- The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation

- One or more symptoms or deficits affecting motor or sensory function that suggest a neurological condition

- Psychological factors seem to be associated with the disturbance, trauma?

- La belle indifference

- Functional neurological symptom disorder

- Psychogenic nonepileptic seizures

Etiology of Somatic Symptom and Related Disorders

- These orders were once referred to as hysterical disorders

- Psychodynamic view: Freud believed that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms due to an Electra complex

- Today, psychodynamic theorists propose that two mechanisms are at work in hysterical

- Behavioral view: propose that the physical symptoms of these disorders bring positive reinforcement to sufferers

- Cognitive view: propose that these disorders are a form of conversion, providing a means for people to express difficult emotions. Thoughts exacerbate somatic symptoms

- Multicultural view: some theorists believe that Western clinicians hold a bias that sees somatic symptoms as an inferior way of dealing with emotions

- What about a possible role for biology?

Treatment of Somatic Symptom Disorder and Illness Anxiety Disorder

- Psychodynamic Therapies

o Provide insight into the connection between emotional and physical symptoms

- Behavioral Therapies

o Reward healthy behaviors and remove rewards related to symptoms

- Cognitive Therapies

o Challenge catastrophizing and learn to interpret physical symptoms appropriately

- Belief Systems

o Address cultural, religious, and other belief systems that may affect symptoms

Therapy for Conversion Disorder

- Psychoanalytic

o Helps express painful emotions or memories that are linked to symptoms

- Cognitive-behavioral – focuses on

o Relieving the person’s anxiety centered on the initial trauma that caused the conversion symptoms

o Reducing any benefits the person is receiving from the conversion symptoms

Factitious Disorders

- Factitious Disorder (Imposed on Self): Falsification of physical or psychological signs of symptoms, or induction of injury or disease, associated with identified deception. Formally known as Munchausen’s Syndrome

- Factitious Disorder (Imposed on Another): Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception. Formally known as Munchausen’s Syndrome by Proxy

Dissociative Disorders (Dissociative Identity Disorder) DID

What is dissociation

- Dissociation: process where components of mental experience are split from consciousness but remain accessible through dreams and hypnosis

- Two modes of consciousness explain how dissociation occurs

o Active mode: conscious plans and desires and voluntary actions

o Passive receptive mode: registers and stores information in memory without being aware that the information has been processed

o Hidden observer phenomenon

Dissociative disorders

- Dissociative identity disorder

o Formerly known as multiple personality disorder

- Dissociative amnesia

o Dissociative fugue (subcategory)

- Depersonalization-derealization disorder

DID

- Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession

- Alternate identities (alters, subpersonalities) may have different names, genders, ages, and personal characteristics

- May also be named after their function or description for example: the strong one

Types of Alters/Subpersonalities

- Child type: alters that are young children, and do not age as the individual ages

- Persecutor type: alters that inflict pain or punishment on the other alters by engaging in self-mutilating acts

- Helper type: alters that protect the weaker alters or control the switching between the alters

- Host: passive, dependent, guilty, and depressed

Dissociative Identity Disorder

- At least two of these identities or personality states recurrently take control of the person’s behavior (switching)

- Mutually amnesic relationships – subpersonalities have no awareness of one another

- Mutually cognizant patterns – each subpersonality is well aware of the rest

- One-way amnesic relationships – some personalities are aware of others, but the awareness is not mutual

DID: DSM-5-TR

- Recurrent gaps in the recall of everyday events, important personal information, and or traumatic events that are inconsistent with ordinary forgetting

- The more passive identities tend to have more constricted memories, whereas the more hostile or controlling identities have more complete memories

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

Epidemiology of DID

- Actual prevalence of DID is unknown

o Socio-cognitive model vs. post-traumatic model

- Higher rates seen in the US than in most other countries

- Diagnosed more often in females than males

- Cases identified across most major racial and ethnic groups, SES classes, and cultures, although most cases are Caucasian

Etiology of DID

- Alters may occur in people under conditions of extreme trauma, often childhood sexual abuse

