3. Marked distress that is out of proportion to the severity or intensity of the stressors:

• Depressed mood: Low mood, tearfulness, or feelings of hopelessness.
• Anxiety: Nervousness, worry, jitteriness, or separation anxiety.
• Disturbance of conduct.

1. Significant impairment in social, occupational, or other important areas of functioning.
2. Emotional or behavioural issues caused by stress don't match the signs of another mental disorder.
3. Symptoms aren't what is expected from normal or prolonged grief after a loss.
4. After the stressful event is over, the symptoms don't last more than another 6 months.

• Common disorder
• Individuals with outpatient mental health treatment (USA) with diagnosis – 5-20%
• Women > men
• No studies available in Malaysia

Acute Stress Disorder

short-term mental health condition that can occur within the first month of experiencing a traumatic events

– symptoms: like PTSD, shorter criteria duration

Criteria

Prevalence

1. Exposure to actual or threatened death, serious injury, or sexual violence.
2. Clinical symptoms: 9/14
3. Intrusion Symptoms:

• distressing memories
• Nightmares
• dissociative reactions
• psychological distress or marked physiological reactions to reminders of traumatic events.

1. Negative Mood : inability to experience positive emotions
2. Dissociative Symptoms
3. Avoidance Symptoms
4. Arousal Symptoms
5. Duration of the disturbance is 3 days to 1 month after trauma exposure.
6. The disturbance causes clinically significant distress or impairment in important areas of functioning.
7. The disturbance is not attributable to substance or another medical condition.

Note: If the symptoms persist for more than 1 month and meet criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Genetic Vulnerabilities

• account for up to 30-40% of the heritability of PTSD
• PTSD: polygenic disorder — multiple genes are involved, each with a small effect
• challenging to pinpoint specific genes responsible for the condition.

Genes:

• Neurotransmitters: implicated in PTSD
• Serotonin
• Dopamine
• Norepinephrine
• Regulation of stress hormones: cortisol

Neurobiological Risk Factors

– involves how the brain’s structure and function change after a traumatic event

Brain Regions

• Amygdala: fear circuitry
• PTSD affects the part of the brain responsible for fear.
• Overactivation of amygdala → heightened fear even when not in danger
• Hippocampus: helps with memory emotion regulation, can be affected in PTSD.
• Hippocampus in people with PTSD is smaller, contributing to memory and emotional difficulties.
• Prefrontal Cortex: involved in decision-making and emotional regulation
• PTSD: reduced activity → difficulties in controlling emotions and responding to stress
• HPA Axis(hypothalamic-pituitary-adrenal): controls the body's response to stress
• Dysfunction – observed in individuals with PTSD.

Neurotransmitter

• Norepinephrine: involved in fight or flight response to stress
• PTSD: dysregulation of norepinephrine, leading to heightened arousal, hypervigilance, and increased reactivity to triggers.
• Corticotropin-releasing Factor (CRF)
• hormone and neurotransmitter involved in the body’s stress response
• PTSD: over activity of CRF, contributing to heightened arousal and anxiety

Pre-Traumatic Risk Factor

Gender

• Females > males

Cognitive Vulnerability

• Low IQ
• History of head injury

Previous trauma

• Exposure to life stressors: childhood abuse or other adult life stressors
• Past history of trauma can have the devastating effects on the developing brain, resulting in a relatively decreased resilience towards new stressors.

Anxiety and Depression

*Manh et al., (2022): Anxiety and depression are risk factors for trauma and stress

*van der Vlegel et al. (2022): Anxiety and depression are risk factors for trauma and stress

Personality Traits

• Neuroticism: more sensitive to stressful events
• Extraversion: protective factor against PTSD

Post-Traumatic Risk Factors

Nature and Severity of Trauma

• Development of PTSD: associated factor
• Intensity and proximity of exposure to trauma
• Direct personal threats to life/witnessing death
• Intentional or assaultive injuries
• Traumas resulting in physical harm or injury
• Traumatic Brain Injury (especially mild cases) → PTSD development

Persistent Dissociation:

dissociation: a temporary detachment from surroundings or emotions during trauma — crucial risk factor for PTSD

Example:

• Feeling as if one is observing the traumatic event from a distance
• Experiencing a sense of unreality of detachment from the situation
• Having altered perception of time, space, or body sensations
• Feeling emotionally numb or disconnected

Psychophysiological Factors

• Elevated heart rate + acute pain – PTSD risk
• PTSD + pain: often co occur and exacerbate each other
• pain acting as a reminder of trauma and worsening PTSD symptoms

Social support

• Post-trauma social support serves as a protective factor against
• Financial stress and legal involvement due to trauma elevated PTSD risk
• Having supportive listeners who validate feelings reduces isolation and self-blame
• Social support combats loneliness and encourages seeking professional help
• It helps individuals stay engages in treatment and prevent avoidance behaviours that worsen symptoms

Cognitive Risk factors

refer to specific thought patterns or beliefs that can increase a person's vulnerability to experiencing or exacerbating symptoms following a traumatic event.

Negative Appraisal of the trauma:

• Self-blame: People who blame themselves for the trauma may be more likely to develop PTSD.
• Shame and Guilt: Feeling ashamed or guilty about their actions, thoughts, or emotions during the trauma can worsen PTSD symptoms.
• Negative Interpretation of symptoms: Misinterpretation of physiological response: Thinking normal body reactions (like a faster heart rate or sweating) mean danger can make anxiety worse.

*Brewin et al., 2000: risk factors

• Previous trauma
• Lack of social support
• Low intelligence
• Low SES
• Lack of education
• Race (minorities)
• Childhood abuse
• Life Stress

*Ozer et al., 2003:

• Perceived life threat

*DiGangi et al., 2013:

• Psychopathy
• Social ecological factor
• Cognitive Abilities
• Coping and response styles
• Personality factors

Pharmacotherapy

• SSRIs + SNRIs – first line medication
• Antidepressants alone are not usually effective in treating the insomnia and nightmares associated with PTSD.

– need for additional medication that improves sleep: Prazosin, trazodone, zopiclone, and atypical antipsychotics are options in treating insomnia and nightmares associated with PTSD.

