Exam 2 

Fear- immediate, present-oriented Sympathetic nervous system activation Anxiety- apprehensive, future oriented Somatic symptoms- muscle tension, restlessness, elevated heart rate Both: negative affect Panic attack- abrupt experience of intense fear Physical symptoms: heart palpitations, chest pain, dizziness, sweating, chills, or heat sensations, etc. Cognitive symptoms: fear of losing control, dying, or going crazy Diagnostic criteria for anxiety, fear, and panic Peak within 10-15 minutes of onset of symptoms The DSM-5 diagnostic criteria for panic attack- 4 or more of the following symptoms occur: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Feeling of choking (dysphagia) Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded or faint (dyspnea) Chills or heat sensations Paresthesias- tingling in extremities Derealization- when things feel surreal Fear of losing control or going crazy Fear of dying Two major types Expected Situationally bound- happens in specific situations Situationally predispositioned- can happen and leaves vulnerability in specific situations, but may not happen every time Unexpected- happens in different types of settings Biological contributions to anxiety Increased physiological vulnerability Polygenic influences- genetic predisposition to anxiety Corticotropin releasing factor (CRF) Affects the HPA axis Involved in anxiety and fear response Brain circuits and neurotransmitters GABA- major inhibitor; increased GABA, decreased anxiety Noradrenergic Serotonergic systems Limbic system Behavioral inhibition system (BIS) Received danger signals from: Brain stem Septal-hippocampal system fight/flight (FFS) system Panic circuit Alarm and escape response Brain circuits are shaped by environment Interactive relationship with somatic symptoms Psychological contributions to anxiety Freud Anxiety = psychic reaction to danger Reactivation of infantile fear situation Behaviorists Classical and operant conditioning- symptoms are a result of learned associations Modeling- learning anxious behaviors from caregivers Beliefs about control over environment Internal vs external control Internal- i have control External- control is pushed on me by external sources Rhoder- locus of control An individual’s perception about the underlying main causes of events in his/her life Social contributions to anxiety Biological vulnerabilities triggered by stressful life events- diathesis stress model Family Interpersonal Occupational Educational Integrated model of anxiety Triple vulnerability Generalized biological vulnerability- heritable contribution to negative affect Diathesis Glass half empty Irritable driven Generalized psychological vulnerability- sense that events are uncontrollable/unpredictable beliefs/perceptions Tendency toward lack of self confidence Low self esteem inability to cope Specific psychological vulnerability- eg: physical sensations are potentially dangerous learning/modeling Anxiety about health Nonclinical panic Comorbidities of anxiety and related disorders High rates of comorbidity This means you will be diagnosed with additional diagnoses Most common comorbid conditions diagnosed: depression Physical conditions: indigestion, IBS, chronic allergies Insomnia Commonalities Features Vulnerabilities Links with physical disorders Suicide- associated with anxiety Suicide attempt rates similar to those in major depression 20% of panic patients attempt suicide across the span of their life Increases for all anxiety disorders Comorbidity with depression = overall increase of suicide risk Anxiety disorders Generalized anxiety disorder (GAD) Diagnostic criteria from the DSM-5 Excessive anxiety and worry occuring more days than not for at least 6 months Difficulty controlling the worry Anxiety and worry associated with other physical symptoms TMJ, acid reflux, chronic pain disorders Anxiety causes clinically significant distress or impairment Not due to substance use or medical condition Not better explained by another mental disorder Clinical description Shift from possible crisis to crisis Worry about minor, everyday concerns Job, family, chores, appointments Accompanied by symptoms such as sleep disturbance and irritability Leads to behaviors like procrastination, over preparation GAD in children Need only one physical symptom Worry = academic, social, athletic performance Statistics Likelihood: 3.1%/year 5.7% lifetime Similar rates worldwide Insidious onset- starts of gradually then builds up; comes on slowly Early adulthood Chronic course- not episodic GAD in the elderly Worries about failing health, loss Up to 10% prevalence Use of minor tranquilizers: 17-50% Sometimes prescribed for medical or sleep problems Increases risk for falls and cognitive impairments Causes of GAD Inherited tendency to become anxious Neuroticism-the degree of negative affect; degree of anxiety Less responsiveness “Autonomic restrictors” Threat sensitivity- more risk averse Frontal lobe activation Left: pleasant images Right: fearful images Treatments of GAD Pharmacological- these are a lot easier to maintain and work quicker than psychological interventions Benzodiazepines- minor tranquilizers Risks vs benefits: there is limited support of effective treatment of GAD, have long term negative effects, more intended for temporary episodic treatment Antidepressants SNRIs Selective Norepinephrine Reuptake Inhibitors Work in the same way as SSRIs, but prevent the uptake of Norepinephrine instead Psychological Similar benefits to drugs and better long term results, although research shows that psychological interventions show better results long term Cognitive-behavioral treatments Exposure to worry process Confronting anxiety provoking images Coping strategies Acceptance- aka third wave CBT Meditation- really accessible to all populations Panic disorder and agoraphobia Clinical description Unexpected panic attacks; anxiety about having a panic attack Anxiety, worry, or fear of another attack Persists for 1 month or more Avoidance can be persistent Use and abuse of drugs and alcohol- an attempt to self medicate Interoceptive avoidance- avoiding situations that give the similar feeling of a panic attack Agoraphobia Fear of avoidance of situations/events Concern about being unable to escape or get help in the event of panic symptoms or other unpleasant physical symptoms (eg incontinence, vomiting, falling) Statistics 2.7% (year) 4.7% (life) Female: male = 2:1 Acute onset, most common in young adulthood (eg ages 20-24) Special populations Children Hyperventilation is a common symptom Earlier cognitive development > fewer cognitive symptoms (eg less fear of dying) Elderly Health focus is more common Changes in prevalence- decreases with age Diagnostic criteria: panic disorder Recurrent unexpected panic attaches At least one attack has been followed by significant worry or maladaptive change in behavior Maladaptivity does not help you to cope Not attributable to substance use Not better explained by another mental disorder Diagnostic criteria: agoraphobia Marked fear/anxiety for two or more: public transportation, open spaces, enclosed spaces, standing in line, being outside the home alone Avoids these situations Situations always provoke fear Anxiety not proportional to real danger Significant distress Anxiety is excessive Not better explained by another mental disorder Gender, culture, panic disorder, and agoraphobia social/gender roles ~75% of those with agoraphobia are female Cultural factors Similar prevalence rates across cultures Variable symptom expression- stigmas among cultures Somatic symptoms more emphasized than emotional symptoms in developing countries Cultural influences of agoraphobia Culture bound syndromes Susto-culturally bound manifestations of anxiety; common in latin america, association with spirits Ataque de nervios- “attack of the nerves” Characterized by suicidal gestures Kyol goeu- Korean/Cambodian; catastrophic thoughts about physiological conditions Nocturnal panic 60% with panic disorder experience nocturnal attacks Occur in non-REM sleep Occur during delta/slow wave sleep Caused by deep relaxation Sensations of “letting go” are anxiety provoking to people with panic attacks Sleep terrors- a childhood condition Isolated sleep paralysis- temporary feeling of not being able to move when transitioning from awake to sleep state Causes Generalized biological vulnerability Alarm reaction to stress Cues get associated with situations Conditioning occurs Generalized psychological vulnerability Anxiety about future attacks Hypervigilance Increase interoceptive awareness Treatment Medications Multiple systems affected by medication Serotonergic Noradrenergic GABA Benzodiazepines (eg Ativan) SSRIs (Prozac, Paxil) High relapse rates after discontinuation of medication Psychological intervention Exposure-based Reality testing Relaxation and breathing skills Example: panic control treatment (PCT) Exposure to interoceptive cues Cognitive therapy relaxation/breathing High degree of efficacy Combined psychological and drug treatments No better than CBT or drugs alone CBT = better long term