- Self-hypnosis or hypnotic suggestibility may be involved

- There is some evidence it runs in families

- Co-morbidities: depression (97%), Anxiety/PTSD (90%); 90% have suicidal ideation, 75% attempt suicide

Treatment of DID

- Tactical integration

- Hypnosis – commonly used but very controversial

- Antidepressant or anti-anxiety medication sometimes used as well

Dissociative Amnesia

- Inability to recall important autobiographical information, typically of a traumatic nature

o Inconsistent with normal forgetting

- Forgetting can be specific to an event(s) or generalized to identity and life history

Types of Amnesia

- Organic amnesia: caused by brain injury

- Psychogenic amnesia: arises in the absence of any brain injury or disease, has psychological causes, and usually not anterograde

- Anterograde amnesia: inability to remember new information

- Retrograde amnesia: inability to remember information from the past. Can have both organic and psychogenic causes

Dissociative fugue

- Now a subtype of dissociative amnesia

- Person suddenly moves away from home and assumes an entirely new identity

o Possesses no memory of previous identity

- Occurs in response to some stressor

- Treatment: psychotherapy to help the person identify the stressors leading to the fugue state and learn better coping skills

Depersonalization/Derealization disorder

- Episodic feelings of detachment from one’s own mental processes or body, like an outside observer of oneself

- Causes: significant stressor, sleep deprivation, or the influence of drugs

- Diagnosis: episodes are frequent and distressing and interfere with the ability to function

o Often involve a history of childhood emotional, physical, or sexual abuse

Controversies around the dissociative disorders

- Many believe these are not valid disorders

- Some argue dissociative disorders are created in patients by suggestions of therapists

- Are repressed memories real or created through the process of trying to retrieve them?

o Critics cite the unreliability of eyewitness testimony as evidence against validity

o Adults and children repeatedly asked about events that never occurred may eventually believe they happened

Chapter 7: Mood disorders and suicide

Depressive disorders

- Major Depressive Disorder (MDD)

- Persistent Depressive Disorder (formerly called Dysthymic Disorder)

- Premenstrual Dysphoric Disorder (PMDD)

- Depressive Disorder due to a medical condition

- MDD is polysymptomatic and includes emotional, behavioral, cognitive and physical symptoms

Major Depressive Disorder

A. For at least 2 weeks

- Must have 5 of 9 symptoms

o Depressed mood

o Loss of interest or pleasure (anhedonia)

o Weight change of 5% loss or gain

o Changes in sleep

o Psychomotor retardation / agitation

o Loss of energy

o Worthlessness

o Decreased ability to concentrate

o Recurrent thoughts of death

§ Must have one of the bolded

MDD: DSM

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

C. The episode is not attributable to the physiological effects of a substance or to another medical condition

- Criteria A-C above represent a major depressive episode

- Bereavement no longer an exclusion

Diagnosing Depressive Disorders

- Major depressive disorder (MDD): Depressive symptoms lasting 2 weeks or more

o Major depressive disorder, single episode

o Major depressive disorder, recurrent episodes

- Persistent depressive disorder: Milder (more moderate) depressed mood for most of the day for at least 2 years

o One year for children and adolescents

- Seasonal affective disorders (SAD): Experience and fully recover from major depressive episodes occurring seasonally for at least 2 years

- Peripartum onset: subtype of major depressive or manic episode used when the episode occurs during pregnancy or in the 4 weeks after childbirth

- Premenstrual dysphoric disorder (PMDD): increase in distress during the premenstrual phase

Epidemiology of Depression

- Lifetime prevalence rate is around 17%

- Females are diagnosed more than males by a ratio of a little over 2:1

- Virtually everyone is vulnerable to depression

Psychosocial predictors of depression

- Stressful life events

- Social support

- Family interaction and cognitive styles

Theories of Depression

- Biological

- Psychological

o Psychodynamic

o Behavioral

o Cognitive

- Sociocultural/personality

Biological theories of Depression

- Genetic Theory: Genes predispose people to depression

- Neurotransmitter theories: Dysregulation of neurotransmitters and their receptors

o Norepinephrine, serotonin, and dopamine

- Structural and functional brain abnormalities

o Prefrontal cortex, anterior cingulate, hippocampus and amygdala. Altered brain-wave activities in these areas affect mood