• MDMA: poised to become a powerful tool in PTSD treatment — research ongoing

*Jennifer et al., (2032): MDMA induces significant attenuation in PTSD symptoms compared to placebo. - MDMA-assisted therapy is highly efficacious and safe for severe PTSD

Psychotherapy

Considered first-line treatment

Cognitive behavioural therapy: involves identifying and challenging negative through patterns and behaviour associated with the trauma

• Exposure therapy: helps individuals confront and process traumatic memories in a safe & controlled manner
• involves gradually facing and processing avoided or feared situations, people, or places related to the trauma — reduces avoidance behaviours

EMDR: involves recalling distressing memories while simultaneously engaging in bilateral stimulation, which can include eye movements, hand taps, or auditory tones.

• Process: helps reprocess traumatic memories → reduces emotional intensity and associated symptoms
• AIM:
• help individuals process traumatic experience
• develop coping mechanism
• integrate experiences into broader life narrative

Trauma-Focused Cognitive Processing Therapy

– type of psychotherapy — specifically for PTSD and related symptoms

– CBT techniques + trauma-focused interventions

• Psychoeducation: Educating the individual about PTSD symptoms, the impact of trauma on the brain, and coping strategies.
• Cognitive Restructuring: Identifying and challenging negative thoughts and beliefs related to the traumatic event.
• Exposure Therapy: Gradually confronting and processing traumatic memories and situations in a safe and controlled environment
• Stress management skills: Teaching relaxation techniques and coping skills to manage distressing emotions and reactions.

Management for Adjustment Disorder

• AD; reaction to an event
• Positive life events can also cause AD
• Risk factors: personality, past experiences, vulnerability, and coping skills

Medication

Very limited value in treatment of the disorder

CBT

Used to improve age-appropriate:

• Problem-solving skills
• Communication skills
• Impulse control
• Coping skills
• Anger management skills
• Stress management skills

Family therapy

Often focused on making needed changes within family system

• Improving communication skills
• Family interactions
• Increase family support among family members

Peer group therapy

Focused on developing and using social skills and interpersonal skills

Schizophrenia

Criteria

Additional Notes

1. 2 or more of the following, present for a significant portion of time during a 1-month period:

• Delusions
• Hallucination
• Disorganised speech
• Grossly disorganised or catatonic behaviour
• Negative symptoms

1. Since the symptoms started — noticeable decline in performance in work, relationships, or self-care
2. Continuous signs of the disturbance persist for at least 6 months

• 6 month period: must include 1 month of symptoms + may include periods of prodromal or residual symptoms

Subtypes

• Paranoid Schizophrenia: one or more delusions (Such as persecution or grandeur) and/or frequent auditory hallucinations
• Hebephrenic/Disorganised type schizophrenia: disorganised speech and behaviour, as well as flat or inappropriate emotional expression.
• Catatonic Schizophrenia: catatonic features such as abnormal physical movements, behaviours, and withdrawal.
• Undifferentiated type: symptoms that do not fit into the paranoid, disorganised, or catatonic types of schizophrenia.

Brief Psychotic Disorder

Criteria

Additional Notes

1. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
2. Delusions
3. Hallucination
4. Disorganised Speech: e.g., frequent derailment or incoherence
5. Grossly disorganised or catatonic behaviour
6. 1 month ≥ duration of disturbance ≥ 1 day + eventual return to premorbid level of functioning

Delusion Disorder

Criteria

Additional Notes

1. presence of one (or more) delusions ≥ 1 month (or longer)
2. Schizophrenia Criterion A has never been met

– Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).

1. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired + behaviours is not obviously bizarre or cold

Subtypes:

• Erotomanic Delusions:
• believes falsely that another person is in love with him or her.
• Example: believe a famous actor is in love with them
• Grandiose Delusions:
• believes that he or she has exceptional abilities, wealth, or fame.
• may believe that they have magical skills or famous personality
• Jealous type:
• the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful.
• Persecutory beliefs:
• belief that one is going to be harmed, harassed, by an individual or group of people
• believe someone/thing is mistreating, spying on or attempting to harm them
• may make repeated complaints to legal authorities
• Somatic Delusion:
• focus on preoccupations regarding health and organ function.
• Example: believe they've been infected by parasites that have taken over their internal organs, or by tiny insects that have burrowed under their skin to lay their eggs
• Mixed type:
• applies when not one delusional theme predominates
• Unspecified type
• dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component).

Genetics

• Family & twin studies: *Gottesman (1991)
• prevalence of schizophrenia in the first degree relative = 10%
• prevalence of schizophrenia in second degree relatives = 3%

Stress diathesis

Diathesis-Stress Model: schizophrenia arises from the interaction between a person's vulnerability (diathesis) and stressful life events (stress).

• Adoption studies:
• Most likely arises from a combination of genetic + environmental factors rather than just genes ONLY

*Tienari et al., 2004

• High Genetic Risk + Disturbed Environment: Schizophrenia risk: 36.8%
• High Genetic Risk + Healthy Environment: Schizophrenia risk: 5.8%
• Low Genetic Risk + Disturbed Environment: Schizophrenia risk: 5.3%
• Low Genetic Risk + Healthy Environment: Schizophrenia risk: 4.8%

Neurotransmitter

Dopamine hypothesis: result from either an excess of dopamine, receptors super sensitivity to normal amounts of dopamine.

*Howes & Kapur, 2009

• drugs that increase dopamine = increase schizophrenia-like symptoms
• drugs that block dopamine activity = reduces schizophrenia-like symptoms

Brain structure

*Basso et al. 1998)

• suggest that negative, disorganised and some positive symptoms ← damage to neural systems
• Enlarged cerebral ventricles:
• various brain regions reduces in size → loss of brain tissue
• decreased cortical volume (temporal and frontal lobe)

Environmental risk

• Viral Infections

*Jones and Canon, 1998): Young children who had viral infections were five times more likely to develop schizophrenia than those who did not

• Pregnancy + Delivery Complication:
• cause brain damage that increases risk for schizophrenia.