Specific phobias Clinical description Extreme and irrational fear of a specific object or situation Feared situation almost always provokes anxiety Significant impairment or stress Diagnostic criteria Marked fear or anxiety about a specific object or situation Phobic object or situation almost always provokes immediate fear or anxiety Phobic object/situation out of proportion to actual danger Lasts more than 6 months Clinically significant distress Not better explained by symptoms of another mental disorder Blood injection injury phobia Decreased heart rate and blood pressure when seeing blood, injections, or injury Fainting Inherited vasovagal response Onset = usually in childhood Situational phobia Fear of specific situations Eg flying, driving, etc No uncued panic attacks Fear centers around risks of the situation (eg plane crashing), not having a panic attack Onset = early to mid 20s Natural environment phobia Heights, storms, water May cluster together Associated with real dangers Onset = usually in childhood Animal phobia Dogs, snakes, mice, insects May be associated with real dangers Onset = usually in childhood Statistics for phobias 12.5% (life); 8.7% (year) Female: male = 4.1 Chronic course Onset = most often childhood Causes of phobias Direct experiences Vicarious experience- seeing someone else encounter a feared object Information transmission-learning about a situation/object being dangerous “Preparedness” Treatment of phobias Cognitive behavior therapies Exposure Graduated Structured Relaxation-used to be practiced more, now often not a part of empirically supported treatment Separation anxiety disorder Clinical description Characterized by unrealistic and persistent worry that something will happen to self or loved ones when apart (eg kidnapping, accident) as well as anxiety about leaving loved ones 4.1% of children meet criteria, 6.6% for adults Social anxiety disorder Clinical description extreme/irrational concern about being negatively evaluated by other people Sometimes (not always) manifests as shyness Leads to significant impairment and/or distress Avoidance of feared situations, or endurance with extreme distress Subtype Performance only: anxiety only in performance situations (eg public speaking) Statistics 12.1% life 6.8% year Female : male = 1:1 Onset = usually adolescence Peak age of onset = 13 More common in people who are young (18-29 years), uneducated, single, and of low SE class 13.6% prevalence in ages 18-29 6.6% prevalence in ages 60+ Social anxiety disorder across cultures Japan-taijin kyofusho Fear of offending others or making them uncomfortable Concern about aspects of personal appearance (eg stuttering, blushing, body odor) More common in males Causes Generalized psychological vulnerability Eg belief that threatening events are uncontrollable Generalized biological vulnerability Eg, propensity toward anxiety Generalized psychological vulnerability Eg belief that threatening events are uncontrollable Generalized biological vulnerability Eg, propensity toward anxiety Treatment Medications Beta blockers Benzodiazepines SSRIs (Paxil, Zoloft, and Effexor) D-cycloserine Psychological Cognitive behavioral treatment Challenging of anxious thoughts about the consequences of social judgement Exposure to anxiety provoking situations Rehearsal Role play Highly effective Selective mutism (SM) Clinical description Rare childhood disorder characterized by a lack of speech Must occur for more than one month and cannot be limited to the first month of school High comorbidity with social anxiety disorder Treatment CBT most efficacious, similar to treatment for social anxiety disorder Trauma-and-stressor-related disorders Attachment disorders PTSD Clinical description Trauma exposure Continued reexperiencing Eg memories, nightmares, flashbacks Avoidance Emotional numbing Reckless or self destructive behavior Interpersonal problems Refers to problems that persist for more than one month after the trauma Acute stress disorder assigned for post traumatic symptoms lasting less than a month Statistics 6.8% (life); 3.5% (year) Prevelance varies Most people who undergo traumatic events do not develop PTSD Type of trauma Eg, experiencing repeated sexual assualt makes an individual 2-3 times as likely to develop PTSD Proximity-more likely to develop PTSD if closer to the trauma Causes Trauma intensity-PTSD more likely with severe trauma Generallized biological vulnerability Twin studies Reciprocal gene environment interactions Generalized psychological vulnerability Beliefs about uncontrollability and unpredictability of threatening situations Poor social support = greater risk Diagnostic criteria Exposure to actual or threatened event Presence of one or more intrusional symptoms Persistent avoidance of stimuli associated with traumatic event Negative alterations in cognitions and mood associated with traumatic event Marked alterations