- Neuroendocrine factors

o Hormonal dysregulation including chronic hyperactivity in the HPA axis (cortisol)

o Sex hormones (testosterone, estrogen)

Psychological views

- Freud: depression is caused by loss or abandonment

o Introjection

- Therapy focuses on gaining insight into unconscious hostility and fears of abandonment

o Not a lot of empirical support

Depressive disorders

Behavioral perspective

- Depression results from changes in rewards and punishments people receive in their lives

o Peter Lewinsohn’s theory

o Behavioral activation

o Martin Seligman: Learned Helplessness (dogs)

Cognitive Perspective

- Negative irrational thinking is at the root of depression (Aaron Beck)

- Negative cognitive triad: people have negative views of themselves, the world, and the future. Cognitive distortion: All or nothing thinking

- Rumination: focusing on what is wrong and on negative emotions rather than problem solving

- Reformulated learned helplessness theory: explains how cognitive factors might influence whether a person becomes helpless and depressed following a negative event

Reformulated Learned helplessness model

- Example, you fail an exam

o Permanence: unstable vs. stable

§ I had a rough day vs. I will never get good grades

o Pervasiveness: specific vs. global

§ The professor is unfair vs. all professors are unfair

o Personalization: external vs. internal

§ The test was difficult vs. I am just stupid

Social/Personality Theories

- Sociocultural theorists propose that unipolar depression is greatly influenced by social context

- Interpersonal theories

o Interpersonal difficulties and losses are commonly reported stressors that trigger depression

o Rejections sensitivity: easily perceiving rejection by others

- Optimism and pessimism: optimists experience less distress when faced with stressful events, use more adaptive coping strategies, experience fewer physical symptoms, better recovery after heart surgery, and live longer

Vulnerability to depression

- Alloy, Abramson, and Francis

o First year university students with optimistic or pessimistic explanatory style tracked for 2.5 years

o For those with no history of depression: who developed depression during that period? 17% of pessimistic group; 1% of optimistic group

o For those with a history of depression: who relapsed? 27% of pessimistic group; 6% of optimistic group

Bipolar and Related disorders

Manic Episode: DSM

- A distinct period of abnormally elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day

Three mood components

- Elevated mood: euphoric, unusually good, cheerful, or high

- Expansive mood: unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions

- Irritable mood: verbally or even physically aggressive or agitated

Manic Episode

- During the period of mood disturbance and increased energy or activity, three or more of the following symptoms are present to a significant degree and represent a noticeable change from usual behavior

o Inflated self-esteem or grandiosity

o Decreased need for sleep

o More talkative and pressured speech

o Racing thoughts or flight of ideas

o High distractibility

o Increased goal-directed behavior

o Excessive involvement in pleasurable activities (with a potential for painful consequences)

Hypomanic episode

- A distinct period of abnormally elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day

- Similar symptoms as a manic episode but to a lesser degree of severity and lower impact on functioning

Diagnosing bipolar disorder

- Bipolar I disorder: elevated, expansive or irritable mood lasting more than 1 week and additional symptoms

o Grandiosity, racing thoughts, impulsivity, rapid speech, increase in activity, decreased need for sleep

- Bipolar II disorder: severe depression

o Hypomania: Main with less severe symptoms

- Cyclothymic disorder: less severe but more chronic bipolar condition

- Rapid cycling bipolar I or II disorder: four or more mood episodes that meet criteria for manic, hypomanic, or major depressive episode within 1 year

- Disruptive Mood dysregulation disorder (DMDD): Chronic irritability plus severe temper outbursts that are grossly out of proportion in intensity and duration to a situation and inconsistent with developmental level

o In children of age 6 and over

o Added to DSM to distinguish children with this pattern from children with classic bipolar disorder

Epidemiology of Bipolar disorder

- Less common than depressive disorders

- Males and females are equally susceptible

- No consistent differences in the prevalence among ethnic groups or across cultures

- Develops mainly in late adolescence or early adulthood

- People living with bipolar disorder often face problems on the job and in their relationships

Bipolar and Related disorders continued

Psychosocial predictors or mania

D. Negative threats to self-esteem lead to increased sensation-seeking

E. Goal dysregulation

F. Circadian rhythm disruption

Theories of Bipolar Disorder

G. Genetic factors

a. Strong and consistent linkage: chromosome 22?