*Meta-analysis: delivery complication → low birth weight, prematurity, lack of oxygen etc during pregnancy

• Social deprivation, Social Adversity & Socioeconomic factors → increased rates of this disorder

Substance abuse

• stimulants: transient psychotic experiences + precipitate relapse of an existing psychotic condition
• cannabis consumption → increases cerebral dopamine → precipitate psychosis
• early marijuana use → disrupt normal brain development

Pharmacotherapy

Antipsychotic Drugs

• Chlorpromazine: affects only positive symptoms
• Haloperidol: affects only positive symptoms
• Clozapine: affects negative symptoms

ECT

sends a mild electrical current through the brain to alter nervous system activity

• works faster, especially with older patients
• used when medication does not affect symptoms

Psychological therapies

Family therapies

• effective in minimise the strength of symptoms of schizophrenia
• reduces level of expressed emotions
• improves communication

*Pharoah et al. (2000):

• reduces risk of relapse by half > medical care
• decreases frequency of hospital admission + time spent in hospital
• improved compliance with medical regimens

Social Skills training: help individuals improve their social interactions and relationship

AIM: address deficits in communication, interpersonal skill, and social cognition

• Social skills deficit
• relating to others
• poor eye contact
• unusual delay in response
• odd facial expressions
• lack of spontaneity
• inaccurate perception or lack of perception of emotions
• Addresses these behaviours through:
• role playing
• watching videos
• Modelling
• practice with therapist and others
• homework assignments

Rehabilitation: helps people overcome social withdrawal by slowly involving them in the activities of the rehabilitation centre — increase in social interaction

• Cognitive retraining → improve cognitive function
• focuses on restoring, strengthening, and sharpening cognitive functions
• Vocational training
• helps become independent and acquire job skills

Substance Use Disorder

Criteria

1. Problematic pattern of substance — causes clinically significant impairments/distress

manifested by at least 2 of the following, occurring within a 12-month period:

1. Substance is often taken in larger amounts or over a longer period than intended
2. Persistent desire or unsuccessful efforts to cut down or control substance use
3. Great deal of time spent in activities necessary to obtain substance, use substance, or recover from its effects
4. Craving to use substance
5. Recurrent substance use → failure to fulfil major role obligations at work, school or home.
6. Continuous use despite experiencing ongoing social or interpersonal difficulties worsened by substance use effects
7. recurrent substance use in situations in which it is physically hazardous (e.g., drinking and driving)
8. Continuous use despite physical or mental issues — made worse by substance use
9. Tolerance: defined as

• need for markedly increased amounts of substance to achieve
• markedly diminished effect with continued use of the same amount of substance.

1. Withdrawal: manifested

• The characteristic withdrawal syndrome for substance
• Other substances such as benzodiazepine are taken to relieve or avoid withdrawal symptoms.

Substance Intoxication

Criteria

1. Recent ingestion of Substance.
2. Clinically significant problematic behavioural or psychological changes (e.g., inappropriate sexual or aggressive behaviour, mood lability, impaired judgement) that developed during, or shortly after, substance ingestion.
3. One (or more) of the following signs or symptoms developing during, or shortly after, substance use:
4. Slurred speech
5. Incoordination
6. Unsteady git
7. Increased gait
8. Increased appetite
9. Dry mouth
10. Tachycardia
11. Impairment in attention/memory

Substance Withdrawal

Criteria

1. Cessation of (or reduction in) substance use that has been heavy and prolonged.
2. 2 or more symptoms develop within several hours to a few days after the cessation of (or reduction in) substance use:

• Autonomic hyperactivity: e.g., sweating or pulse rate greater than 100 bpm
• Increased hand tremor
• Nausea or vomiting
• Transient visual, tactile, or auditory hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Seizures

1. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Substance Induced Mental Disorder

• Mood Disorder
• Anxiety Disorder
• Neurocognitive Disorders
• Etc

clinical symptoms that develop during or soon after intoxication with or withdrawal from alcohol

Characteristics

• Symptoms
• Severity/length greatly surpasses the mood swings, psychotic episodes, or anxiety – typically associated with substance intoxication or withdrawal
• Can't be better explained by primary health conditions
• Do not persists for a substantial period of time after discontinuance of substance use or withdrawal
• Substance Use:
• Amount and duration is capable of producing these symptoms
• No evidence of a pre-existing primary mental disorder: history of prior episodes not associated with alcohol use

Alcohol Use Disorder

Criteria

1. Problematic pattern of alcohol use → significant impairment/distress — manifest by at least 2/11 criteria, occurring within a 12-month period:
2. Alcohol is often taken in larger amounts or over a longer period than was intended.
3. Persistent desire or unsuccessful efforts to cut down or control alcohol use.
4. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
5. Craving, or a strong desire or urge to use alcohol.
6. Recurrent alcohol use resulting in a failure to fulfil major role obligations at work, school, or home
7. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
8. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
9. Recurrent alcohol use in situations in which it is physically hazardous.
10. Tolerance, as defined by either of the following:

• A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
• A markedly diminished effect with continued use of the same amount of alcohol.

1. Withdrawal: manifested by

• The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal).
• Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Alcohol Intoxication

Criteria

1. Recent ingestion of alcohol.
2. Clinically significant problematic behavioural or psychological changes (e.g., inappropriate sexual or aggressive behaviour, mood lability, impaired judgement) that developed during, or shortly after, alcohol ingestion.
3. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use:

• Slurred speech.
• Incoordination
• Unsteady gait
• Nystagmus (vision condition in which the eyes make repetitive, uncontrolled movements).
• Impairment in attention or memory.
• Stupor or coma.

1. The signs or symptoms are not attributable to another medical including intoxication with another substance.

Alcohol Withdrawal

Criteria

1. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
2. 2 (or more) of the 8 following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A:

• Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
• Increased hand tremor.
• Insomnia.
• Nausea or vomiting.
• Transient visual, tactile, or auditory hallucinations or illusions.
• Psychomotor agitation.
• Anxiety
• Generalised tonic-clonic seizures.

1. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
2. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Statistics

• Worldwide prevalence = 2.2%

*Castaldelli-Maia and Bhugra, 2022: higher prevalence of of alcohol-use disorders = 1.5% > drug-use disorders = 0.8%

• Cannabis = 0.32%
• Opioid = 0.29%
• Amphetamines = 0.10%
• Cocaine = 0.06%
• Striking increase in prevalence rates from 13 - 18 years old → adolescence → key period of development of substances use disorders

Gender Difference

• Men > women: illicit drug use (CBHSQ, 2016)
• Women > men: more fat, less water, less alcohol metabolisation (oesophagus and stomach) → more likely to develop higher blood alcohol level per drink
• Women > men: drinking → vulnerable to physical consequences of alcohol — black-outs and liver disease

Genetics and family history

• Genetics play a role: heritability accounting for approximately 60%
• Parents’ drinking pattern may also influence likelihood of developing Alcohol Use Disorder

Environmental Risk factor

Stress and Coping Model

• Individuals may turn to substance use as a way of coping with stressors and negative life events
• substance use — provide temporary relief from emotional pain, anxiety or other forms of distress

Trauma and Adverse Childhood Experience (ACEs)

• vulnerable to developing SUD — way of coping with emotional aftermath

Marital Conflict

• marital problems + less intimate relationship → develop drinking alcohol
• break-up of marital relationship → highly stressful → increased alcohol abuse

Peer Influence and Peer Pressure:

• desire to conform or gain social acceptance → experimentation

Cultural Norms and Expectations

• cultural beliefs and norms surrounding substance use → likelihood of engaging in such behaviour
• social events revolve around alcohol use
• enhances euphoric feeling and reduces stress
• (findings) psychological and socio-cultural factors in the high intake of alcohol
• high accessibility → rates of substance use
• high availability may experience higher rates of use

PICA

regular consumption of non-nutritive substances

• non-food objects and materials: clay, soil, chalk, plaster, plastic, metal and paper
• raw food ingredients: large quantities of salt or corn flour

Criteria

1. behaviour is persistent or severe enough to require clinical attention

• reached developmental age: expected to distinguish between edible and non-edible substances (~ 2 years old)

1. behaviour causes:

• damage to health
• impairment in functioning
• significant risk due to frequency, amount or nature of the substance/objects ingested

1. behaviour is not part of a culturally supported or socially normative practice
2. Eating behaviours occurs in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability], autism spectrum disorder, schizophrenia) or mental condition (including pregnancy) — sufficiently severe to warrant additional clinical attention

*(Papini et al., 2023): significant relationship between PICA and developmental delays & Autism

Risk Factors

Nutritional Deficiencies

*Nasser and Alsaad (2023): Review

• PICA ↔ stress + child neglect + abuse + maternal deprivation (Singhi et al., 1981)
• Iron deficiency anaemia (López et al., 2004)
• Low level of serum iron and other micronutrients

Management

Medical Evaluation: essential to identify and address underlying medical conditions or nutritional deficiencies that may contribute to PICA

• blood test — nutrient deficiencies
• imaging studies — evaluate for gastrointestinal blockages
• Nutrient supplementation when deficiencies is identified

Environmental modification

• minimise access to non-food items
• childproofing the home
• keeping hazardous substances out of reach
• providing appropriate supervision

Behavioural Intervention

• affective in patients with mental disabilities — ABA
• differential reinforcement: redirecting the undesired behaviour to other activities

Anorexia Nervosa

Criteria

1. Restriction of energy intake relative to requirement → significant low body weight in the context of age, sex, developmental trajectory and physical health
2. Intense fear of gaining weight/becoming fat or persistent behaviour that interferes with weight gain — even though already at a significantly low body weight
3. disturbance in experiencing one’s body weight or shape, excessive impact of body weight or shape on self-worth, or continuous denial of the severity of being underweight

• result in significant and potentially life-threatening medical conditions
• poor nutrition affects most major organ systems + produce a variety of disturbances
• physiological disturbance — amenorrhea and vital sign abnormalities
• associated with malnutrition → reversible — nutritional rehabilitation

Prevalence

• most prevalent in post-industrialised, high-income countries — United States, many European countries, Australia, New Zealand, and Japan.
• increasing in many countries in Global South — Asia and the Middle East
• women(0 - 0.08%) > men(0 - 0.01%)

Risk Factors

Genetics

• Family history of eating disorders or other psychiatric conditions may be at a higher risk of developing anorexia nervosa.

Biological factors:

• imbalance of neurotransmitter (serotonin & dopamine)

Psychological factors

• personality traits: perfectionism, low self-esteem, body dissatisfaction, tendency toward obsessive compulsive traits

Environmental Risk Factors: raised or live in Western Cultures are exposed to a high level of pressure related to weight and appearance.

• societal norms → high importance on beauty and thinness
• reinforced by media messages, magazines, social media
• pressure + high degree of stress: especially on young women
• Family relation difficulties
• History of bullying – fat shaming
• Adverse life events that cause stress or trauma

Management

involve multidisciplinary approach — addresses physical + psychological aspects

GOALS:

• Restore healthy weight
• Address medical complaints
• Address underlying psychological issues contributing to eating disorders

Psychotherapy

• CBT: effective in treating anorexia nervosa
• helps individuals identify and change unhealthy thought patterns and behaviours related to to food and body image
• Skills training

Bulimia Nervosa

• typically within the normal weight or overweight range [BMI] ≥ 18.5 and < 30 in adults
• between bingeing: typically restrict caloric intake + prefer low-calorie diet food while avoiding foods that they perceive to be fattening or likely to trigger a binge

Criteria

1. recurrent episodes of binge eating

• Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
• A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

1. recurrent inappropriate compensatory behaviours — prevent weight gain

• self-induced vomiting
• misuse of laxatives, diuretics, or other medication
• fasting
• excessive exercise

1. Binge eating and inappropriate compensatory behaviours = on average or at least once a week for 3 month
2. Self-evaluation is unduly influenced by body shape and weight

Prevalence

• average onset: 18 years old — prevalence of 0.3%. (3/10,000.)
• women > men: 5 times more common
• commonly begins in adolescence or young adulthood
• onset: before puberty or after 40 is uncommon
• experiencing multiple stressful life events

Binge Eating Disorders

• occurs in normal-weight or overweight and obese individuals

Criteria

1. recurrent episodes of binge eating

• Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
• A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

1. Episode are associated with 3 or more:

• Eating much more rapidly than normal.
• Eating until feeling uncomfortably full.
• Eating alone because of feeling embarrassed by how much one is eating.
• Feeling disgusted with oneself, depressed, or very guilty afterward

1. Marked distress regarding binge eating is present
2. The binge eating — at least once a week — 3 months
3. Binge eating doesn't involve repeated use of harmful behaviors to compensate, like in bulimia nervosa, and it doesn't only happen during bulimia nervosa or anorexia nervosa.

