ABNORMAL PSYCHOLOGY - Midterm 1

Abnormal Psychology

Lecture 1: Intro / History of Psychopathology

Good & Bad Reasons for Believing

More bad reasons than good

• Observation

• Tradition

• Authority → they disagree

• Intuition / Common Sense → many of the most important scientific discoveries have been counterintuitive → commons nse differs from theoretical sense

• Good reason → science

  • Truth 

• Theoretical sense → evolution

Truth & Knowledge

• ‘Nullius in verba’ (‘take no one’s word for it’)

How do we know the things we know?

Dogmatism

Empiricism

The scientific method → a procedure for finding truth using empirical evidence →is simply a way of knowing something

• Any scientific theory that cannot be disprove is worse than useless**

• In science, we don't’ attempt to prove, we attempt to disprove

  • The scientific theories that we adhere to are those that have withstood many attempts to be disproven

• Not perfect, but the best method we have

• Science is a way of knowing [period]

  • Silent regarding what we do with what we know

Science

• Theory, hypothesis, data collection, examination of evidence, refinement of theory, peer review, replication, methods, reliability, presentation of data

History of Psychopathology

History

• Efforts to understand and resolve problems of psychopathology

  • Traced throughout many centuries and cultures → times and places where mysticism and charlatanism flourished

  • Have unfolded without the care and watchful eye of scientific methods → based largely off of “bad reasons for believing”

• Each historical period is a response to a previous period, but incorporates from past periods too (retains element)

• Historical review → helps us understand how current conceptualizations have roots in 

Ancient History

• The sacred approach → psychopathology was the expression fo f transcendent magical action brought about by external forces

  • Animistic phase → connection between primitive beings and forces of nature

  • Mythological phase → every symptom of a disorder was thought to be caused by a deity who, if appropriately implored, could benevolently cure

  • Demonological phase → two competing forces struggled for superiority → creative + positive vs. destructive and negative

• Susruta → suggested that passions and strong emotions of the mentally disordered brought about physical ailments → these were best served by psychological help 

Hindu Medicine → proposed the existence of three emotional inclinations

• Wise and enlightened goodness → brain

• Impetuous passions → chest

• Blind crudity of ignorance → abdomen

• Doshas → bodily fluids → vata, pitta, and kapha

• Mental disorders are seen as largely metaphysical

Babylonian Empire

• Assigned a demon to each disease → insanity was caused by the demon Idta

Chinese Medicine

• Vicious air

• Complementary: yin & yang

• Five elements: gold, wood,water, fire, and earth 

• Tao → achieved by integrating self into the realm of nature

Greek Civilization

Pythagoras → thought the mathematical principles of balance and ratio accounted for characterological differences 

• First philosopher to claim that the brain was the organ of the human intellect & source of mental illnesses

• Soul comprised of three parts → reason, intelligence, + impulse

• Brain → rational center ||  Soul/chest/heart → irrational center

Hippocrates

• Identified four basic temperaments → choleric, melancholic, sanguine, phlegmatic → these terms are still used today… 

Plato 

• Powerful emotional forces

• Conflicts exist among different components of the psyche

Abnormal Psychology

Lecture 2: Classification 

Diagnosis is Difficult

• Many diagnostic instruments for the same disorder do not completely converge

• Many disorders are ego-dystonic (e.g. obsessive compulsive disorder) rather than ego-syntonic (obsessive compulsive personality disorder)

  • This makes some patients “unreliable narrators” of their own experiences

• Many diagnoses have overlapping criteria

• In the DSM, not all criteria are required to make a diagnosis

  • Ex: there are 0 criteria for Borderline Personality Disorder and a patient needs to meet 5 to make a diagnosis

  • This means that you can have two patients with the same diagnosis and only 1 overlapping criterion

Some Definitions…

• Diagnostic / Classification systems – lists of terms for conventionally accepted concepts used to describe psychopathology

  • Generally called classifications

  • DSM-5 and ICD-10 are examples

• Classification – the activity of forming groups

• Diagnosis – the process by which individuals are assigned to already existing groups

• Taxonomy – the study of how groups are formed

  • A meta-level concept looking at different theoretical ways classifications can be organized, studied, and changed

Two Classification Systems

• Diagnostic and Statistical Manual of Mental Disorders (DSM)

  • First published in 1952

  • Currently in its 5th edition

• International Classification of Diseases (ICD)

  • First published in 1948

  • Currently in a revision of its 10th edition

Fundamental Problems of Psychiatric Classification

Unresolved issues

• The nature of the entities being classified

  • We’ve been classifying them while their definitions were being understood and developed

• The definition of what a mental disorder is

  • Defined as a problem to the self and/or others?

• The nosological principles for organizing psychiatric classifications

  • That is, what’s the best way to classify disorders?

  • Should it be based on insurance? Should it be based on theory? What if you have different theories?

• Distinction between normality and pathology 

• Validity of many diagnoses

More Problems… 

Controversies

• Definitions and logical status of some diagnoses

• Whether some entities are pathological conditions

  • There were heated debates in the 1960s and the 1970s over whether homosexuality should be considered a mental disorder

  • Current debates exist on whether Internet Addiction belongs in an official classification

No current consensus regarding taxonomic principles for resolving these controversies

Why Classify?

Classification defines boundaries

• Ultimately establishes where the discipline ends and begins

1. Provides nomenclature for practitioners

2. Serves a basis for organizing and retrieving information

3. Describes the common patterns of symptom presentation

4. Provides a basis for making predictions

5. Forms the basis for the development of theories

Nomenclature

• Nomenclature – a list of names or terms of the categories within a classification system

  • This allows psychologists to “talk to each others”

  • Otherwise, we’d always describe people as a collection of symptoms

  • This provides a short-hand for psychologists to use when talking to

    • Other psychologists

    • Lay people

    • Insurance companies

    • Other professionals

  • Must be careful, as any short-hand isn’t as descriptive as a full picture could be…

Information Retrieval

• Knowing a diagnosis helps the clinician retrieve information about etiology, treatment, and prognosis

• Classified concepts are useful devices for people to obtain information about a diagnosis

Descriptive Basis

• Classification establishes a descriptive basis for a science of psychopathology

• This is required to transform individual cases into principles and generalizations

• Cases within a diagnosis should be

  • Similar to other cases that share a diagnosis

  • Different from cases that don’t share a diagnosis

• This can be a bit circular, in my opinion, but I suppose it’s a necessary evil 🙁

Prediction

Information about a diagnosis gives the clinician information relevant to the person’s

• Clinical course: the clinical can make an informed prediction about how the person is likely to behave in various situations

• Response to treatment: gives the clinician a means of selecting which treatment option is best for the person 

The Development of Theories

• In other fields (i.e. biology and chemistry), classification was required for theoretical progress

  • The systematic classification of species by Linnaeus prompted important question about the relation between species (this eld to theories of evolution)

  • Theories of the relationship between diagnoses can also be helpful

  • Various disorders might have common pathological mechanisms that could increase our understanding of etiology, treatment, etc. 

Taxonomic Issues

• There are many! Here are a few important ones:

  • Classification of syndromes, disorders, or diseases

  • Classification of disorders versus classification of individuals

  • Definition of mental disorder

  • Dimensions versus categories

  • DSM as atheoretical 

Classification of Syndromes, Disorders, or Diseases

The terms syndrome, disorder, and diseases are often used interchangeably, but refer to different assumptions about the nature of what they describe

• A person experiences symptoms and show signs

  • Symptoms - self-reported issues

  • Signs - issued observed by others

• Symptoms and signs often co-occur

  • If they didn’t, classification and diagnosis would be extremely difficult

  • Why do signs and symptoms co-occur?*

• When signs and symptoms co-occur frequently, the condition is termed a syndrome

  • Term is silent regarding causes. Only descriptive

• Disorder - a pattern of symptoms and signs that includes an implied impact of the functioning of an individual

  • The term is more descriptive than syndrome

  • Some causal factors might be understood

  • Etiology is still unclear and/or multiply determined

• Disease - a condition with a 

  • Known etiology (cause)
    Known path front he causal agent to the symptoms and signs

Classification of Disorders vs. Classification of Individuals

• What are being classified are disorders that people have

• Done to avoid stigmatization → goal was to have no or minimal harm done by assigning a diagnosis

• Classifying individuals implies the individual is a member of a diagnostic category that is unchanging & destructive to the person and those in their life

• Classifying disorders

  • Implies that the person isn’t inherently (e.g. schizophrenic)

  • Implies that the disorder is something that happens to an individual

Definition of Mental Disorder

• First definition of a mental disorder came in DSM III

• “Mental disorders are a subset of medical disorders” 

• This became controversial as some thought it gave exclusive rights to psychiatrists → leaving out other mental health professionals, like psychologists and social workers

• Later rewritten

• Wakefield (1993) → argued that Spitzer and Endicott’s definition failed to operationalize the role of dysfunction inherent to mental disorders

Dimensions versus Categories

• Advantages and disadvantages of a categorical system

Advantages

• Easy to use because they are more “black and white”

• Consistent with biological and medical classification systems

Disadvantages

• Result in the loss of some information

• Some of the boundaries are arbitrary or ill-defined

Jaspers (1963)

• Suggested that different classification models might be required for different forms of psychopathology

• Categories: might be best for conditions traditionally described as organic disorders and similar to those in physical medicine

• Dimensions: might be best for affective disorders or personality disorders

DSM as Atheoretical

• Committee members of DSM-III decided it should be atheoretical

  • This was for the classification to be more accessible to all mental health professionals

    • Regardless of their theoretical orientation

• The positive is that all mental health workers can use it

• But what does it say about our field that we don’t have an overarching theory?

Diagnostic Overlap

• Of those in the general population who meet criteria for a disorder, ½ meet criteria for two or more other disorders

• About 95% of patients meeting criteria for borderline personality disorder meet criteria for another personality disorder

Meaning of Comorbidity

• We would expect some comorbidity to occur by chance

• However… epidemiological studies have found that mental disorders co-occur much more often in the population than expected by chance

• Two hypothetical examples:

1. Comorbid diagnoses of panic disorder and insomnia → meaningfully related, or one may cause the other, or both may have the same cause

2. Comorbid alcohol use disorder and specific phobia → could be of less theoretical interest; might also be more likely to be attributed to chance

• Another example → unipolar affective disorders and anxiety disorders co-occur at a very high rate; this has led some to believe they are  the same thing (or different manifestations of the same thing)

Abnormal Psychology

Lecture 3: Research & Causation 

What Is a Cause?