H. Structural and functional brain abnormalities

a. Altered structure and functioning of the limbic region (amygdala) and prefrontal cortex

b. Basal ganglia shows abnormal response to rewards in the environment

I. Neurotransmitter factors

a. Dysregulation of the dopamine system

Biological treatments for mood disorder

- Drug therapy for depressive states

o Selective serotonin reuptake inhibitors (SSRIs)

o Selective serotonin norepinephrine reuptake inhibitors (SNRIs)

o Norepinephrine-dopamine reuptake inhibitor

o Tricyclic antidepressants

o Monoamine oxidase inhibitors (MAOIs)

- Mood stabilizers used in bipolar disorders

o Lithium and anticonvulsant and atypical antipsychotic medications

- Electroconvulsive therapy (ECT)

o Brain seizure is induced by passing electrical current through the patient’s head

Other biological treatments

- Repetitive transcranial magnetic stimulation (rTMS)

o Patients are exposed to repeated high intensity magnetic pulses focused on particular brain structures

- Vagus nerve stimulation

o Vagus nerve is stimulated by a small electronic device that is surgically implanted under the patient’s skin in the left chest wall

- Deep brain stimulation

o Electrodes are surgically implanted in specific areas of the brain

- Light therapy

o Exposing people to bright light for a few hours everyday

Psychological treatments for mood disorders

- Behavior therapy

o Increasing positive reinforcers and decreasing aversive events

o Teaching a person new skills of managing interpersonal situations and environment

- Cognitive behavioral therapy

o Discover, understand, and change the negative, hopeless patterns of thinking

o Help people solve concrete problems in their lives and develop skills for being more effective in their world

Cognitive therapy for depression

Other psychotherapies

- Designed specifically for bipolar disorder

- Interpersonal and social rhythm therapy (ISRT): Combines interpersonal therapy techniques with behavioral techniques and helps patients maintain

o Regular routines of eating, sleeping, and activity

o Stability in personal relationships

- Family-focused therapy (FFT): Reduces interpersonal stress in the context of families

o education about the disorder

o improves communication patterns in family

Comparison of treatment

- different therapies are effective in treatment

o CBT is the best psychotherapy for MDD

- Combination of psychotherapy and drug therapy is more effective than either type alone

- Relapse rates in depression and bipolar disorder are high after discontinuing any treatment

Mood disorders and suicide

Suicide stats

- Across life span, males are four times more likely to commit suicide than females

- For both males and females, the rate of suicide increases as an individual ages

- The highest US suicide rate seems among European Americans, although the rates appear to be increasing in all ethnic racial groups

- Increasing rate

Non-suicidal self-injury

- Significantly injuring oneself without the intention to die

o People with NSSI are at increased risk of attempting suicide

o May function as a way for regulating emotion

§ People report sense of calm upon feeling pain and seeing blood

o May function as a way of influencing the environment

§ Gain attention and sympathy

§ Punish others

Suicide cluster vs. contagion

- Suicide cluster: suicides or attempted suicides are nonrandomly bunched together in space or time

o More likely to affect those who

§ Knew the person who committed suicide

§ Are linked to the suicide by media exposure

- Suicide contagion: survivors who become suicidal may be modeling the behavior of the friend or admired celebrity who committed abuse

Risk factors for suicide

- Psychological disorders

o Depression

o Bipolar disease

o past suicidal thoughts and behavior

- Stressful life events/traumas

o Interpersonal violence and sexual abuse

o Loss of a loved one

o Economic hardship

o Physical illness

Factors in suicide

- Personality and cognitive factors

o Impulsivity: tendency to act on one’s impulse rather than inhibiting them

o Hopelessness: feeling that the future is bleak and there is no way to make it more positive