Prevalence

• affect 1.5% of women and 0.3% of men worldwide
• commonly con-occurring condition:
• Obesity
• Type 2 diabetes
• hypertensio n

Risk Factors

Genetic factors

• a family history of eating disorders may be at a higher risk.

Biological factors

• imbalance in neurotransmitter (serotonin)

Biological Hunger and Fullness regulation:

• dysregulation in the ability to recognise hunger and fullness cues

Psychological factors

• Body Image Disturbance:
• Dissatisfaction with body image and a desire for an unrealistic body shape can contribute to the development of bulimia.
• Perfectionism
• High levels of perfectionism and the pursuit of an idealized body image are associated with an increased risk
• Low Self-esteem:
• Individuals with low self-esteem may be more susceptible to developing bulimia nervosa.
• Impulsivity and poor regulation
• malnutrition in childhood
• Life transition
• life changes
• stressors
• transitions: puberty, going to college
• significant life events

Social and Environmental Influences

• societal pressures & cultural attitudes — body weight and shape
• Models and actors often suggest that fame is linked to being sexually attractive and having a good-looking body.
• Unrealistic body standards reinforced by media
• parents and coaches — pressure to lose weight
• bullying or weight-related stigma → emotional distress

Management

Medical evaluation and monitoring

• medical assessment: evaluate physical impact on health
• Monitoring and management of any medical complications or nutritional deficiencies
• Electrolyte and metabolic disturbances resulting from severe purging may necessitate hospitalization.

CBT: benchmark, first-line treatment

• Cognitive and behavioural procedures
• Interrupt the self-maintaining behavioral cycle of binging and dieting
• Alter the individual’s dysfunctional cognitions; beliefs about food, weight, body image; and overall self-concept.

Support groups: provide a sense of understanding and community.

Family involvement: can be beneficial, especially in cases where family dynamics contribute to the disorder.

Paranoid Personality Disorder

Characterisation

pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.

Symptoms

4 or more/7:

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Schizoid Personality Disorder

Characterisation

pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.

Symptoms

4 or more / 7:

• Neither desires nor enjoys close relationships, including being part of a family.
• Almost always chooses solitary activities.
• Has little, if any, interest in having sexual experiences with another person.
• Takes pleasure in few, if any, activities.
• Lacks close friends or confidants other than first-degree relatives.
• Appears indifferent to the praise or criticism of others.
• Shows emotional coldness, detachment, or flattened affectivity.

Schizotypal Personality Disorder

Characterisation

pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviors

Symptoms

5 or more /9:

• Ideas of reference (excluding delusions of reference).
• Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
• Unusual perceptual experiences, including bodily illusions.
• Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
• Suspiciousness or paranoid ideation.
• Inappropriate or constricted affect.
• Behavior or appearance that is odd, eccentric, or peculiar. •
• Lack of close friends or confidants other than first-degree relatives.
• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Antisocial Personality Disorder

Characterisation

pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years.

• at least 18 years ago
• evidence of conduct disorder with onset before 15 years old
• occurrence it not exclusively during the course of schizophrenia or bipolar disorder

Symptoms

3 or more/7:

• Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
• Impulsivity or failure to plan ahead.
• Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
• Reckless disregard for safety of self or others.
• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Borderline Personality Disorder

Characterisation

pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.

Symptoms

5 or more / 9:

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
• Identity disturbance: markedly and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms

Histrionic Personality Disorder

Characterisation

pervasive pattern of excessive emotionality and attention seeking.

Symptoms

5 or more /9:

• Is uncomfortable in situations in which he or she is not the center of attention.
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour.
• Displays rapidly shifting and shallow expression of emotions.
• Consistently uses physical appearance to draw attention to self.
• Has a style of speech that is excessively impressionistic and lacking in detail.
• Shows self-dramatization, theatricality, and exaggerated expression of emotion.
• Is suggestible (i.e., easily influenced by others or circumstances).
• Considers relationships to be more intimate than they actually are.

Narcissistic Personality Disorder

Characterisation

pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.

Symptoms

5 or more /9:

• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
• Is preoccupied with fantasies of unlimited success, power, beauty, or ideal love.
• Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
• Requires excessive admiration.
• Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
• Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). • Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. • Is often envious of others or believes that others are envious of him or her. • Shows arrogant, haughty behaviors or attitudes.

Anvoidant Personality Disorder

Characterisation

pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Symptoms

4 or more/7:

• Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless certain of being liked.
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
• Is preoccupied with being criticized or rejected in social situations.
• Is inhibited in new interpersonal situations because of feelings of inadequacy.
• Views self as socially inept, personally unappealing, or inferior to others.
• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Dependent Personality Disorder

Characterisation

pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation.

Symptoms

5 or more / 8:

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
• Needs others to assume responsibility for most major areas of his or her life.
• Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
• Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
• Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
• Urgently seeks another relationship as a source of care and support when a close relationship ends.
• Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Obsessive-Compulsive Personality Disorder

Characterisation

pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.

Symptoms

4 or more /8:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
• Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
• Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
• Is unable to discard worn-out or worthless objects even when they have no sentimental value.
• Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
• Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
• Shows rigidity and stubbornness.

Nature – Nurture

inter-relationship between Nature (biology and temperament) and Nurture (social environment and life experience) in the formation of personality

Biological vulnerabilities

explains predisposition

Psychological theories

explains deviation of personality development towards unhealthy development

Parenting

NOT A DIRECT CONSEQUENCES

Other

mix of a person's unusual temperament (which is often genetic) and a negative environment.