• How do we know that one thing causes another?

• There is no easy answer to this question  → philosophers, scientists, and economists have been arguing for centuries over what constitutes causality

  • No reason to believe any of these fields has a great answer to the question

Aristotle

• Presented notion that we do not have knowledge of something until we know its cause

• This notion seems central ot human psychology

The Why Game

• Children ask why

• The desire to know the why  of things seems basic → aristotle simply formalized notion by saying that we aren’t satisfied with our knowledge until we know the “why” behind it

David Hume

• HUme was obsessed with the ntoiono f “experience” and how it generates knowledge

• How we perceive causality will be based on temporality & contiguity

• We are naturally inclined to attribute the experience of constant contiguity to causality

John Stuart Mill – Five Methods of Induction

1. Direct method of agreement

• If something is a necessary cause, it must always be present when we observe the effect

2. Method of difference

• If two situations are exactly the same in every aspect except the effect occurs in one but not ht either situation

• Then the one aspect they do not have in common is likely to be the cause of the effect

3. Combination of the methods of agreement and difference

4. Method of Residue

• If many conditions cause many outcomes and we have matched the conditions to the outcomes on all factors except one, then the remaining condition must cause the remaining outcome

5. Method of Concomitant Variation

• If one property of a phenomenon varies in tandem with some property of the circumstance of interest, then the property most likely causes the circumstance

Austin Bradford Hill - Nine Criteria for Causal Inference

1. Strength – the larger the association, the roe likely it is causal

2. Consistency - consistent observations of suspected cause and effect in various times and places raise the likelihood of causality

3. Specificity – the proposed cause results in a specific effect in a specific population

4. Temporality - the cause precedes the effect in time

5. BIological gradient – greater exposure to the cause leads to greater effect

6. Plausibility - the relationship between cause and effect is biologically and scientifically plausible

7. Coherences – epidemiological observation and laboratory findings confirm each other

8. Experiment – when possible, experimental manipulation can establish cause and effect

9. Analogy – cause-and-effect relationships have been established for similar phenomena

Karl Popper – Empirical Falsification

• “In so far as a scientific statement speaks about reality, it must be falsifiable, and in so far as it is not falsifiable, it doesn’t not speak about reality”

If It Can be Falsified, It Might be True

• Popper is seen as the forefather of empirical falsification

• Proving causality was the wrong goal for Popper

• Induction should proceed not by proving, but by disproving

• The idea is often difficult for non-scientists to grasp 

• This is why the statement “There is a God” is not a scientific hypothesis

  • It is impossible to disprove

• The goal of scientific experimentation:

  • To try to disprove a hypothesis by a process that resembles experience or empirical observation

• This is why we are always trying to disprove /reject a null hypothesis in statistics

• A scientific finding: 

  • Always a matter of rejecting the null hypothesis

  • Never a matter of accepting the alternative hypothesis

• A crazy idea can’t be disproven, so it is not a scientific hypothesis → frame questions to disprove

• A scientist doesn’t frame a question “can we prove that this new drug works?” → it’s always “with how much certainty can we disprove the idea that this drug does not work?”

• Scientists are hesitant to make declarative statements such as “vaccines do not cause autism” → much more comfortable saying “there is no difference in incidence of autism between vaccinated and non-vaccinated individuals

The Counterfactual

• The counterfactual condition refers to what would have happened in a different world

• This is the very condition that would establish causality once and for all

• Unfortunately, it is impossible to observe

• This doesn’t stop us from trying to approximate it → scientific methodologies like random designs, replication etc.

• Scientists will always be reluctant to say the magic word (“cause”)

• Laypeople, on the other hand, are primed to look for causality and never feel secure until they have established it

Sufficient Component Cause Model

• Ken Rothman (1976)

• Model imagines the causes of phenomena of a series of “causal pies”

• Component causes – individual factors that contribute to a disease

  • Shown below as individual “slices” of the pie

  • After all of the pieces of a pie fall into place

    • The pie is complete

    • The disease occurs

• Sufficient cause - the complete pie → may be considered a causal pathway

• A disease may have more than one sufficient cause

  • Each sufficient cause can be composed of several component causes that may or may not overlap

  • Component causes B and C → either one, the other, or both can contribute to the disease neither are a necessary cause

• Necessary cause - a component cause that appears in every pie or pathway → without it, the disease does not occur

  • Component cause A is necessary because it exists within each pie → assuming that these three represent the only “causal” pies

• Causes can come in four varieties

  • Necessary and sufficient

  • Necessary but not sufficient

  • Sufficient but not necessary

  • Neither sufficient nor necessary

Sufficient Component Cause Model – Examples

• The presence of a third copy of chromosome 21 is a necessary and sufficient cause of Down Syndrome

  • It is all that is needed to cause Down Syndrome

  • One can’t have down syndrome without it

• Alcohol consumption is a necessary, but not sufficient cause of alcoholism

  • In order to be classified as an alcoholic, one must drink alcohol

  • Drinking alcohol, but itself, is not enough to cause alcoholism

• Exposure to high doses of ionizing radiation is a sufficient, but not necessary cause of sterility in men

  • This factor can cause sterility on its own

  • It is not the only cause of sterility and sterility can exist without it

• A sedentary lifestyle is neither sufficient nor necessary to cause coronary heart disease

  • On its own, will not cause heart disease

  • Heart disease can certainly occur in the absence of a sedentary lifestyle 

• Smoking is neither a necessary nor sufficient cause of lung cancer

  • People who smoke may not develop lung cancer

  • People who do not smoke may develop lung cancer

  • This does not mean that smoking is not a cause of lung cancer

  • Smoking is part of the “causal pie” of lung cancer → it is not part of every “causal pie” (i.e. it is not necessary)

  • It cannot constitute its own casual pie (i.e., it’s not sufficient) → because smoking by itself does not produce lung cancer

• Smoking causes lung cancer, even if we do not observe cancer in every case of smoking 

Conducting Research in the Field of Psychopathology

Paul Meehl: Causes

• Paul Meehl (1977)

  • Described several meanings of causation within psychopathology

  • They differ in strength

• Specific etiology

  • A categorical (all-or-none) variable that is both necessary and sufficient for a disorder to emerge

  • Example: Huntington’s Disease

    • A single dominant gene is both necessary and sufficient to produce the disease

    • This is rare in psychopathology 

• Threshold Effect

  • A dimensional variable

  • When the threshold is exceeded, the individual is at risk for the disorder

  • Below the threshold, there is no risk for the disorder

• Step Function

  • A dimensional variable

  • The individual’s risk for the disorder increases sharply once past the threshold

  • The individual’s risk for the disorder is low below the threshold, but not zero

• Diathesis-Stress

  • These variables are necessary, but not sufficient for a disorder

  • Elevated levels of certain variables create a diathesis (i.e., vulnerability)

    • This vulnerability is often genetically influenced and actualized only when one encounters a stressor

  • Both vulnerability factors and stressors are necessary for a disorder to emerge → neither is sufficient

• A causal factor can also be neither necessary nor sufficient for psychopathology

  • Ex: hyperreactivity to negative emotions (e.g. neuroticism) fits this model

Case Study Methodology

• Case Study – the detailed examination of a single individual

  • Good for the context of discovery – hypothesis generation

  • Poor for the context of justification – hypothesis testing

    • Lack the controls found in systematic research

    • Impossible to generalize findings

• Example: Imagine a case study of an individual with bipolar disorder who reports her parents were extremely critical while she was young

  • We cannot make any conclusions about bipolar disorder and critical parents

    • The experience may be unique to the individual

  • No matter how meticulous the case study is, it can never justify a generalization

Positives

• Can demonstrate the existence of rare phenomenon not previously recognized

  • For example, H.M. had a surgically removed hippocampus and was unable for form new memories

• Can function as existence proofs by negating a general proposition

  • For example, many psychologists thought that individuals with severe mental retardation were incapable of learning

  • Only one exception is needed to disprove this rule

Quasi-Experimental Designs

• Experimental design – when researchers randomly assign participants to one of two conditions

  • Experimental group – received the experimental manipulation

  • Control group – does not receive the experimental manipulation

• It’s rarely possible to randomly assign conditions in psychopathology research → Even if it was, it’d be super unethical!

• Quasi-experimental design – a comparison of two or more groups defined by pre-existing characteristics (e.g., depressed vs. nondepressed individuals)

  • “Mother Nature” has already assigned these groups

  • These are technically correlational studies → Thus, they suffer from the same design limitations

• Should not draw causal inferences from quasi-experimental studies

  • Researchers do not randomly assign groups

  • Thus, participants may also differ on numerous potential confounding variables

• It is impossible to isolate confounding variables 

• Matching - equating the quasi-experimental groups on potentially confounding variables 

  • Several difficulties:

  • There could always be a confounding variable we haven’t thought of

  • Rests on causal assumptions that may be incorrect

  • Matching on a variable can create additional systematic differences

• Analogue Experiment – an attempt to produce variants of psychopathology in either humans or animals

  • For example, rather than study clinical depression, a research might use a mood induction paradigm

  • Two pitfalls: We assume that the analogue provides an adequate model of the condition & may be unethically unacceptable or impractical to create symptoms

• Animal Models of Psychopathology

• Involves attempts to produce a simulated form of a mental disorder in non-humans

• Learned helplessness (Seligman, 1975)

  • Exposing animals to uncontrollable aversive stimuli produced common symptoms of human depression

• Pitfalls:

• Researchers must be cautious in generalizing findings to humans

• Using animals does not sidestep ethical issues

• Challenge Paradigm – when researchers present participants with stimuli thought to trigger a pathological response

  • Example: Researchers have used biological challenges, such as CO2 inhalation, with panic patients to test panic responses

  • Pitfalls: Ethical concerns

• Single-Subject Experimental Designs

  • Each subject serves as his or her own control

  • ABA or Reversal design: a researcher might measure baseline behavior (e.g. nail-biting, then after introducing an intervention, then again after withdrawing the intervention

  • Pitfalls: some interventions can’t be withdrawn/reversed

Epidemiological Studies: Gathering Clues to Etiology

• Epidemiology is the study of the distribution of disorders in a given population & the variables associated with this distribution

• Answers

  • How common is a psychological disorder?