in arousal and activity associated with the traumatic event Sleep disturbance Significant stress Not attributable to substance use Neurobiological model for PTSD Threatening cues activate CRF system This system activates fear and anxiety areas Amygdala (central nucleus) Increased HPA axis activation Cortisol release Treatment CBT Imaginal exposure to memories of traumatic events Graduated or massed Increase positive coping skills Increase social support Highly effective Psychoanalytic therapy Catharsis- reliving emotional trauma to relieve suffering Medications SSRIs Relieve heightened anxiety and panic attacks common to PTSD Adjustment Disorders Anxious or depressive reactions to life stress Milder than PTSD/acute stress disorder Occur in reaction to life stressors like moving, new job, divorce, etc Clinically significant distress or impairment Attachment disorders Disturbed and developmentally inappropriate behaviors in children Child is unable or unwilling to form normal attachment relationships with caregiving adults Occurs as a result of inadequate or neglectful care in early childhood Reactive attachment disorder Abnormally withdrawn and inhibited behavior Less receptive to support from caregivers Disinhibited social engagement disorder A pattern of abnormally low inhibition in children Eg, approaching unfamiliar adults without fear Obsessive-Compulsive and Related Disorders OCD Clinical description Obsessions Intrusive and nonsensical Thoughts, images, or urges Attempts to resist or eliminate Compulsions Thoughts or actions Provide relief from obsessive thoughts DSM criteria Presence of obsessions, compulsions, or both obsessions/compulsions are time consuming Disturbance is not due to substance abuse Disturbance not better explained by another mental health disorder Obsessions 60% of people meeting criteria for OCD have multiple obsessions Need for symmetry Forbidden thoughts or actions Cleaning and contamination Compulsions Four major categories Checking Ordering Arranging washing/cleaning Association with obsessions Tic disorder Involuntary movements (eg sudden jerking of limbs, movement of jaw, etc) Often co-occurs in patients with OCD Sometimes tics are used as compulsive behaviors-performed to relieve anxiety associated with obsessions OCD statistics 1.6% to 2.3% (life); 1% (year) Female = male Chronic Onset = childhood to 30s Causes of OCD Similar generalized biological vulnerability to having anxiety in general Specific psychological vulnerability Early life experiences and learning Thoughts are dangerous/unacceptable Thought-action fusion Distraction temporarily reduces anxiety Increases frequency of thought OCD treatment Medications SSRIs 60% benefit High relapse when discontinued Psychosurgery (cingulotomy)- sever the corpus callosum 30% benefit CBT Exposure and ritual prevention (ERP)- artificial exposure to cues for obsessions and block them from completing the compulsions, aims to break the link between the two Highly effective One study found that 86% of patients benefit No added benefit from combined treatment with drugs Electroconvulsive therapy Body dysmorphic disorder A preoccupation with some imagined defect in appearance Actual defect, if present, appears slight to others Comorbid with OCD 10% Lifelong course Onset- early adolescence through 20s Two treatments SSRIs Exposure and response prevention Diagnostic criteria Preoccupation with one or more defects or flaws in physical appearance that are small or not observable to others Repetitive behaviors Significant distress preoccupation with body not better explained Plastic surgery and body dysmorphic disorder Fully 76.4% had sought this type of treatment and 66% were receiving it 8% to 25% of all patients who request plastic surgery may have BDD Usually doesn't work, does not fix the distortion in thought about their body Plastic surgery can also intensify the thoughts Other disorders Hoarding disorder Excessively collecting and keeping items with minimal value, leading to cluttering and disruption of living space Prevalence: between 2% and 5% of the population, (twice as high as the prevalence of OCD) Men = women Usually more men than women OCD tends to wax and wane, whereas hoarding behavior can begin early in life and get worse with each passing decade Trichotillomania (hair pulling disorder) The urge to pull out one’s own hair from anywhere on the body Leads to noticeable hair loss on scalp, eyebrows, arms, pubic region, etc Similar to OCD in that they cant explain why they do it; associated with high stress levels Excoriation (skin picking disorder) Characterized by repetitive and compulsive picking of the skin, leading to tissue damage 1 to 5% prevalence rate Behavioral habit reversal treatment is most effective treatment Face is the most common target for picking Can be associated with pre-existing skin conditions; can wax and wane with stress A chronic course