Genetic factors

increasing evidence: genetic factors → fundamental influence on PD development

Definition

Clinical psychology focuses on psychological aspects of human functioning: emotional, biological, cognitive, social and behavioural

APA: definition – specialty that provides:

• · continuing and comprehensive mental and behavioural health care for individuals, couples, families and groups
• · consultation to agencies and communities
• · training, education and supervision
• · research-based practice

Aim

1. To understand, predict, and treat or alleviate disorders, disabilities or any kind of maladjustment

2. To act on a preventative level to promote human adaptations, adjustment, and personal development

Professional Role and Function

Clinical psychology → area of applied research — transfers findings into practice (evidence-based practice)

• · Work directly with individuals at all developmental levels and groups
• · use a wide range of assessment and intervention methods to promote mental health
• · Research, teaching and supervision, program development and so on

Addresses: behavioural and mental health issues face by individuals across the lifespan including -

• · Intellectual, emotional, psychological, social and behavioural maladjustment.
• · Disability and Discomfort.
• · Minor adjustment issues as well as severe psychopathology: change of setting/occupation
• · Interpersonal difficulties: marital/couples therapy
• · Skill deficit

Work Setting

1. 1. Private practice
2. 2. Counselling centres
3. 3. Mental health service units, Managed health care organisations
4. 4. Different departments in hospitals, schools, universities, industry, legal systems, medical systems, and government agencies

Skills

• · Understanding of psychopathology and mental health across the lifespan
• · Assess cognitive, behavioural, emotional, and interpersonal functioning
• · Conduct psychological and behavioural interventions
• · Conduct, disseminate, and implement research (published research)
• · Establish and maintenance of therapeutic relationships and communication
• · Recognise and respond to ethical, legal, and regulatory issues

Assessment

• · Diagnostic Interviewing: asking the right question
• · Behavioural assessment
• · Administration of interpretation of psychological test

Consultation

• · Inter- and intra-professional practice with other health and behavioural health professionals and organisations.

Example: giving therapy to coupled who come in for fertility clinics

Intervention

• Clinical services:
• Individuals
• Families
• Groups

Research

Engagement with research and critical review of science, knowledge and methods pertaining to clinical psychology

United Kingdom

• · BSc Psychology accredited by BPS (3y)
• · PhD Clinical Psychology (3y) clinical psychology

Malaysia

• · BSc Psychology
• · MSc Clinical Psychology
• · Clinical training

United States

• ● BSc (4-5y)
• ● MSc (2-4y)
• ● PhD/PsyD (3-8y)
• ● Post-doctoral supervised experience (1-2y)

Aim

boost scientific advancements in clinical psychology.

Suggestion

graduate programs should focus on:

• enhancing psychologists' understanding of psychological theory
• practical experience
• research methods.

Encourages

integration of empirical research into practice + use of practical experience to guide future research → field can continuous progress and refine its approaches

General Principles:

• aspirational in nature
• Intent: to guide and inspire psychologists toward the highest ethicla ideals of the profession
• They do not represent obligations and should not form the basis for imposing sanctions

Principle

Elaboration

1. Beneficence and Non-maleficence

• Benefit and do not harm to those you work with
• Welfare and rights protection of those you interact with professionally and other affected persons
• Resolve conflicts responsibly to avoid or minimise harm
• Self-awareness of how you own physical and mental health can impact your ability to help others
• Welfare of animal subjects of research

B. Fidelity and Responsibility

• Build trust with people you work with
• Awareness of your responsibilities to society and the specific communities you serve — awareness of stigma
• Uphold:
• Professional standards of conduct
• Define their professional roles and obligations clearly

Example: Treating Schizophrenia involves medication that should be handled by psychiatrist

• Accept responsibility of their behaviour
• Manage Conflict of Interest to avoid harm

C. Integrity

• Promote Accuracy and Truthfulness in the science, teaching, and practice of psychology
• Avoid dishonesty and fraud, stealing, or purposeful misrepresentation
• Commitment to promises and avoid unwise or unclear commitments

D. Justice

• Equal Access and Benefit from the contributions of psychology to all persons
• Uphold equal quality in processes, procedures and services
• Guard Against Biases and Unjust Practices
• Be aware of boundaries of competence, and limitations of expertise

E. Respect for People's Rights and Dignity

• Respect the dignity and worth of all people
• Respect the rights of individuals to privacy, confidentiality, and self-determination
• Protect the rights and welfare of vulnerable communities (whose vulnerability impair autonomous decision making)
• Respect cultural, individual, and role of differences:
• Age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status

Ethical Standards: APA Code of Ethics

Standards

Elaboration

Resolving Ethical Issues

• Misuse of Psychologist’s work
• Conflicts between Ethics and Law
• Conflicts between Ethics and Organisational Demands
• Informal Resolution of Ethical Violations
• Reporting Ethical Violations
• Cooperation with Ethical Committees
• Improper Complaints
• Unfair Discrimination against Complainants and Respondents

Human Relations

• Unfair discrimination
• Sexual Harassment
• Other Harassments
• Avoiding Harm
• Multiple Relationships
• Conflict of Interest
• Third-party Requests for Services
• Exploitative Relationships
• Cooperation with Other Professionals
• Informed Consent
• Psychological Services delivered to or through organisations
• Interruption of psychological services

Privacy and Confidentiality

• Maintaining Confidential
• Discussing the Limits of Confidentiality
• Recording
• Minimizing Intrusions on Privacy
• Disclosures
• Consultations
• Use of Confidential Information for Didactic or Other Purposes

Competence

• Boundaries of competence
• Providing Services in Emergencies
• Maintaining competence
• Bases for scientific and professional judgments
• Delegation of work to others
• Personal problems and conflicts

Advertising and Other Public Statements

• Avoidance of False or Deceptive Statements
• Statements by Others
• Descriptions of Workshops and Non-Degree-Granting Educational Programs
• Media Presentations
• Testimonials
• In-Person Solicitation

Education and Training

• Design of Education and Training Programs
• Descriptions of Education and Training Programs
• Accuracy in Teaching
• Student Disclosure of Personal Information
• Mandatory Individual or Group Therapy
• Assessing Student and Supervisee Performance
• Sexual Relationships with Students and Supervisees

Record Keeping and Fees

• Documentation of Professional and Scientific Work and Maintenance of Records
• Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work
• Withholding Records for Nonpayment
• Fees and Financial Arrangements
• Barter with Clients/Patients
• Accuracy in Reports to Payors and Funding Sources
• Referrals and Fees

Therapy

• Informed Consent to Therap
• Therapy Involving Couples or Families
• Group Therapy
• Providing Therapy to Those Served by Others
• Sexual Intimacies with Current Therapy Clients/Patients
• Sexual Intimacies with Relatives or Significant Others of Current
• Therapy Clients/Patients
• Therapy with Former Sexual Partners
• Sexual Intimacies with Former Therapy Clients/Patients
• Interruption of Therapy
• Terminating Therapy