  • What characteristics are associated with the disorder?

  • How often do cases of this disorder arise and disappear?

• Research on the rate of a disorder can provide a baseline comparison

  • EX: The prevalence of schizophrenia is 1% of the general population, YET Identical twins of individuals with schizophrenia have a 50% chance of developing schizophrenia–This number is only meaningful in comparison to the baseline rate

• Characteristics covarying with the frequency of a disorder can provide clues to etiology

• Behavior genetics – the study of genetic and environmental influences on behavior

  • Biological parents contribute the following to their offspring

    • Genetic influences

    • Environmental influences

    • Interaction between genetic + environmental influences 

  • These cannot be distinguished using family studies

  • Adoption and twins studies can determine their specific effects 

Biological Studies

• Psychophysiology – the study of involuntary physiological responses that may be affected by psychological processes

  • Measures include: heart rate, blood pressure, brain waves (EEG), muscle activity (EMG), eye movements (EOG)

• Brain Imaging Technology

  • Observing Brain Structure → CAT and MRI

  • Observing Brain Functioning → EEG, fMRI, PET

Abnormal Psychology

Lecture 4: Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, and Specific Phobias

Generalized Anxiety Disorder DSM-5 Criteria

1. Excessive anxiety and worry (apprehension expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)

2. The individual finds it difficult to control the worry

3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least more symptoms having been present for more days than not for the past 6 months):

1. Restlessness, 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 restless, unsatisfying sleep)

4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism)

6. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder

Panic Disorder – DSM-5 Criteria

1. Recurrent unexpected panic attacks.  A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate

2. Sweating

3. Trembling or shaking

4. Sensations of shortness of breath or smothering

5. Feelings of choking

6. Chest pain or discomfort

7. Nausea or abdominal distress

8. Feeling dizzy, unsteady, light-headed, or faint

9. Chills or heat sensations

10. Paresthesia (numbness or tingling sensations)

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)

12. Fear of losing control or “going crazy”

13. Fear of dying

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

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”)

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situation

3. The disturbance is not attributable to physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyper

4. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder)

Social Anxiety Disorder – DSM-5 Criteria

1. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.  Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

2. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others)

3. The social situations almost always provoke fear or anxiety

4. The social situations are avoided or endured with intense fear or anxiety

5. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context

6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

8. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition

9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder

10. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive

Specific Phobia – DSM-5 Criteria

1. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)

2. The phobic object or situation almost always provokes immediate fear or anxiety

3. The phobic object or situation is actively avoided or endured with intense fear or anxiety

4. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and the sociocultural context

5. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

7. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects of situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder)

Fear & Anxiety

• The constructs of fear and anxiety are central in defining and differentiating these diagnoses

Fear (or panic) – an alarm response when danger is perceived to be present 

• Involves a triggering of the fight-flight-freeze (FFF)

Anxiety – a future-oriented mood state associated with preparation for possible harm

• Involves a priming (simultaneous excitatory and inhibitory input to) the FFF mechanism when danger is perceived to be possible at a later point in time

Overlapping features

• Both involved the perception of danger

• Both involve excitatory input to the FFF mechanism

Distinctive features

• Temporal aspects → Fear (panic) is more immediate // Anxiety is longer lasting and future oriented

• Fear (panic) → Purely excitatory input to the FFF mechanism

• Anxiety → Simultaneous excitatory and inhibitory input to the FFF mechanism

Panic Attacks

2 types of panic attacks

• Expected – the individual is aware of a cue or trigger at the time of the attack

• Unexpected – the individual is not aware of a cue or trigger at the time of the attack

Panic attacks are seen across all anxiety disorders (and even in major depression)

• Anxiety is central to the definition of each of the anxiety disorders

Non-clinical panic vs. panic disorder

• Non-clinical panic → do not experience anticipatory anxiety about their attacks

• Panic disorder – do experience anticipatory anxiety about their attacks 

Panic Disorder

Central Features in DSM-5

• Recurrent, unexpected panic attacks

• One of the following:

  • Persistent worry about having attacks (or about their consequences)

  • The development of significant, maladaptive behavioral changes designed to avoid having attacks

• Note:–If all panic attacks are expected, a diagnosis other than Panic Disorder would be made

  • Maybe Social Anxiety Disorder, Specific Phobia, Post-Traumatic Stress Disorder, or Obsessive Compulsive Disorder

Agoraphobia – the fear and avoidance of situations in which the individual fears having a panic attack and from which it would be difficult to leave or get out

• DSM-5 has reverted to identifying agoraphobia as an independent diagnosis, as in DSM-III

• Someone with PD who develops agoraphobia would have two diagnoses instead of one (as in DSM-IV)

Generalized Anxiety Disorder 

• Cardinal feature – Excessive, uncontrollable worry about a number of different life circumstances

  • This worry must be accompanied by at least three common manifestations of anxiety–e.g. muscle tension, sleep disturbance, or irritability

Specific Phobia 

Five subtypes:

1. Animal – fear cued by animals or insects

   1. e.g. dogs, snakes, or spiders

2. Natural environment – fear cued by an object in the natural environment

   1. e.g. heights, thunderstorms, or water

3. Blood-injury-injection – fear cued by seeing blood, injury, or receiving an injection

4. Situational – fear cued by specific situations

   1. e.g. driving, enclosed spaces, or flying

5. Other – fear cued by other triggers

   1. e.g. falling down, costumed characters such as clowns, or emetophobia (the fear of vomiting)

Specific Phobia

To receive a DSM-5 diagnosis of specific phobia:

• The cue has to almost invariably provoke an immediate fear response

• The fear has to be excessive*

• The fear must be associated either with:

  • Some avoidance of the phobic cue

  • Endurance of exposure to that cue with intense fear

• The fear must be associated either with:

  • Some functional impairment•Significant distress about having the fear

Specific Phobia

• Who judges “excessiveness”?

  • DSM-IV – the patient

  • DSM-5 – the clinician

Social Anxiety Disorder

• Key feature–A persistent and marked fear of social situations in which the individual might be judged or evaluated by others

• Exposure to the feared social situation(s) has to almost invariably provoke an immediate fear response

• The fear must be associated with either

  • Some avoidance of the phobic cue

  • Endurance or exposure to that cue with intense fear or anxiety

Who judges “excessiveness”?

• DSM-IV – the patient

• DSM-5 – the clinician

Distinct Categories?

Controversy within the field

• Some see these anxiety disorders as distinct categories

• Others think they represent inconsequential variations of a broader syndrome

  • Differ solely at the descriptive level in terms of the content of apprehension

• This is why we are discussing them within the same lecture…

women are more likely to have the internalizing disorders, and men with the externalizing disorders

**comorbidity is common (having more than one personality disorder)

Epidemiology for Specific Phobia

• Specific phobia is the most prevalent of the anxiety disorders

• The mean number of fears reported by an individual is approximately three

  • Most common subtypes

  • Natural environment

  • Situational

  • Animal

  • Blood-injection injury

Epidemiology for Social Anxiety Disorder

• Social anxiety disorder is the second most prevalent anxiety disorder covered here

• Between-group racial and ethnic differences

• Higher percentage of White Americans diagnosed than Black/African, Hispanic/Latino, and Asian Americans–Higher percentage among Native Americans than White Americans

• Most common fears reported are those related to performance-based situations

• e.g. public speaking, participating in class, performing in front of others

• Comorbidity

  • Highly comorbid with other mood, anxiety, and personality disorders

  • Particularly avoidant personality disorder

• Most common comorbid anxiety disorders are PD, SP, and GAD

Epidemiology for Generalized Anxiety Disorder

• Between-group racial and ethnic differences

  • White Americans are more likely to be diagnosed than are Black/African, Hispanic/Latino, and Asian Americans

• Comorbidity

  • Of those with comorbid disorders…

  • 71% meet criteria for a mood disorder

  • 90% have a comorbid anxiety disorder–Most common being PD with agoraphobia and SAD

Epidemiology for Panic Disorder with Agoraphobia

• Prevalence

  • Lifetime prevalence of panic attacks (which often do not warrant a diagnosis) is 23%

  • PD (with or without agoraphobia) is less common•PD with agoraphobia is less common than PD

• Treatment

  • Those with PD with agoraphobia are more likely to seek treatment than those with (just) PD

Conditioning

• J. B. Watson (pictured) and Rayner (1920)–Hypothesized that SPs are intense classically conditioned fears that develop when a neutral stimulus is paired with a traumatic event•Until the 1970’s this was the dominant thinking regarding anxiety disorders–The approach then became widely criticized

• Demonstrated this in their experiment with Little Albert–Little Albert acquired an intense fear of a white rat after hearing a frightening gong paired with the presence of the white rat–Unconditioned Stimulus (US)•Gong–Conditioned Response (CR)•Fear of the white rat

Criticisms of the Conditioning Model

Vicarious Conditioning

• Many phobias do not appear to have had any relevant history of classical conditioning

• In response, clinicians speculated that vicarious conditioning may play a role

• Vicarious conditioning

  • Simply observing others experiencing a trauma or behaving fearfully can sufficiently induce phobia

• Some retrospective studies suggest vicarious conditioning may play a role in the development of PD, SAD, and SPs

  • Studies including reports from a) mothers of individuals with SAD and b) the individuals with SAD

  • Both mother and individual reports indicate more social avoidance among families of patients with SAD compared with non-clinical controls

• Because these are family studies, it is impossible to determine whether these similarities are due to environmental or heritable factors (or both)

  • That is, the individuals may have either a) learned anxiety through vicarious conditioning, b) inherited anxiety from parents, or c) some combination of both

• Primate models have shown that strong and persistent phobic-like fears can be learned rapidly through observation alone

  • This vicarious conditioning has occurred simply through videotapes of models behaving fearfully

  • This suggests that humans may also be susceptible to acquiring fears vicariously through movies and television

• Direct social reinforcement and verbal instruction

  • Patients with PD receive more parental encouragement for sick-role behavior during childhood experiences of panic-like symptoms in comparison to non-clinical controls → e.g. “Take care of yourself and avoid strenuous activities.”