- Biological factors

o Genetic component

o Low serotonin levels

Treatment of suicidal persons

- Hospitalization

- Community based crisis intervention programs

- Drug therapy

o Lithium

o Selective serotonin reuptake inhibitors

- Psychological therapies

o Dialectical behavior therapy (DBT) – focuses on managing negative emotions and impulsive behaviors

Chapter 8 – Schizophrenia spectrum and other psychotic disorders

Brief history of schizophrenia

- Emil Kraepelin: dementia praecox

- Eugen Bleuler: Schizophrenia

o Four A’s

§ Associations

§ Affect

§ Autism

§ Ambivalence

o Kurt Schneider: Early DSM

Psychosis

- Inability to differentiate between what is real and what is unreal

- Psychotic symptoms divided into two groups: positive and negative

o Positive symptoms: delusions, hallucinations, disorganized speech, disorganized behavior

o Negative symptoms: lack of expected or normal emotions, behaviors, and motivations

Delusions

- Disturbances in inferential thinking that involve firmly held beliefs that are untrue

- Persecutory, grandiose, somatic, religious, nihilistic

- Delusions of reference

Hallucinations

- Perceptions experienced without an external stimulus to the sense organs that have qualities similar to true perceptions

- Auditory, Visual, Gustatory, Olfactory, Tactile

Positive symptoms

- Formal thought disorder: Schizophrenia involves significant problems with thinking

o Loose associations or derailment: tendency to slip from one topic to an unrelated topic with little coherent transition

- Disorganized behavior: unpredictable and apparently untriggered agitation – shouting, swearing, pacing

o Catatonia: disorganized behavior that reflects unresponsiveness to the environment

o Waxy flexibility

Negative symptoms

- Certain behaviors, emotions, and motivations one would expect to see are absent in the person affect by schizophrenia

- Restricted affect: severe reduction in or absence of emotional expression

- Avolition/asociality: inability to initiate or persist at common, goal-directed activites

- Cognitive deficits: deficits in basic cognitive processes, including attention, memory and processing speed

DSM-5-TR criterion A: active phase

- Two ore more of the following, each present for a significant portion of time during a 1 month period

o Delusions

o Hallucinations

o Disorganized speech

o Grossly disorganized or catatonic behavior

o Negative symptoms

§ Must have 1,2, or 3

DSM-5 Criteria B and C

- For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset

- Continuous signs of disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms meeting criterion A

Other Psychotic disorders

- Schizoaffective disorder

o Mix of schizophrenia and a mood disorder

- Schizophreniform disorder (1 month to 6 months)

o Symptoms of schizophrenia present for less than 6 months

- Brief psychotic disorder (<1 month)

o Sudden onset of delusions, hallucinations, disorganized speech, and or disorganized behavior lasting for up to a month

- Schizotypal personality disorder

DSM-5: Delusional disorder

- The presence of one or more delusions with a duration of 1 month or longer, but Criterion A for Schizophrenia has never been met

o Subtypes

§ Erotomanic

§ Grandiose

§ Jealous

§ Persecutory

§ Somatic

Epidemiology of Schizophrenia

- Lifetime prevalence is around 1%

- Equal number of males and females, but females have better long-term outcomes

- Age of onset: males are usually late teens, females are usually late 20s

- Chronic, debilitating condition with a poor long term outcome

Three phases of schizophrenia

- Prodromal phase: beginning of deterioration; mild symptoms

- Active (acute) phase: symptoms become apparent

- Residual phase: a return to prodromal-like levels

Prognosis

- Overall poor prognosis even with treatment

o One of the most sever and debilitating mental illnesses

- Rehospitlization rates between 50 and 80 percent

- 5-10 percent die by suicide

- Some may reach some stabilization between 5 and 10 years after psychotic episode

- High rate of medical problems

Factors affecting prognosis

- Sex and age

o Females develop the disorder later, display milder symptoms, and have a more favorable course than males

o Functioning in some may improve with age

- Sociocultural factors

- Socioeconomic status

- Cultural factors

o Not as disabling in less developed countries

o Broader and more intensive family support

o More hostility, overinvolvement, and criticism by family members in developed countries worsens outcomes.