Assessment

• Bases for Assessments
• Use of Assessments
• Informed Consent in Assessments
• Release of Test Data
• Test Construction
• Interpreting Assessment Results
• Assessment by Unqualified Persons
• Obsolete Tests and Outdated Test Results
• Test Scoring and Interpretation Services
• Explaining Assessment Results
• Maintaining Test Security

Research and Publication

• Institutional Approval
• Informed Consent to Research, Recording Voices and Images in Research
• Client/Patient, Student, and Subordinate Research Participants
• Dispensing with Informed Consent for Research
• Offering Inducements for Research Participation
• Deception in Research
• Debriefing
• Humane Care and Use of Animals in Research
• Reporting Research Results
• Plagiarism
• Publication Credit
• Duplicate Publication of Data
• Sharing Research Data for Verification
• Reviewers

Pioneer

What they did

William Tuke (1732–1822) [England]

• Raised funds to establish the York retreat — residential treatment centre

AIM: provide care for the mentally ill with kindness, dignity and decency

• “Retreat” → signal shift in approach
• diverged from the conventional methods of the time
• Patients received good food, frequent exercise, and friendly interactions with the staff
• Influence on Mental Health Care: It became an example of humane treatment.
• similar institutions opened throughout Europe and US

Philippe Pinel (1745–1826)[France]

• Worked to move the mentally ill out of dungeons in Paris
• Inmate-like confinement → patient-focused approach
• Created new institutions → patients were not kept in chains or beaten
  • given healthy food and benevolent treatment
• Advocated for comprehensive patient care
• Instructed staff to include patient a case history, ongoing treatment notes, and an illness classification of some kind for each patient

Eli Todd (1762–1832) (USA)

• 1800: only 3 states in the US had hospitals for the mentally ills
• Burden of care was on families who often his their relatives due to societal stigma
• 1842: Raised funds to establish The Retreat in Connecticut
• Patients: treated in a humane and dignified way
• Emphasised patient’s strengths rather than weaknesses + allowed to have input in treatment decisions
• Influence of Mental Health Care: Similar institutions were soon opened in other states as leaders learned of Todd’s successful treatment of the mentally ill.

Dorothea Dix (1802–1887) (USA)

• A sunday school teacher in Boston jail
• Observed that many inmates were there due to mental illness or disability not crime
• Travelled to cities — gathered data on mental health treatment
• Presented findings to community leaders, advocating for more humane and adequate care
• Led to Establishment of more than 30 state institutions for the mentally ill throughout the US (and even more in Europe or Asia)

Lightner Witmer (1867–1956) and the Creation of Clinical Psychology

• Born in Philadelphia
• undergraduate degree in Business at the UPenn
• 1892: Doctorate in Psychology in Germany under Wilhelm Wundt
• At the time — Psychology was an academic discipline → research and theoretical exploration focused
• Key role in transforming psychology from purely academic → field with practical application

Pioneering Psychological Clinics

• 1896: founded the first psychological clinic at UPenn
• first time: science of psychology was intentionally and systematically applied to address people’s issues
• 1914: inspired about 20 psychological clinics in the US
• 1953: Number of psychological clinics over 150
• issue of his journal was dedicated to a survey of activities taking place in these clinics
• Suggestions for the training of clinical psychologists

Diverse Application in Witmer’s Clinics

• Primary focus was on children
• Problems related to learning or behaviour in school settings
• Referred to the clinic by schools, parents, physicians, or community authorities
• Emphasises that CP was not limited to children or school-related problems
• Can be applied to adults and a wide range of issues beyond the education context

Pioneering Journal and Terminology

• 1907: established the first scholarly journal in the field — "The Psychological Clinic."
• Authored the first article — “Clinical Psychology”: included the first known publication of the term clinical psychology , as well as other terms and explanation of the need for its existence and growth

Definition of Clinical Psychology

• Clinical Psychology: related to medicine, education, and social work
• Physicians, teachers, and social workers wouldn't automatically qualify as clinical psychologists.

→ Clinical psychology represented a unique and hybrid profession, incorporating influences from various discipline

• Specifically trained professional in clinical psychology → distinct from individuals in medicine, education, or social work
• Clinical psychologist would work collaboratively with members of related fields

Neurosis

Psychosis

• Neurotic individuals were believed to experience mild psychiatric symptoms.
• Maintain an intact grasp on reality

→ Now: anxiety and depression

• Psychotic individuals were characterised by a break from reality
• manifested through hallucinations, delusions, or grossly disorganized thinking.

Distinguishing factor: level of connection to reality

Neurotic individuals were seen as having a preserved connection.

Psychotic individuals experienced a significant break.

Emil Kraeplin (1855–1926)
→ German Psychiatrist — Recognized as the "Father of Descriptive Psychiatry”

Kraepelin's Disorder Classifications

• Exogenous Disorder: those caused by external factors.
• More treatable
• Endogenous Disorders: Those caused by internal factors.

• Assigned names to specific disorders.
• Introduced the term "dementia praecox" to describe an endogenous disorder, similar to contemporary concepts of schizophrenia.
• Coined several terms that had not yet been established.
• His contributions laid the foundation for the development of diagnostic language.

Intelligence

Edward Lee Thorndike (1874 –1949) – American Psychologist

• theory of learning: how reinforcement and punishment shape behavior.

Each person possesses separate, independent intelligences

• Abstract: capturing what tests of intelligence measure;
• Mechanical: related to visualizing relationships among objects and understanding how the physical world works;
• Social intelligence: Reflective of the degree of success in functioning in interpersonal situations.

Charles Spearman (1863 - 1945 ) – English psychologist

• Known for work in statistics, as a pioneer of factor analysis, and for Spearman's rank correlation.

Two factor Theory

• General intelligence and specific abilities
• General intelligence "g" is correlated with specific
• All tasks on intelligence tests (verbal or mathematical), were influenced by underlying “g” factor.