  • Parents of anxious children may be more likely to reciprocate their children’s proposals of avoidant solutions

  • When anxious children discuss potentially threatening situations with their parents, such discussions strengthen the anxious child’s avoidant tendencies → Anyone see a problem with this conclusion?!

Selective Associations

• Equipotentiality

  • Early conditioning models predicted that nay random group of objects could be conditioned to elicit fears, SPs, and anxiety 

• Prepared fears – fears that are not truly inborn or innate, but which are very easily acquired and/or especially resistant to extinction

  • e.g. snakes, water, heights, enclosed spaces, elevated heart rate, other people, etc.

• People are much more likely to have fears of “prepared” stimuli than they are of bicycles, guns, or cars

  • bicycles, guns, and cars pose a much greater threat (today) than “prepared” stimuli

  • Seligman (1970) suggested that “prepared” fears pose a greater threat in our species history, thus conferring a selective advantage to those who fear them

• Empirical findings

  • Fear-relevant stimuli (snakes, spiders, and angry faces)

  • Fear-irrelevant stimuli (flowers, mushrooms, electric outlets, or neutral or happy faces)

  • Found that the fear-relevant stimuli were more easily conditioned to be fearful than fear-irrelevant stimuli

Uncontrollability and Unpredictability 

• Early conditioning models do not explain why many individuals who undergo traumatic experiences do not develop an anxiety disorder

  • Perceptions of controllability can explain these individual differences

• Fear is more easily conditioned when the aversive event is inescapable than when it is escapable

  • Animal research

    • Electric shock increases social submissiveness only when uncontrollable

    • “Learned helplessness” results from repeated social defeat → This effect is usually seen in response to uncontrollable shock (and not controllable shock)

    • Some suggest that this means that uncontrollable social stressors may play a role in SAD

• Social Anxiety Disorder

  • Cross-sectional evidence documents a strong association between generalized perceptions of uncontrollability and SAD

• Study on panic disorder

  • Patients with PD underwent a panic provocation procedure

    • Breathing of air with higher than normal CO2

  • They were told that they could turn down the level of CO2 if and when a light came on

    • Two conditions

    • One where the light came on (perceived control)

    • Another where the light never came on (no perceived control)

  • Results

    • 80% reported experiencing a panic attack in the no perceived control condition

    • 20% reported experiencing a panic attack in the perceived control condition

Temperament / Personality and Conditioning

• Individual differences in temperament / personality could explain why not all exposed to trauma develop anxiety disorders

• Evidence

  • Individuals high on trait anxiety / neuroticism more rapidly acquire aversive conditioned responses and expectancies than others

  • These traits could serve as nonspecific vulnerability factors for the development of SPs, SAD, and MDD

Abnormal Psychology

Lecture 5: Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Spectrum Disorders (OCSD)

• New DSM-5 category separate from the anxiety disorders

  • Based on similarities and differences between OCD and the other anxiety disorders

• Similarities between OCD and other anxiety disorders

  • Pattern of comorbidities (in probands (individual with disorder) and families)

  • Cognitive and emotional processing

  • Certain temperamental antecedents

    • E.g. behavioral inhibition

Differences between OCD and other anxiety disorders

• Centrality to anxiety symptoms

  • Anxiety symptoms commonly occur in OCD → however, they are seen in other disorders not categorized as anxiety disorders

  • Central role of anxiety is the common denominator among anxiety disorders

• Neurobiological pathways

  • Contemporary models associate anxiety disorders with amygdala hyperresponsivity and amygdala cortical interactions

  • Contemporary models of OCD center around frontostriatal abnormalities

These similarities and differences resulted in the new OCSD DSM-5 category 

Includes:

• Obsessive-compulsive disorder

• Body dysmorphic disorder

• Hoarding disorder

• Hair-pulling disorder (trichotillomania)

• Skin picking disorder (excoriation)

Obsessive-Compulsive Disorder (OCD) Diagnostic Criteria 

1. Presence of obsessions, compulsions, or both (obsessions defined by [1] and [2]) – (compulsions defined by [3] and [4])

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action

3. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly

4. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

2. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 

Prevalence

• Worldwide prevalence ranging between 1.5% to 3% → among the most prevalent mental disorders

• World Health Organization found OCD to be the 10th most burdensome condition among all medical conditions 

Defined by presence of obsessions and compulsions

• Obsessions → characterized by recurrent intrusive thoughts, images, and impulses

• Compulsions → repetitive behaviors or mental rituals, governed by specific rules that the individual feels compelled to perform → typically performed to neutralize intrusions / obsessions

Ego-dystonic disorder

• The majority of patients have good insight regarding their obsessions → painfully aware

Cognitive Behavioral Model

• Patients misinterpret normally occurring intrusive thoughts as overly important and dangerous

• This causes the patient to feel distressed

• Patient attempts to alleviate the distress using

  • Ritualistic behaviors

  • Avoidance behaviors

• Behaviors results in transient distress reduction

  • Paradoxically reinforces the likelihood that patients will engage in these behaviors in the future

• Ritualistic and avoidance behaviors

  • Maintain the false interpretations that intrusive thoughts are dangerous

  • Maladaptive beliefs are never given the chance to be disconfirmed

  • The patient never has the opportunity to learn that his or her feared outcome does not occur when behaviors aren’t complete

• Created a vicious cycle in which thoughts and beliefs are never challenged

Responsibility 

• Healthy individuals feel responsible for their actions

• Individuals with OCD are characterized by an inflated sense of responsibility

  • Defined as the feeling that they have power to cause or prevent negative outcomes that are perceived as highly probable to the patient

  • Referred to as “magical thinking”

  • This not in a narcissistic (or psychotic) way 

Treatment

• Exposure and response treatment

• Thought-Action-Fusion (TAF) - cognitive biases seen in patients with OCD

  • Moral TAF - the belief that thoughts have an equal moral weight to actions → “im a bad person”

  • Likelihood TAF - the tendency to believe that thoughts increase the probability of real-life events occurring 

  • These are directly targeted in CBT for OCD → “oh no, im actually gonna do it”

Symptom dimensions

• OCD is a heterogeneous disorder (almost all disorders are)

  • Different patients are characterized by different symptomatic manifestations

  • contamination/washing and checking are the most prevalent → seen in more than ½ of OCD patients 

  • Also fear of “gay thoughts” is prevalent

Yale-Brown Obsessive Compulsive Scale (YBOCS)

• Widely used scale for OCD → 74 obsessions and compulsions associated with 15 predefined symptom categories

• Meta-analysis found four basic symptom categories

  • Symmetry → repeating, ordering, and counting compulsions

  • Forbidden thoughts

  • Cleaning

  • hoarding

Average age of onset - 19.5 years

OCD is usually chronic and persistent

Being married and having a lower global severity score at intake predicts partial remission after 5 years

Pharmacological 

• Neurochemical research implicates dysfunctional serotonergic and dopaminergic systems

• Most effective pharmacological treatment

Psychological

• Most effective psychological treatment is cognitive-behavioral therapy (CBT)

  • With a prominent exposure and response prevention (ERP) component

• Cognitive therapy for OCD

  • Developed to challenge maladaptive cognitive processes

• Deep brain stimulation (DBS)

  • Typically for patients who don’t respond to pharmacological and psychological intervention

  • Shown to be effective in at least 50% of cases

Genetics and Familiality

• Genetics → twin studies estimate that 45% - 61% of OCD symptoms may be attributed to genetics 

  • Approximately 50% of the symptomatic variance in OCD is attributed to environmental factors

• Familiarity

  • Prevalence in families of non-psychiatric controls: 2.7%

  • Prevalence in families with an OCD member: 11.7%

• Around 90% of patients with OCD are diagnosed with at least one other psychiatric disorder, major depressive disorder being the most common 

  • Anxiety disorders are the second most common

  • Specific phobia – 42.7%

Body Dysmorphic Disorder (BDD) Diagnostic Criteria 

1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

2. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns 

3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of function

4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder 

History

• Formerly dysmorphophobia → derived from dysmorfia, Greek word for “facial ugliness”

• Described as condition where patients believe they are physically deformed or ugly in socially noticeable ways despite normal appearance

• Was previously classified as a somatoform disorder

  • Because of early associations with hypochondriasis and somatic complaints

Cosmetic & Dermatological procedures are generally not effective in treating BDD symptoms

• Patients with BDD seek and receive dermatological interventions and cosmetic surgery

  • Prevalence of BDD in cosmetic surgery settings → ranges between 6-15%

  • Prevalence of BDD in dermatology settings → 12%

• Cosmetic and dermatological procedures are generally not effective in treating BDD symptoms

  • Results consistently demonstrate no symptomatic change and, at times, symptom exacerbation

  • 90% of patients report no symptomatic change after medical and surgical treatment

Shared clinical features

• Patients with both disorders experience obsessions or preoccupations

  • Differences in obsessions and preoccupations

  • BDD → preoccupied primarily with appearance; perceive their appearance as defective; believe that others view them as deformed and evaluate them negatively because of this

• In this way, BDD more closely resembles MDD than OCD

  • Focus is on self-defeating and negative self-worth beliefs

Comparing OCD and BDD

Differences in level of insight

• OCD

  • Majority perceive the content of their obsessive thoughts to be irrational

  • Intact level of insight reported in 66% - 85% of patients 

  • “Delusional insight” only observed in 2-3% of patients

• BDD

  • “Delusional insight” is highly prevalent → observed in 32-39% of patients

  • Nearly 50% report delusional appearance-related beliefs

  • Delusions of reference are seen in ⅔ of patients → e.g., belief that others are taking special notice of the patients’ perceived defects