1. Somatic Symptom and Related Disorders

1. Definition

       1. Somatic symptom disorders - excessive or maladaptive response to physical symptoms or health concerns 2. Soma = body

          1. The preoccupation with health or symptoms  2. Physical complaints 3. Usually no identifiable medical condition

             1. If there is a condition present, it is not nearly as severe

2. Somatic symptom disorder

       1. First identified by French doctor who noticed patients coming to him with numerous complaints with no medical basis  2. Formerly called Briquet’s syndrome 3. Presence of one or more somatic symptoms

          1. Symptom is often medically unexplained 4. Excessive thoughts, feelings, and behaviors related to the symptoms (eg excessive thoughts about seriousness of the symptom, frequent complaints and requests for help, health related anxiety, excessive research) 5. Substantial impairment in social or occupational functioning  6. These patients eat up a lot of time with providers without an actual cause/ reason for them being there  7. DSM-5 diagnostic criteria

          1. One or more somatic symptoms that are distressing and/or result in significant disruption of daily life 2. Excessive thoughts, feelings, and behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

             1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms 2. High level of health related anxiety 3. Excessive time and energy devoted to these symptoms or health concerns 3. Although anyone symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

             1. Specify if: with predominant pain (previously pain disorder): this specifier is for individuals whose somatic complaints predominantly involve pain 2. Specify current severity: 