Alfred Binet (1857- 1911)

IQ Test

• Early 1900s: French government sought help in identifying students who needed special services in public schools.
• This test yielded a single overall score - endorsing the concept of “g.”
• First to incorporate a comparison of mental age to chronological age as a measure of intelligence.
• When expressed as a division problem, yielded the “intelligence quotient”.

Lewis Terman (1877 –1956) – American Psychologist

• Alfred Binet's test gained popularity and underwent significant revision by Lewis Terman in 1937.
• This revision resulted in the Stanford-Binet Intelligence Scales.
• The Stanford-Binet test is recognized as one of the most widely used intelligence tests globally.

David Wechsler (1896- 1981) – Romanian-American Psyhologist

• 1939: David Wechsler addressed the need for an intelligence test designed specifically for adults.
• He introduced the Wechsler-Bellevue test.
• It quickly gained popularity among psychologists.
• its more recent revisions remain popular today.
• 1949: he expanded his contributions by releasing the Wechsler Intelligence Scale for Children (WISC)
• creating a direct competitor for the Stanford-Binet in assessing intelligence in children.

Personality

James McKeen Cattell (1860 –1944)
→ Doctoral under Wilhelm Wundt

• 1890: He coined the term "mental test" in an article titled "Mental Tests and Measurements.”
• Initially, the term referred to basic tests of abilities such as reaction time, memory, and sensation/perception.
• The term later embraced measures of personality characteristics.

Hermann Rorschach (1884 – 1922)

• Hermann Rorschach (1884 – 1922)
• 10 inkblots, which rose quickly in popularity: Several different competing Rorschach scoring systems existed.
• Projective personality test.:
• The way individuals perceive and make sense of the blots corresponds to the way they perceive and make sense of the world around them.

Success of Rorschach’s test was followed by a number of other projective techniques.

Christiana Morgan and Henry Murray

published the Thematic Apperception Test in 1935

• depicted people in scenes or situations that could be interpreted in a wide variety of ways.
• depicted people in scenes or situations that could be interpreted in a wide variety of ways.
• Their responses were thought to reflect personality characteristics.

Object Personality Test

Paper pencil test

emerged as an alternative to projective test

• They presented a distinct and scientifically sound method of assessing personality.
• Scoring: interpretation were more straightforward than projective test
• some focused of specific aspects of personality
• others aimed to provide more comprehensive overview of an individuals personality

Object Personality Test

emerged as an alternative to projective test

• They presented a distinct and scientifically sound method of assessing personality.
• Scoring: interpretation were more straightforward than projective test
• some focused of specific aspects of personality
• others aimed to provide more comprehensive overview of an individuals personality

Prominent Objective Personality Test

Minnesota Multiphasic Personality Inventory

• Developed by Starke Hathaway and J. C. McKinley in 1943, the MMPI
• Comprehensive personality measure and assessing psychopathology.

16 Personality Factor

• Developed by Raymond B. Cattell in 1949
• Objective personality test developed using factor-analytic approach..
• It assesses 16 personality factor

NEO Personality Inventory

• Developed by Costa and McCrae in 1989
• Personality measure less geared toward psychopathology

Specialized Personality Assessment and Expanded Applications

• focus on measuring specific states or traits.

Example: Beck Depression Inventory and the Beck Anxiety Inventory

• Providing targeted assessments in the realm of mental health.
• In recent decades, personality assessment tools have expanded beyond traditional uses.
• Job screenings
• Forensic purposes

Franz Mesmer (1734 –1815)

→ Pioneer of Hypnotherapy (1700s)

• Recognized as the "Father of Western Psychotherapy".
• He used hypnosis to treat psychosomatic problems and various disorders.

Sigmund Freud (1856 –1939)

→ Austrian neurologist and the founder of psychoanalysis

• He developed psychodynamic therapy
• Therapeutic techniques such as the use of free association and dream analysis.
• People could be cured by making conscious their unconscious thoughts and motivations, thus gaining "insight”.

John B. Watson (1878 – 1958)

→ An American psychologist.

• Popularized scientific theory of behaviorism — Known for the Little Albert experiment.
• Demonstrated that a child could be conditioned to fear a previously neutral stimulus.
• Emergence of Behavior therapy.
• Techniques like token economy and Skinner boxes (operant conditioning environments) were employed.

Example: Metropolitan State Hospital, to apply behaviorist principles in treating psychotics.

Carl Rogers (1902-1987)

→ American psychologist

• One of the founders of humanistic psychology
• Humanistic Therapy/ client-centered therapy flourished in the 1960s.
• Relationship- and growth-oriented approach to therapy.
• Unconditional positive regard
• An alternative to both psychodynamic and behavioral approaches that many therapists and clients found attractive.

Murray Bowen (1913 – 1990)

→ American psychiatrist

• Pioneer of family therapy
• Family therapy revolution took root in 1950s.
• Understanding mentally ill individuals as symptomatic of a flawed system.
• FT became a preferred therapy in 1960s and 1970s.
• Objectives:
• Improving the communication
• Solving family problems
• Understanding and handling special family situations
• Creating a better functioning home environment

Aaron Beck (1921 – 2021)

→ Aaron Beck (1921 – 2021)

• Father of cognitive behavior therapy.
• He noticed that patients with depression frequently verbalized thoughts that were objectively untrue.
• Pinpointed a set of characteristic “cognitive distortions” in their thinking patterns.
• Started viewing depression as a cognitive disorder rather than a mood disorder
• Development of CBT.

Recent Trends

• Combining therapy approaches in both eclectic and integrative ways.
• Incorporation of mindfulness-based approaches.
• Mindfulness practices, rooted in Eastern traditions, have gained widespread acceptance in the Western therapeutic context.
• Cognitive-behavioral mindfulness based therapy (CBT),
• Mindfulness based stress reduction therapy
• Dialectical behavior therapy (DBT)
• Acceptance and commitment therapy (ACT).
• Clinical psychology field continues to grow in both size and scope.
• Increasing demand for psychotherapy services.
• Numerous specializations within clinical psychology
• forensic psychology and health psychology, are flourishing.
• Focus on empirical support for clinical techniques.
• Evidence-based practices have become increasingly emphasized.
• Integration of new technologies in assessment, diagnosis, and treatment.
• Virtual reality, Tele-health, online platforms, and digital tools have expanded access to mental health services.