Differences in suicidal ideation and attempts

• Among OCD patients 

  • Suicidal ideation → 36% report ideation at some point in life

  • Suicidal attempts → 11%

• Among BDD patients

  • Suicidal ideation → 80%

  • Suicidal attempts → 28%

• Higher rates in BDD attributed to 

  • Delusional level of insight

  • Self-defeating perceptions 

Course of Illness

• Typically begins in adolescence  → ⅔ of cases onset before age 18 

• Appears to be a disabling and chronic condition

Hoarding Disorder Diagnostic Criteria

1. Persistent difficulty discarding or parting with possessions, regardless of their actual value

2. Difficulty due to perceived need to save the items and the distress associated with discarding them

3. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties

4. Hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

5. Hoarding is not attributable to another medical condition

6. Hoarding is not better explained by the symptoms of another mental disorder 

Characterization

• DSM-5 marks the first time that hoarding disorder is a separate disorder – was preivously a diagnostic criteia for OCD

• Hoarding disorder is characterized by persistent difficulty in discarding or parting with posessions, regardless of their actual value, which results in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible

• Doesn’t yet have prevalence rates of HD using DSM-5 criteria

  • There are a few epidemiological studies using reliable and valid instruments similar to the current criteria

Comparing OCD and HD

Diagnostic overlap

• 20% to 40% of patients with OCD have symptoms of hoarding

  • Less than 5% are at clinically significant levels

Differences

• OCD

  • Thoughts are intrusive and unpleasant

  • Primary aim is to avoid, reduce, or neutralize anxiety

• HD 

  • Thoughts are ego-syntonic

  • Distress comes from clutter and/or interference in role obligations rather than collecting items

  • Avoid discarding items to

    • Avoid the experience of loss

    • Avoid making difficult decisions or errors in deciding what should be discarded

Course of Illness

• Commonly onsets in adolescence

• Has chronic course with very little waxing and waning

  • This is distinct from the variable course of OCD

• Hoarding symptoms do not typically become interfering until middle age

Trichotillomania (Hair-Pulling Disorder) Diagnostic Criteria

1. Recurrent pulling out of one’s hair, resulting in hair loss 

2. Repeated attempts to decrease or stop hair pulling

3. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

4. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition)

5. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder

Excoriation (Skin-Picking Disorder) Diagnostic Criteria

1. Recurrent skin picking resulting in skin lesions

2. Repeated attempts to decrease or stop skin picking

3. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

4. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies)

5. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypes in stereotypic movement disorder, or intention to harm oneself in non-suicidal self-injury)

Hair Pulling and Skin Picking Disorder

• Both recognized in DSM-5 as psychological conditions involving repetitive grooming behaviors

Hair Pulling Disorder

• The recurrent pulling out of one’s hair resulting in hair loss, consequential distress, or functional impairment, and repeated attempts at reducing hair-pulling behaviors

• Estimated to occur in 3 million individuals in the U.S. → True prevalence is unknown, as epidemiological studies have not yet been conducted

• Considered to be a significant public health concern 

Skin Picking Disorder

• The recurrent skin picking resulting in skin lesions, clinically significant distress, or functional impairment, and repeated attempts to decrease or stop skin picking

• Prevalence estimates → 2% of dermatology patients // 5% of clinical samples

Symptom Comparison: HPD< SPD< OCD

Similarities

• Each involve repetitive behaviors in response to urges

• Behaviors are 

  • Anxiety relieving

  • Often symmetrical possess ritualistic characteristics

• Repetitive motor symptoms of individuals with SPD parallel certain compulsions in OCD

Differences

• Feelings following behaviors

  • Patients with OCD experience a reduction of anxiety after repetitive behaviors

  • Patients with grooming disorders experience a sense of gratification after behaviors

• Obsessional preoccupation

  • Neither grooming disorders are associated with obsessional preoccupation prior to the repetitive behavior

Abnormal Psychology

Lecture 6: PTSD & Dissociative Disorder

Posttraumatic Stress Disorder (PTSD)

Posttraumatic Stress Disorder: Diagnostic Criteria

Criterion A: stressor

• The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence as follows: (one required)

1. Direct exposure

2. Witnessing, in person

3. Indirectly, by learning that a close relative or close friend was exposed to trauma.  If the event involved actual or threatened death, it must have been violent or accidental

4. Repeated or extreme indirect exposure to aversive details of the events(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse).  This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: intrusion symptoms

• The traumatic event is persistently re-experienced in the following way(s): (one required)

1. Recurrent, involuntary, and intrusive memories
   Note: children older than six may express this symptom in repetitive play

2. Traumatic nightmares
   Note: children may have frightening dreams without content related to the trauma(s)

3. Dissociative reactions (e.g. flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness
   Note: children may reenact the event in play

4. Intense or prolonged distress after exposure to traumatic reminders

5. Marked physiologic reactivity after exposure to trauma-related stimuli

Criterion C: avoidance

• Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)

1. Trauma-related thoughts or feelings

2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations)

Criterion D: negative alterations in cognitions and mood

• Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)

1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs)

2. .Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” The world is completely dangerous”)

3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequence

4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame)

5. Markedly diminished interest in (pre-traumatic) significant activities

6. Feeling alienated from others (e.g., detachment or estrangement)

7. Constricted affect: persistent inability to experience positive emotions

Criterion E: alterations in arousal and reactivity

• Trauma related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

1. Irritable or aggressive behavior

2. Self-destructive or reckless behavior

3. Hypervigilance

4. Exaggerated startle response

5. Problems in concentration

6. Sleep disturbance

Criterion F: Duration

• Persistence of symptoms (in Criteria B,C,D, and E) for more than one month

Criterion G: functional significance

• Significant symptom-related distress or functional impairment

Criterion H: exclusion

• Disturbance is not due to medication, substance use, or other illness

Posttraumatic Stress Disorder

• Now clear that traumatic events can produce psychiatric symptoms

• Used to be held that stress-induced symptoms were transient and persistent symptoms implied the presence of another neurotic or characterological disturbance

The Vietnam War

• Psychiatric sequelae of the war altered the prevailing view

• Clinicians became convinced that the war itself could cause chronic psychiatric disability

  • Rather than seeing them as having pre-existing conditions exacerbated by the war

• Veterans Administration (VA)

  • Would not provide treatment and psychiatric disability compensation unless veterans’ problems were a direct consequence of the war → Not simply exacerbated pre-existing conditions

• “Post-Vietnam syndrome”

  • Antiwar psychiatrists and leaders of the Vietnam veterans’ organizations began lobbying to include this in the then-forthcoming DSM-III

DSM-III

• Leaders of the DSM-III revision process initially opposed this proposal for two reasons:

1. Combinations of several traditional diagnoses could cover the problems of these veterans

2. Atheoretical DSM aimed to be explicitly defined by signs and symptoms, rather than debated etiology

Results

• Similarities in the symptoms of Vietnam veterans were similar to those who survived other traumatic experiences–e.g. rape, disaster, and concentration camps

• This resulted in the consensus that any terrifying, life-threatening event could cause a chronic syndrome

• PTSD was added to DSM-III and classified as an anxiety disorder

Central Idea

• A traumatic event establishes a memory that gives rise to a characteristic profile of signs and symptoms

  • Natural selection ensures that people remember potentially life-threatening experiences–Forgetting them would court disaster

  • Stress hormones released during the trauma render the central features of the trauma highly memorable

• Psychopathology

  • When people continue to recall traumas involuntarily with the full emotional force of the original experience

  • Failure of stress symptoms to abate despite the absence of danger justifies PTSD as a mental disorder

PTSD Four Symptomatic Clusters

1. Intrusion Cluster

• Includes re experiencing symptoms such as:

  • Traumatic nightmares

  • Intrusive sensory images of the trauma

  • Physiological reactivity to reminders of the trauma

2. Avoidance cluster

• includes efforts to avoid feelings, thoughts, and reminders of the trauma

3. Negative Alterations in Cognitions and Mood

• Includes symptoms such as

  • Emotional numbing

  • Distorted blame of self or others

  • Pervasive negative emotional state

4. Alterations in Arousal and Reactivity

• Includes symptoms such as

  • Exaggerated startle

  • Aggression

  • Reckless behavior

  • Hypervigilance

What counts as a Traumatic Stressor

To qualify for PTSD, one must have exposure to a stressor → This is essential to the concept of PTSD for 2 reasons:

1. Core symptoms of PTSD possess intentionality

• Symptoms possess intentional content or “aboutness”

• Key symptoms are not merely “caused” by a trauma; they are about the trauma → e.g. to have intrusive images is to have intrusive images about something, namely the trauma

2. Many symptoms of PTSD overlap with other disorders (e.g., loss of pleasure in activities, insomnia, etc.)

• It’s the memory of the trauma that unites them into a coherent syndrome

DSM-III

• Presupposed that only traumatic stressors falling outside the boundary of everyday experience could produce PTSD

  • e.g. rape, torture, natural disasters

  • Events that would produce intense distress in anyone

• Conversely, ordinary stressors falling outside this boundary could not cause PTSD

• However… Two findings complicated the DSM-III framework

  • First, epidemiological studies documented that most people exposed to Criterion A traumatic stressors don’t develop PTSD

    • This implies that risk factors influence who develops the disorder–Diathesis stress?