                1. mild: only one of the symptoms in criterion 2 is fulfilled 2. Moderate: two or more of the symptoms specified in criterion 2 are fulfilled 3. Severe: two or more of the symptoms specified in criterion 2 are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom) 8. Statistics

          1. Relatively rare condition 2. Onset usually in adolescence 3. Ore likely to affect unmarried, low SES women 4. Runs a chronic course 5. Research to date is limited due to recent redefinition of the disorder in the DSM-5

             1. Because of the separation and recategorization, the past research on the condition doesn't match up correctly anymore 

3. Illness anxiety disorder

       1. Very similar to DSM-IV hypochondriasis 2. Clinical description

          1. Severe anxiety about the possibility of having or acquiring a serious disease 2. Actual symptoms are either very mild or absent 3. Strong disease conviction 4. Medical reassurance does not seem to help 3. DSM-5 diagnostic criteria

          1. Preoccupation with fears of having or acquiring a serious illness 2. Somatic symptoms are not present, or if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (eg strong FHx is present), the preoccupation is clearly excessive or disproportionate 3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status 4. The individual performs excessive health-related behaviors (eg repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (eg, avoids doctors’ appointments and hospitals) 5. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time 6. The illness related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, generalized anxiety disorder, or obsessive compulsive disorder 7. Specify whether:

             1. Care seeking type: medical care, including physician visits or undergoing tests and procedures is frequently used 2. Care avoidant type: medical care is rarely used 4. Statistics

          1. Only 20% of patients who used to meet the diagnostic criteria for DSM-IV hypochondriasis now meet criteria for illness anxiety disorder 2. Severe illness anxiety has a late stage of onset, possibly because more physical health problems occur with aging 3. Often comorbid with anxiety and mood disorders 5. Difference between somatic symptom disorder and illness anxiety disorder:

          1. In somatic disorder, a symptom is being amplified 2. In IAD, you have anxiety that you have a condition without any indication that you do 

4. Causes of somatic symptom disorders

       1. Consistent overreaction to physical signs and sensations 2. Cause is unlikely to be found in isolated biological or psychological factors 3. May have learned from family to focus anxiety on physical sensations 

          1. If a family’s anxiety about health is high, this is a significant risk factor for this  4. Three addition factors contributing to etiology

          1. Stressful life events 2. Illness in family during childhood 3. Benefits of illness (sympathy, attention)

5. Treatment for Somatic Symptom disorders

       1. Limited research on treatment effectiveness to date

          1. This is a result of it being such a rare condition  2. Mild cases of illness anxiety disorder may benefit from cognitive behavioral treatments, detailed education, and some reassurance from medical professionals

          1. This can sometimes work but not often 3. Exposure treatment can effectively treat illness anxiety disorder 4. Antidepressants may be helpful- help suppress the rumenation 5. “Gatekeeper” physician assigned to limit excessive use of medical services 6. Reduce supportive consequences of illness- not getting attention anymore

          1. Eg, family members stop providing attention 7. Psychodynamic approach

          1. Uncover and process the underlying conflict or traumatic event 8. Cognitive-behavioral approach- focus on reward systems

          1. Withdraw reinforcement for complaints regarding body symptoms 2. Modifying distorted cognitions about risks or body image  3. Exposure and response prevention (like OCD treatment) 9. Biological approach

          1. Same antidepressant medication which seems to help treat anxiety disorders also helps with somatic symptom disorders

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6. Psychological factors affecting medical condition

1. Diagnostic label useful for clinicians
2. Indicates that psychological variables may be impacting a general medical issue

       1. Ex:

          1. Patient’s concentration difficulties make it hard to take a medication on time 2. Patient fails to comply with medical advice due to being in denial about diagnosis 

             1. This prevents the seeking of treatment

7. Conversion disorder

    1. Aka Functional Neurological Symptom Disorder 2. Key feature

        1. Altered motor or sensory function that is inconsistent with neural/medical conditions and not better explained by another disorder

           1. Often suggestive of neurological problem, but no such problem is detected 3. Must cause significant distress/impairment 4. May display indifferent attitude toward symptoms (“la belle indifference”) 5. Not deliberately faking symptoms for the purpose of concrete gains (malingering) 6. DSM-5 diagnostic criteria

        1. One or more symptoms of altered motor or sensory function 2. Incompatibility between symptom and medically recognized conditions 3. Not better explained otherwise 4. Causes significant distress 7. Rare condition, with a chronic intermittent course 8. Often comorbid with anxiety and mood disorders 9. Seen primarily in females