Chapter 8 continued

Biological theories

- Genetic transmission

o Family studies – biological relative with schizophrenia increases an individual’s risk

o Adoption studies – parent with schizophrenia creates a stressful environment for children

o Twin studies – genetic predisposition plus biological and environmental factors influence manifestation of the disorder

o COM-T gene anomaly (22q11 deletion syndrome): regulates dopamine

§ Polygenic

Structural models

- CT/MRI scans show ventricular enlargement and cerebellar atrophy

- MRI shows decrease in volume or size of frontal cortex, temporal regions (hippocampus, thalamus), and the cerebellum

- PET shows hypo frontality (low blood flow to frontal lobes)

Biological theories

- Birth complications or prenatal exposure to viruses affect brain development

- Neurotransmitter theories – excess levels of dopamine contribute to schizophrenia

o Phenothiazines or neuroleptics: reduce the functional level of dopamine in the brain

o Drugs that increase the functional level of dopamine increase the incidence of the positive symptoms

o Neuroimaging studies – presence of more receptors for dopamine and higher levels of dopamine

- Mesolimbic pathway: subcortical part of the brain involved in the processing of salience and reward

- Antipsychotics work by binding to a specific type of dopamine receptor common in the mesolimbic system, blocking the action of dopamine

o Unusually low dopamine activity in the prefrontal area of the brain related to negative symptoms

- Serotonin neurons regulate dopamine neurons in the mesolimbic system

o Serotonin and dopamine interactions are critical

Biological treatments: typical antipsychotics drugs

- Older antipsychotic medications (neuroleptics) reduce positive symptoms

- Chlorpromazine: belongs to a class of drugs called the phenothiazines, calms agitation and reduces hallucinations and delusions

- Blocks type 2 receptors for dopamine, thereby reducing its action in the brain

- Side effect – extrapyramidal

o Tardive dyskinesia: neurological disorder involving involuntary movements of the tongue, face, mouth, or jaw

Newer biological treatments

- Atypical antipsychotics: newer antipsychotics bind to the D4 dopamine receptor and influence several other neurotransmitters like serotonin

o Target both positive and negative symptoms

o Side effects

§ Dizziness, nausea, sedation, seizures, hypersalivation, weight gain, and tachycardia

§ Agranulocytosis – deficiency of granulocytes, substances produced by the bone marrow to fight infection

Psychosocial perspectives

- Social drift: tendency to drift downward in social class compared to the class of one’s family of origin

o Caused by schizophrenia symptoms that interfere with the ability to complete an education or get a job

- Birth in a large city related to higher risk of prenatal exposure to infection

- Stress increases risk and is linked to relapse

- Families thwart the growth of the autonomous sense of self

Predictors of poor outcomes

- Male

- Poor pre-morbid functioning

- Social isolation (or poor social support)

- Medication non-adherence

- Longer duration of active episode

- History of other psychiatric disorders (including behavioral problems in childhood)

Psychological views

- Psychodynamic regression to a pre-ego stage and efforts to re-establish ego control

o Schizophrenogenic mother: cold, domineering, over-controlling, and uninterested

- Behavioral: operant conditioning and principles of reinforcement (attention)

- Cognitive: biologically based but maintained by faulty interpretations and a misunderstanding of symptoms

Cognitive perspectives

- Fundamental difficulties in attention, inhibition, and adherence to the rules of communication leads to conserving limited cognitive resources

- Delusions – person tries to explain strange perceptual experiences

- Hallucinations – hypersensitivity to perceptual input, with a tendency to attribute experiences to external sources

- Negative symptoms – expect social interactions to be aversive and so conserve scarce cognitive resources

Expressed emotion

- Expressed emotion: highly intrusive, critical and overly involved family members associated with less recovery and more relapse

o Critical comments: unambiguous statements of disapproval or resentment, rejecting remarks, or statements delivered in a critical tone of voice to the patient

o Hostility: rejection of the patient of expression of global criticism

o Emotional over-involvement: family member engages in self-sacrifice, overprotection, or over-identification with the patient