  • Second, other studies found that those who didn’t meet the DSM-III Criterion A could still meet criteria for PTSD

• Some people met criteria for PTSD with no direct traumatic experience → Some met criteria after learning of the violent death of a loved one

• In response, DSM-IV broadened the concept of trauma exposure to include being “confronted with” information about a threat to the “physical integrity” of another person

• Other examples of reportedly meeting PTSD criteria…

  • People encountering obnoxious jokes in the workplace

  • Giving birth to a healthy baby after an uncomplicated delivery

  • Having a wisdom tooth removed

• A delicate balance in broadening criteria

• On one hand…

  • Concern that suffering people would be denied the diagnosis and reimbursable treatment

• On the other hand…

  • It means that nearly everyone qualifies as a trauma survivor

• A study of residents of southeastern Michigan found that 89.6% of adults had been exposed to a DSM-IVCriterion A stressor

• A study of American adults living far from the scenes of September 11th terrorist attacks–4% developed apparent PTSD seemingly from watching the events on television

• DSM-5 committee tightened the Criterion A

  • People who learn of physical threats to others must be a close friend or relative of the threatened person

  • Trauma exposure via the media has also been excluded except for those whom such exposure is part of their vocational role

Epidemiology and Sex ratio

• Life-time prevalence in 6.8%

  • Women - 9.7%

  • Men - 3.6%

• Men are exposed to traumatic events more often than women are, yet the rate of PTSD is more than twice as great in women as in men

  • Differences remain even when controlling for type of trauma

  • Suggests that men and women differ in ways that influence their risk of developing PTSD following exposure to trauma

• Military personnel are at a heightened risk for exposure to trauma

• Vietnam Veterans Readjustment Study (NVVRS)

  • 30.9% of all men who served in Vietnam developed DSM-III-R PTSD

  • 22.5% had partial PTSD•So, 53.4% of all men who served in Vietnam had either the full-blown or partial diagnosis

  • 15% still had the diagnosis in the 1980’s

Longitudinal Course of PTSD

• Acute stress symptoms are common following exposure to traumatic events

• Rothbaum and Foa (1993)

  • Study on help-seeking rape victims found that 95% met PTSD criteria within 2 weeks

  • Study on victims of nonsexual assault found that 64.7% met PTSD criteria after 1 weeks

• Symptoms of PTSD usually emerge within hours or days after the trauma

  • Delayed-onset PTSD is extremely rare

• Jones & Wessely, 2005

  • Only 1 person among the 93 diagnosed with PTSD appeared to have a delayed onset

Comorbidity of PTSD

• Pure PTSD is unusual, and comorbidity is common

  • Vietnam Veterans Readjustment Study (NVVRS)

    • 98.8% of veterans who had a lifetime diagnosis of PTSD had one other mental disorder

    • This is in contrast to the 40.6% of those without PTSD

  • Most common comorbid disorders

    • Men and women → Alcohol use and depression

    • Men → Generalized anxiety disorder

    • Women → Panic disorder

Risk Factors for PTSD

• Female sex

• Neuroticism

• Lower social support

• Preexisting psychiatric illness → Especially anxiety and mood disorders

• Family history of anxiety, mood, or substance abuse disorders

• Neurological soft signs → e.g. nonspecific abnormalities in central nervous function

• Small hippocampi

Cognitive Aspects of PTSD Phenomenology of Traumatic Memory

• Two types of thoughts in PTSD patients

  • Ruminative and intrusive thoughts about the trauma → e.g. “Why did this have to happen to me?”

  • Repetitive and intrusive thoughts of the trauma → e.g. vivid sensory flashbacks of the event

• A DSM-5 distinction

  • Only intrusive sensory memories qualify as reexperiencing symptoms

  • Ruminative thoughts about the trauma no longer qualify

• Memories of trauma differ in content and emotional qualities

  • Are the memories processed differently? → Porter and Peace (2007)

    • Compared to traumatic memories, memories of positive events

    • Fade in terms of vividness and emotional intensity

    • Decrease in accuracy over the course of several years

• Are the memories more fragmented?

  • Memory fragmentation in PTSD patients is seen in patients’ subjective ratings, but not in objective rater-coded or computer assessed measures of fragmentation

Dissociative Disorders

Dissociative Disorders

• These disorders have the chief feature of “dissociation”

• Broad definition that includes diverse phenomena that may not have a common source

  • Ex: one self-report measure includes mundane occurrences (staring off into space + being unaware of time passing) and eerie occurrences (failing to recognize oneself in a mirror)

• Other phenomena dubbed “dissociative”

  • Feelings of unreality (depersonalization and derealization)

  • Emotional numbing

  • A sense of time slowing down

  • Reported inability to recall encoded autobiographical information too excessive to count as ordinary forgetting

• Some clinicians regard seemingly opposing phenomena as the same dissociative process

  • Vivid sensory recollection of traumatic events → . “dissociative flashbacks”

  • Reports of inability to recall traumatic events → “dissociative amnesia”

DSM-5 Dissociative Disorders

• Dissociative amnesia

• Dissociative identity disorder (DID) – formerly, multiple personality disorder (MPD)

• Depersonalization/derealization disorder

• Other specified dissociative disorder–e.g. dissociative trance

• Unspecified dissociative disorder

Dissociative disorders have been omitted from major epidemiological surveys, such as the NCS-R due to:

• Their presumed rarity

• Controversial nosological status

Clinicians specializing in dissociative disorders hold that “dissociative disorders are common in general population samples and psychiatric samples” (van der Hart & Nijenhuis, 2009)

So why include dissociative disorders within a lecture on PTSD?

• Many experts who study dissociative disorders believe that “trauma causes dissociation” (Dalenberg et al., 2012)

• However, many other scholars, after examining the same studies, argue that the hypothesis that trauma causes dissociation is far from convincingly confirmed (Lynn et al., 2014)

Dissociative Amnesia

• The more often trauma occurs and the more emotionally distressing it is for the victims

  • The more likely it supposedly is that they will not remember having suffered any trauma

  • Encoded, but dissociated, memories of trauma will not be accessible by ordinary means (e.g. interviewing people ordinarily)

• Dissociative fugue

  • Previously a distinct syndrome in DSM

  • Now a subtype of Dissociative Amnesia in DSM-5

  • Characterized by aimless wandering often coupled with amnesia for parts of the journey

Dissociative Identity Disorder

• Those diagnosed with DID act as if they have different personalities (a.k.a. alters, identities) seize control of the person at various times

• The personalities vary in their behavior, thoughts, and feelings, and each has its own name, history, and memories

• Specialists interpretation

  • The syndrome arises from chronic, severe sexual and physical abuse during childhood

  • Victim’s sense of self dissociates into multiple identities

    • Some of these harbor the memories of trauma too horrific for the host personality to entertain consciously

• In many cases of DID, patients had no memories of childhood abuse until therapists (using hypnosis, guided imagery, etc.) helped them recall presumably dissociated traumatic memories

• Authentication of these memories is questionable

  • Traumatic memories are seldom, if ever, inaccessible to awareness

  • Many patients retracted their recovered memories, especially of satanic ritual abuse

• Problem/paradox inherent in this interpretation

  • Many patients with DID report histories of childhood trauma that they have never forgotten

    • The motivation for the emergence of dissociation in general (and in DID in particular) is to quarantine memories of trauma

    • Yet, if these patients have remembered their trauma all too well, why, then, are they dissociative?

• Case reports of MPD were rare in the literature before the 1980s

• Sybil (Schrieber, 1973), bestselling book about a case of MPD → after its publication, an epidemic erupted 

  • Putname, Guroff, Silberman, Barban, and Post (1986)“... more cases of MPD have been reported within the last 5 years than in the preceding two centuries.”

Depersonalization / Derealization Disorder

• During a depersonalization episode

  • People feel emotionally numb and disconnected from their body

  • Experience the world as an unreal dream (i.e. derealization)

• Many people experience brief episodes of depersonalization or derealization

  • e.g. when exhausted, during marijuana intoxication, when encountering sudden danger

• People with depersonalization/derealization disorder

  • Some experience the state unremittingly, sometimes for months or years

  • Others experience recurrent episodes interspersed with periods of normal consciousness

  • Onset is usually sudden

  • Many fear for their sanity

Abnormal Psychology

Lecture 7: Social and Cognitive Aspects of Depression

Major Depressive Disorder Diagnostic Criteria

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3. Significant weight loss when not dieting or weight gain (in children, failure to make expected weight gain)

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day

9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide

2. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

3. Episode not attributable to the physiological effects of a substance or another medical condition

4. At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders

5. There has never been a manic episode or a hypomanic episode 

MDD and Grief

• Exception for grief 

• Majorly criticized 

Persistent Depressive Disorder (Dysthymia)

1. Depressed mood for most of the day, for more days than not, as indicated, for at least 2 years

2. Presence, while depressed, of two (or more) of the following

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessnes

3. During the 2-year period (1 year for children and adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time

4. Criteria for a major depressive disorder may be continuously present for 2 years

5. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder

Premenstrual Dysphoric Disorder

1. In the majority of menstrual cycles, at least five 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, and become minimal or absent in the week postmenses

2. Presence, while depressed, of two (or more) of the following symptoms is present:

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection)

2. Marked irritability or anger or increased interpersonal conflicts

3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts

4. Marked anxiety, tension, and/or feelings of being keyed up or on edge

3. One (or more) of the following symptoms must additional be present, to reach a total of five symptoms when combined from Criterion B above

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies)

2. Subjective difficulty in concentration

3. Lethargy, easy fatigability, or marked lack of energy

4. Marked change in appetite; overeating; or specific food cravings

5. Hypersomnia or insomnia

6. A sense of being overwhelmed or out of control

7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain

4. The symptoms cause clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home

5. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder, or a personality disorder (although it may co-occur with any of these disorders)

6. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.

7. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism)

Major Depressive Disorder

Disabling disorder that is associated with

• Substantial emotional misery

• Sever interpersonal disruption

• Increased risk for physical illness and death

“Intrapsychic” disorder

• Internalizing → happening within the individual

• That is, depression exists within the mind or psyche

• However, can significantly disrupt the lives of those who close to the sufferer

Frequently a chronic disorder

• Can alst for months or year s(or a lifetime)

• Commonly re-occurs after recovery

Extensive public health problem

• Associated with considerable loss of productivity

  • Work days 

  • Diminished work quality

• Costs the economy billions of dollars

Early Conceptions

Depression is found in the earliest human records

• Conditions resembling depression are seen in the bible; egyptian writings circa 260 BC

Ancient Greeks provided the first causal theories of depression

• Hippocrates → melancholia stems from a preponderance of black bile

Aretaeus of Cappadocia (120 BC) 

• Characterized melancholia by sadness, suicidal tendencies, feelings of indifference, psychomotor agitation

Kant

• Suggested that emotions could not cause mental illness, saw depression as a somatic ailment (of the body)

Abraham (1911/1960 ) and Freud (1917/1950)

• Were first to associated psychological emotional factors in a causal manner with depression 

Epidemiology of Depression Prevalence

• Several epidemiological surveys have gathered data on the prevalence of depression 

• Differences in the various surveys likely reflect

  • The use of somewhat different measures 

  • Sampling differences

Epidemiology of Depression Sex Differences

• Women are at a much higher risk for depression

  • Average female-to-male ratio is 2:1

  • Ratios differ across studies

  • 21.3% lifetime prevalence for women

  • 12.7% lifetime prevalence for men

• Sex differences remain across countries, where overall prevalence rates vary

• Sex difference first appears in adolescence

• Men can defend themselves more easily, so the best option for them is to be more aggressive, and less depressive

Epidemiology of Depression Age and Cohort Effects

Age effects

• Rate of onset increases dramatically during adolescence

• Depression appears more commonly in younger than older adults

  • Rates are highest for individuals from 25 to 45 years of age

  • Rates of first onset are considerably lower for individuals over 65 years old

Cohort effects

• Some data suggest that younger generations are more prone to depression than comparably aged individuals were in the past 

• Rate of depression seems to be greater for those born after the mid-twentieth century

• Rates of depression seem to be increasing most quickly in young men

Models of Depression

• 0.5 or higher → heritability of depression

Contemporary approaches to depression have become increasingly multifactorial and integrative

• Negative life events

• Genetics

• Biochemistry

• Social skills

• Interpersonal interactions

• Cognitive processes

Most realize that each play a role in the onset, maintenance, remission, and relapse of depressive episodes

Life Event Models

• Life events – sudden, or at elast relatively distinct, changes in the external environment

• Contribution of life events to depression is mroe complicated

• Severe events – events with “marked or moderate long-term threat”

  • Clearly related to hte onset of a depressive disorder

• Less severe events

  • Appear insufficient to elicit depression

• Additivity effects - when severe or less-severe life events are summed

  • Severe life events have an even greater effect if they are summed

  • Less-severe life events are insufficient to elicit depression even when they are summed

• The relationship between severe events and depression is strongest for initial depressive episodes

• “Kindling” – early occurrences of depression increase neurobiological sensitization

  • This is to the point where recurrent episodes are largely initiated by these neurobiological processes

  • In extreme versions of this hypothesis, depression becomes autonomous and occurs independent of life stress

• Stress sensitization model

  • A major event is needed to trigger a first onset

  • Less severe (but more common) life events can initiate recurrent episodes

Behavioral Models

Lewinsohn (1974)

• Argued that depression is the result of a low rate of response-contingent positive reinforcement

  • Behavioral responses extinguish when individuals fail to receive positive reinforcement for them

• Loss of positive reinforcement leads to dysphoria

• Social skills

  • Individuals with depression have poor social skills

  • As such, they are denied access to the reinforcing properties of social relationships

Interpersonal Models

Coyne (1976)

• Stressful life events lead to a display of depressive symptoms

• These symptoms function to restore social support and gain reassurance regarding his or her self-worth and acceptance

Cognitive Models

Beck’s Cognitive Theory of Depression

• Depression results from activation of depressive self-schema

• Self-schema

  • Negative organized mental structures

  • Representations of self-referent knowledge

  • Guide appraisal

  • Interact with information to influence selective attention, memory search, and cognitions

• Content develops from interactions that occur during childhood → childhood experiences characterized by abuse, stress, or chronic negativity produced schemes that guide attention towards negative events, distort info to fit the schema etc. 

• We all have schemas

• Those with depression have dysfunctional schemas that lead to negative thoughts about the self, the world, and the future → this is Beck’s “cognitive triad”

• Schemas underlie tacit beliefs → characteristic errors in thinking

Cognitive Distortions

• All-or-nothing thinking – when situations are viewed in only two categories instead of on a continuum 

  • i.e. “If I am not a complete success I’m a failure.

• Selective abstraction – when negative details are focused on without taking into consideration the entire context 

  • i.e. in conversing with a group of people, the depressed person may only notice the one person who yawned and not the others who appeared interested

• Overgeneralization – sweeping judgements or predictions based on a single incident

  • e.g. “Because last night’s date did not go well, all women find me unattractive.”

• Emotional reasoning – on thinks something must be true because one feels it to be so

  • e.g. “I feel ugly so I must look ugly

• Personalization – when the individual takes responsibility for the negative actions of others without considering more plausible explanations for their behaviors

Attribution-Based Models

Seligman (1975)

• Noticed a similarity between depressed people & lab dogs who didn’t attempt to escape after they had been unable to avoid intermittent painful electric shocks

• Focused on depressed persons’ expectations that they are helpless

  • Resulting behavior stems from these expectations of helplessness

• Learned helplessness theory

Abramson et al., (1978)

• Based off of Seligman’s work, an attributional style was proposed as a critical causal variable in depression

  • Positive events are given specific unstable, external attributions

    • e.g. “I succeeded because the test was really easy.

  • Negative events are given global, stable, and internal attributions

    • e.g. “I failed because I am a stupid person.

• Negative attributions styles are seen as a vulnerability factor to depression

Evolutionary Models

Nesse (1991, 2000)

• Suggests that depression is nature’s way of telling us that we are barking up the wrong tree

  • Keeps us from spending energy on activities that are unlikely to contribute to our fitness or from taking senseless risk

  • Keeps us from spending more energy on futile goals which would risk even greater loss

• Often seen in depressed individuals coming into therapy

• Evolutionary Psychology suggests that those who were prone to depression out-reproduced those who did not experience depression

• For this to be effective, proper calibration is necessary → “Depression Threshold”

  • Experience depression only at functional times

  • Death of a loved one vs. parking ticket

• Those with clinical depression may have too sensitive a depression threshold

• Depressive Realism

  • People who are depressed have a lower opinion of themselves and of their prospects for success → this assessment is more accurate

  • Normally, it is adaptive to have an inflated self-image

  • Depression takes off these “rose-colored glasses

• Depression tells us when to cut our losses

• Helps us to realize when our goals are unrealistic

  • Competing for attractive mates

  • Competing for higher positioning

Pomerleau (1997)

• Depression is much more common in the winter

• Seasonal Affective Disorder (SAD)

• Winter → food is more scarce, moving is more metabolically expensive

• SAD may have kept our ancestors from wasting energy on activities that were less fruitful in the winter

Hagen (1999)

• Suggests that depression serves as a negotiating tool to extract more investment from others

• Primarily concerning postpartum depression

  • Rearing a child is extremely expensive

  • Mothers suffering from postpartum depression may need to negotiate higher levels of cooperation to succeed

• “I argue that PPD may be a strategy to negotiate greater investment from father and kin, or to reduce the mother’s costs by functioning somewhat like a labor strike. In a labor strike, workers withhold their own labor in order to force management to increase their wages or benefits, or reduce their workload”

• “Similarly, mothers with PPD may be withholding their investments in the new and existing offspring, or , in cases of very severe depression, putting at risk their ability to invest in future offspring by not taking care of themselves.  This may force the father and kin to increase their investment.”

Abnormal Psychology

Lecture 8: Substance-Related and Addictive Disorders

Alcohol Use Disorder Diagnostic Criteria (same criteria for Cannabis etc)

1. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended

2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects

4. Craving, or a strong desire or urge to use alcohol

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home

6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol

7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use

8. Recurrent alcohol use in situations in which it is physically hazardous

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol

10. Tolerance, as defined by either of the following:

    1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect

    2. Markedly diminished effect with continued use of the same amount of alcohol

11. Withdrawal, as manifested by either of the following:

    1. The characteristic withdrawal syndrome for alcohol

    2. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms

Substance Use Disorders (SUDs)

• Among the most common psychiatric conditions in the United States

  • Over 8% of the individuals aged 12 or older meet criteria within the past year

  • Of those, 13% met criteria for both alcohol and another SUD

•  National Representative Epidemiology Study

  • Rates have stayed pretty similar in alcohol use disorders and substance use disorders

Behavioral Addictions

• Behavioral addictions

• Similar to SUDS in their neurological impact and pathways

  • Specifically true for pathological gambling

• Pathological gambling

  • Lifetime prevalence is less than 1%

  • Of those who meet criteria for pathological gambling, 73% met lifetime criteria for an alcohol use disorder; 38% met lifetime criteria for a SUD

Evolution of the Diagnosis

DSM-I (1953)

• SUDs were grouped under sociopathic personality disturbances

• Also included paraphilias (“sexual deviations”) and antisocial personality disorder

• This was reflective of the social climate, which conceptualized those with SUDs as social deviant

DSM-II

• Kept consistency with personality disorders and sexual deviation

• Removed sociopathic categorization

DSM-III

• Included tobacco/nicotine dependence for the first time

DSM-III-R

• Included the discretion between abuse and dependence (dependence = worse than abuse)

• Diagnoses were refined based on empirically bound criteria 

DSM IV

• Didn’t make substantial changes

• Allowed for listing specifiers

• Social consequences were moved from the dependence criteria to the abuse criteria

DSM-5

• Abuse and dependence categories were removed

• There is now a single substance use disorder category with specifiers based on an unweighted symptom count

  • Mild severity specifier – two to three symptoms

  • Moderate severity specifier – four to five symptoms

  • Severe severity specifier – six or more symptoms 

Gambling Disorder

• Only non-substance-related addition to be included in the DSM-5 SUDS category

• Previously included as an impulse control disorder

Gambling Disorder Diagnostic Criteria

1.  Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period

1. Needs to gamble w/ increasing amounts of money in order to achieve the desired excitement

2. Is restless or irritable when attempting to cut down or stop gambling

3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling

4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money to gamble with)

5. Often fambles when feeling distressed

6. After losing money gambling, often returns another day to get even

7. Lies to conceal the extent of involvement with gambling

8. Has jeopardized or lost a significant relation, job, or education or career opportunity because of gambling

9. Relies on others to provide money to relieve desperate financial situations caused by gambling

2. Gambling behavior is not better explained by a manic episode

Internet and Sex Addictions

• Were considered…

• However, the DSM-5 work groups didn’t believe there was enough empirical evidence for them to be included

Clinical Subtyping for SUDs (WILL NOT BE ASKED ON EXAM)

• There has been ongoing concern about the heterogeneity with the SUD diagnoses

  • This has resulted in the proposal of a variety of clinical typologies in order to increase specificity

Cloinger’s neurobiological model (1981)

• Sample were all men

• Differentiates between two genetically driven subtypes

1. Type 1

• Later onset of alcohol-related problems (after age 25)

• More psychological (as opposed to physiological) dependence

• Experience guilt associated with their use

2. Type 2

• Earlier onset of alcohol-related problems

• Have more extensive behavioral problems associated with their use

• More severe

• Associated with a positive family history for alcoholism

Babor

1. Type A → Similar to Cloninger’s Type 1

2. Type B → Similar to Cloninger’s Type 2

Moss, Chen, and Yi (2007)

• Youngadult subtype

• Functional subtype

• Intermediate familial subtype

• Young antisocial subtype

• Chronic severe subtype

Risk Factors for Addictive Disorders Family History

Familial link has been widely established in the research literature

• Several studies have found a potentially stronger heritability for illicit drug use than for alcohol → 8 fold increase (Merikangas 1998)

Level of response to alcohol

• A heritable mechanism influencing one’s propensity to develop an alcohol disorder

• Participants given a challenge dose of alcohol — researchers then assess two correlated indicators of intoxication → body sway, subjective perception of alcohol effects 

Lower response to alcohol has been associated with

• Family history of alcoholism

• Development of tolerance to alcohol

• A 4-fold greater likelihood of future alcohol dependence

• Also, a unique predictor of alcohol use disorders above and beyond a variety of other risk factors

• A robust predictor of alcohol use disorders in both young and middle-aged groups

Expectancies 

• Beliefs about the anticipated effects of alcohol or other substance use

• Individuals’ beliefs of the effects of substance use on social, affective, cognitive, and motor functioning

• Alcohol expectancies have been shown to predict, initiation, progression, problem use, and posttreatment relapse

  • Elevated risk is associated with expenactions that alcohol use will have positive effects

• Marijuana expectancies are shown to have similar effects to alcohol expectancies

• Cocaine expectancies include unique domains 

• Expectancies can be modifiable

• Interventions

Gambler’s Fallacy

• The belief that, despite the random nature of a process, a certain outcome can be expected

• This cognitive bias is viewed as one of the causes of “chasing losses” → a common symptom of pathological gambling and a criterion for DSM-5 gambling disorder

Other cognitive distortions

• Overconfidence about one’s ability

• Illusory correlations (e.g., superstitions)

• Interpretive control

• Illusion of control

• **These distortions are not specific to gambling→ play a role in its initiation and continuation  

Influence of Peers

• Influence of peers on substance use during adolescence is clear from decades of research → not all peer influences are equal → peers perceived as more similar exert a greater impact

• Greater peer involvement with substances 

• Higher perceptions of peer use

• Greater perceived peer acceptance of substance use 

Gender Differences in Addictive Disorders

• Men & women share commonalities, but important differences exist

  • Men consume greater quantities

  • Men abuse substances at higher rate

• However, this gap is narrowing for both alcohol and illicit drugs

  • Telescoping → Accelerated development of alcohol problems and dependence in women when compared to men

• Women are more vulnerable to many physiological consequences of alcohol use and abuse

  • Women have higher blood alcohol concentrations after consuming the same amount of alcohol as me

• Women develop liver disease more quickly than men and have higher rates of liver-related mortality

• Increased risk of breast cancer has been associated with moderate to heavy alcohol consumption in numerous studies

Teratogenic effects of alcohol

• Fetal alcohol syndrome (FAS) → Among children born to women consuming significant amounts of alcohol during pregnancy

• Involves physical (facial dysmorphology and small stature) and neuropsychological (mental retardation and attention impairment) effects that continue throughout life–Fetal alcohol effects (FAE)

• Less severe fetal alcohol effects also occur with lower levels of alcohol consumption

Teratogenic effects of other substances

• Use of cocaine during pregnancy → Associated with slow fetal growth, low birth weight, early labor, spontaneous abortion, and sudden infant death syndrome–Infants born to mothers who are opiate dependent

  • Are addicted and require treatment for withdrawal

  • Are more likely to be premature

  • Experience respiratory illness

  • May be underweight

  • Have an increased mortality risk

Gender differences in gambling behaviors and related problems

• Male adolescents report more gambling and experience a greater number of gambling-related problems than female adolescents

• Men and women are equally likely to have gambled in the past year–Men gamble more frequently and have greater wins and losses–Female pathological gamblers appear to be at greater risk for mood and anxiety disorders

• Depression, dysthymia, and panic disorder–Male pathological gamblers appear go be at greater risk for SUDs

Abnormal Psychology

Lecture 9: Schizophrenia

Schizophrenia Diagnostic Criteria

1. Two or more of the following each present for a significant portion of time during a 1-month period (or less if successfully treated).  At least one of these must be (1), (2), or (3):

1. Delusions

2. Hallucinations

3. Disorganized speech (e.g., frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

5. Negative symptoms (i.e. diminished emotional expression or avolition)

2. 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 (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning)

3. Continuous signs of the disturbance persist for at least 6 months.  This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.  During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences

4. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness

5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition

6. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated)

History of the Clinical Disorder

Kraepelin

• Construct of schizophrenia that we use today derives largely from the work of Kraepelin

• Termed it dementia praecox (premature dementia)

• Described it as a pattern of symptoms over time rather than any particular cluster of symptoms

• Believed it to be progressive and largely untreatable

Eugene Bleuler

• Coined the term Schizophrenia, meaning “splitting of the functions of the mind”→ confused with split personality / multiple personality disorder / DID → he meant, that Schizophrenia has elements of dissociation, but is not a description of separate personalities as in DID

• Didn’t think that deterioration was inevitable

• Felt the term dementia praecox misled trainees to focus on the wrong aspect of the disease entity

Epidemiology

World Health Organization (WHO)

• Lifetime morbid risk was similar across sites and approximately 1% (actually 0.7%)

• Consistent in developed & developing countries, east & west, and urban & rural districts

Population based epidemiological studies

• Highest incidence (first occurence) of schizophrenia

• 20-24 years for men

• 25-29 years for women

• Men have earlier onset & more severe course than women

• No sex difference in the median estimates of lifetime morbid risk for the disorder → Women gradually “catch up” to men with more later-onset cases

Definitions and Clinical Constructs

• Psychosis - a broad term for describing a state of “losing touch with reality”

• In DSM-5, psychotic symptoms include

  • Delusions

  • Hallucinations

  • Formal thought disorder (consisting of disorganized thinking and speaking)

• Psychotic symptoms are present in many psychiatric illnesses other than schizophrenia

Schizophrenia Spectrum

• Term is now synonymous with a dimensional approach to psychosis → continuum of symptom expression

• May also refer to diagnoses similar to schizophrenia

  • Schizophreniform disorder, schizotypal

• coined by several authors in the late 1960s

• Was used in the study of single penetrance genes associated with a genetic liability

• Severed as short-hadn for describing someone with a genetic vulnerability to schizophrenia who had yet to fully decompensate

Schizoaffective

• Coined by Kasanin

• Refers to patients who have features of both schizophrenia and bipolar disorder or depression

Clinical Presentation and structure of Symptoms

• Even within schizophrenia, there exists a high level of 

Bleuler’s subtypes

• Paranoid → preoccupation w/ delusions or auditory hallucinations

• Catatonic → immobile, or flat affect and little motivation

• Undifferentiated (hebephrenic) → those who don’t fall conveniently into either of those categories but also didn’t have a milder form of the illness

Positive Symptoms → symptoms that are characterized by something being added to normal behavior or experience → present in people with schizophrenia, but not present in people without schizophrenia

• Hallucinations – false perceptions such as things seen or heard that are not real or present → auditory hallucinations are most common type

• Delusions – false belief about reality maintained in spite of strong evidence to the contrary → almost always something bad

  • Delusions of grandeur – false belief that one is a noted or famous person, such as Napoleon or the Virgin Mary

  • Delusions of persecution – false belief that one is being mistreated or interfered with by one’s enemies 

• Most hallucinations and delusions have a negative valence and are frequently disturbing → almost never emotionally neutral

Negative Symptoms → symptoms that reflect an absence or deficit in normal functions → present in people without schizophrenia, but not present in people with schizophrenia 

• Blunted affect – reduction in range of affective expression

• Flat affect - lack of emotional expression

Difference between blunted and flat affect: when the reduction in affective range is more pronounced and extreme (such that the person is almost expressionless), the patient may be said to have flat affect

• Alogia – poverty of speech → a symptom that causes you to speak less, say fewer words or only speak in response to others

• Avolition – lack of drive or motivation to pursue meaningful goals

Genetic and Biological Factors

• Schizophrenia is “familial” → runs in families

  • Overwhelming evidence for higher-than-expected rates of schizophrenia  among relatives who have the diagnosis

  • There is a strong relationship between the “closeness” of the blood relationship and the risk for developing the disorder

  • Again, familial doesn’t specify whether the relationship is due to genes, environment, or an interaction between the two

Twin Studies

• Many studies have shown a higher concordance for schizophrenia among identical, or monozygotic twins than among fraternal

  • Suggests a high genetic component

  • But if illness were completely genetic, the concordance between identical twins would be 100% → Implies that some environmental factors are at play

Adoption Studies

• Data shows a higher concordance among biological parents and children with schizophrenia in comparison to adoptive parents and children with schizophrenia

Interpersonal Adjustment in Schizophrenia 

Relationships have been classified by function

• Instrumental relationships – task-oriented and goal-driven

• Those with schizophrenia show significant impairment in their instrumental relationships

• Those with schizophrenia show significant impairment in their instrumental relationships

  • Those with schizophrenia are frequently unable to finish school or to achieve the level of education they desire

• Many with schizophrenia are unable to hold a job for a sustained period of time → only about 10-20%

• When they do find work, it is often at an employment level that is lower than that of their parents

• Drift Hypothesis → argument that illness causes one to have a downward shift in social class

• Social Causation Thesis → The argument that being in a lower social class is a contributor to the development of a mental illness → Opposes the drift hypothesis

• The great majority of schizophrenic patients never marry

• Women have shorter and less frequent psychotic episodes

• Women show a better response to treatment

• Female patients have a milder range of interpersonal problems and a characterized by better social functioning