Psychological treatments

- Behavioral – token economy

- Social skills training and support (Milieu therapy)

- Adherence interventions

- Cognitive rehabilitation – stress management and CBT

Psychological and social treatment

- Family therapy (for high EE)

o Basic education of the illness

o Train family to ignore negative behaviors and reinforce positive behaviors

o Address disorder’s impact on caregivers to provide support and decrease overall stress levels

- Assertive community treatment programs

Chapter 9: Personality Disorders

Personality

- Determines how one feels, interacts with others, and perceives events

- Personality trait: aspect of personality that is stable across time and across many situations

- Five-factor model: perspective that everyone’s personality is organized along five broad personality traits or factors

Personality Disorder

- Personality disorder: patterns of thinking, feeling, and behaving markedly interfere with an individual’s ability to function adaptively in the world and relate to others

o Typically evident by early adulthood

o Pattern must be evident across multiple settings and environments

o Pattern must be chronic, not occurring only during the context of a mood episode or only when symptoms of another disorder are active

General Personality Disorder: DSM-5-TR

- An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas

1. Cognition (ways of perceiving and interpreting self, other people, and events)

2. Affectivity (the range, intensity, lability, and appropriateness of emotional response)

3. Interpersonal functioning

4. Impulse control

Personality Disorders

- Cluster A: Odd-Eccentric personality disorders

- Symptoms are similar to those for schizophrenia, including inappropriate or flat affect, odd thought or speech patterns, and paranoia

- Schizoid, Schizotypal, and paranoid personality disorders

Odd-Eccentric Personality disorders

- Paranoid Personality Disorder:

o A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts

Paranoid Personality Disorder

1. Person suspects that others are exploiting, harming, or deceiving them

2. They are preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

3. Individuals is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them

4. Person reads hidden demeaning or threatening meanings into benign remarks or events

5. They persistently bears grudged

6. Individuals perceives attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack

7. Person has recurrent suspicions regarding fidelity of spouse or sexual partner

Theories and treatment of paranoid personality disorder

- Theories

o Genetics basis – on schizophrenia spectrum?

o Cognitive distortion that others cannot be trusted and one cannot defend oneself

- Treatment

o Typically receive treatment during a crisis or for treatment of anxiety and depression – do not see a problem with their paranoia

o Often too guarded and suspicious to engage in therapy

o Therapy should not confront paranoid beliefs but rather increase social skills and skills for handling problems

Odd-Eccentric personality disorders

- Schizoid Personality Disorder

o A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts

Schizoid Personality disorder

1. The person neither desires nor enjoys close relationships

2. Almost always chooses solitary activities

3. Has little interest in having sexual experiences with another person

4. Takes pleasure in few activities

5. Lacks close friends or confidants other than first degree relatives

6. Appears indifferent to the praise or criticism of others

7. Shows emotional coldness, detachment, or flattened affectivity

Theories and Treatment of Schizoid Personality disorder

- Theories

o Some evidence that underlying personality traits may have genetic basis

- Treatment

o Typically unmotivated for treatment as close interpersonal relationships are viewed as unpleasant

o Increase awareness and expression of feelings and improve social skills and number of social contacts

Odd-Eccentric personality disorders

- Schizotypal Personality Disorder

o A 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 behavior, beginning by early adulthood and present in a variety of contexts

Schizotypal personality disorder

1. Odd or unusual behavior

2. Ideas of reference

3. Odd beliefs or magical thinking that influences behavior

4. Unusual perceptual experiences

5. Odd thinking and speech

6. Suspiciousness

7. Inappropriate or constricted affect

8. Behavior or appearance that is odd, eccentric, or peculiar

9. Lack of close friends or confidants

10. Excessive social anxiety that does not diminish with familiarity

Theories of Schizotypal Personality Disorder

- Biological basis – may share genetics with schizophrenia

o Problems with a gene that regulates the NMDA receptors system

o Cognitive difficulties in verbal fluency, with inhibiting information, and in memory

o Dysregulation of the neurotransmitter dopamine in the brain

- Frequent histories of childhood adversities reported, including child abuse, substance abuse, and incarceration

Treatment of Schizotypal personality disorder

- Drug therapy

o Same as of schizophrenia – neuroleptics, antipsychotics, and antidepressants

- Psychological therapy

o Difficult to engage clients because of paranoia

o Help them test validity of suspiciousness by realistically evaluating the environment

o Help them identify and disregard bizarre thoughts rather than believing them and acting on them

Personality disorders

- Cluster B: dramatic-emotional personality disorders

o Manipulative, volatile, and uncaring in social relationships. Impulsive, sometimes violent behaviors that show little regard for their own safety or the safety or needs of others

o Histrionic, narcissistic, antisocial, and borderline personality disorders

Dramatic-emotional personality disorders

- Histrionic personality disorder

o A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts

Histrionic personality disorder: DSM 5

1. Uncomfortable in situations in which they are not the center of attention

2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

3. Displays rapidly shifting and shallow expression of emotions

4. Consistently uses physical appearance get attention

5. Has a style of speech that is excessively impressionistic and lacking in detail

6. Shows self-dramatization, theatricality, and exaggerated expression of emotion

7. Is suggestible

8. Considers relationships to be more intimate than they are actually are

Theories and treatment of histrionic personality disorder

- Theories

o Little know about it

o Question as to relative genetic versus environmental influences

- Treatment

o Psychodynamic – uncover repressed emotions and needs and teach patient to express feelings and get needs met in socially acceptable ways

o Cognitive – help patient function more autonomously and independent of others’ approval; tone down dramatic evaluations of experiences by replacing them with more realistic appraisals

Borderline personality disorder

- In 1921, Emil Kraepelin described the excitable personality

- Psychoanalytic formulation

o Adolf stern: borderline group of neuroses

o Melitta Schmeideberg: borderline insanity

o Otto Kernberg: borderline personality organization

- Introduced in its modern form as Borderline personality disorder in the DSM-III 1980

Dramatic-Emotional Personality Disorder

- Borderline Personality disorder

o A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts

1. Frnatic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships

3. Identity disturbance

4. Impulsivity in at least two areas that are potentially self-damaging

5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

6. Affective instability due to marked reactivity of mood

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger

9. Transient, stress-related paranoid ideation

Theories of borderline personality disorder

- Cognitive theory

o Childhood abuse, neglect, and instability contribute to difficulties in regulating emotions and in attaining a positive stable identity

- Psychoanalytic theory

o People never learned to fully differentiate their view of themselves from their view of others

o Makes them extremely reactive to others’ opinions of them and to the possibility of abandonment

Object relations theory

- Undifferentiated stage

- Symbiosis

- Separation – individuation: splitting of the ego

- Integration stage

Theories of borderline personality disorder

- Neurobiological theory

o Smaller amygdala and hippocampus results in difficulty in regulating moods

o Structural and metabolic abnormalities in the prefrontal cortex resulting in dysregulation of emotional reactions and in poor control of impulsive behavior

- Biological theory

o Symptoms are heritable

o Early abuse and maltreatment also are associated with changes in the structure and organization of the brain

Neurobiology of Borderline Personality disorder

- Impulsive aggression (angry outbursts, self-destructive behavior, impulsiveness) is heritable, as demonstrated by twin and adoption studies, and has been consistently correlated with biological indices, particularly those associated with reduced serotonin activity

- Affective instability (marked emotional reactivity to environmental events, particularly events such as separations, frustrations, or loss) has been related to elevations in norepinephrine and dopamine activity

Borderline Personality disorder

- Marsha Lnehan has developed a biosocial theory of BPD implicating two components

o Emotional dysregulation plus invalidating environment

o Dialectical behavior therapy (DBT) helps patients adapt a realistic and positive sense of self, regulate emotions, learn adaptive skills for solving problems, and correct dichotomous thinking

Systems training for emotional predictability and problem s

Knowt