10. Onset usually in adolescence
11. Common in some cultural and/or religious groups
12. Causes

        1. Not well understood 2. Freudian psychodynamic view is still common, though unsubstantiated

           1. Past trauma or unconscious conflict is “converted” to a more acceptable manifestation, i.e., physical symptoms  3. primary/secondary gains

           1. Frued thought primary gain was the escape from dealing with a conflict 2. Secondary gains: attention, sympathy, etc 4. Sociocultural factors

           1. More common in lower education, lower SES 2. Patients likely to adopt symptoms with which they are already familiar

13. Treatment

        1. If onset after a trauma, may need to process trauma or treat posttraumatic symptoms 2. Remove sources of secondary gain 3. Reduce supportive consequences of talk about physical symptoms 

14. Ex: glove anesthesia/glove paralysis 

    2. Factitious disorders

1. Purposely faking physical symptoms
2. May actually induce physical symptoms or just pretend to have them
3. No obvious external gains

       1. Only external gain may be benefit of “sick role” (eg sympathy) 2. Distinguished from malingering, in which physical symptoms are faked for the purpose of achieving a concrete objective (e.g, getting paid time off, avoiding military service)

4. DSM diagnostic criteria

       1. Falsification of physical or psychological signs or symptoms 2. Individual presents self as ill or injured  3. Deceptive behavior is evident in absence of external rewards 4. Not otherwise explained 

5. Factitious disorder imposed on another

       1. More commonly known as Munchausen syndrome by proxy 2. Inducing symptoms in another person

          1. Typically caregiver induces symptoms in a dependent (eg, child) 3. Purpose = receive attention or sympathy

3. Dissociative disorders

1. Overview

       1. Severe alterations or detachments from reality 2. Affect identity, memory, or consciousness 3. Depersonalization- distortion in perception of one’s body or experience (eg, feeling like your own body isn't real) 4. Derealization- losing a sense of the external world (eg, sense of living in a dream)

2. depersonalization/derealization disorder
3. Dissociative amnesia
4. Dissociative identity disorder

Overview of depression and mania Mood disorders = gross deviations in mood Composed of different types of mood “episodes” Periods of depressed or elevated mood lasting days or weeks, including: Major depressive episodes Manic episodes Hypomanic episodes Depressive disorders Major depressive episode Extremely depressed mood and/or loss of pleasure (anhedonia) Lasts most of the day, nearly every day, for at least two weeks At least four additional physical or cognitive symptoms: Eg: indecisiveness, feelings of worthlessness, fatigue, appetite change, restlessness, or feeling slowed down, sleep disturbance DSM-5 criteria for Major Depressive Episode 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 Note: do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad or empty) or observation made by others (eg, appears tearful) Note: in children and adolescents can be irritable mood Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day Note: in children, consider failure to make expected weight gains Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guild about being sick) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for commiting suicide The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning The symptoms are not due to the direct physiological effects of a substance (eg a drug of abuse, a medication) or a general medical condition (hypothyroidism) Major depressive disorder: an overview Clinical features One or more major depressive episodes separated by periods of remission Single episode- highly unusual recurrent episodes- more common DSM-5 (unipolar) depressive disorders Major depressive disorder Persistent depressive disorder New to DSM-5 Premenstrual dysphoric disorder Disruptive mood dysregulation disorder DSM-5 criteria: Major Depressive Disorder At least one major depressive episode The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders There has never been a manic episode or hypomanic episode Note: this exclusion does not apply if all the manic-like or hypomanic-like episodes are substance induced or attributable to the direct physiological effects of another medical condition Specify the clinical status and/or features of the current or most recent major depressive episode: Single episode or recurrent episode: mild, moderate or severe; with anxious distress; with mixed features; with melancholic features; with atypical features; with mood-congruent psychotic features; with mood-incongruent psychotic features; with catatonia; with peripartum onset; with seasonal pattern (recurrent episode only); in partial remission, in full remission Persistent depressive disorder: an overview At least two years of depressive symptoms Depressed mood most of the day on more than 50% of days No more than 2 months symptom free Symptoms can persist unchanged over long periods (>20 years) May include periods of more severe major depressive symptoms Major depressive symptoms may be intermittent or last for the majority or entirety of the time period Types of PDD Mild depressive symptoms without any major depressive episodes (“with pure dysthymic syndrome”) Mild depressive symptoms with additional major depressive episodes occurring intermittently (previously called “double depression”) Major depressive episode lasting 2+ years (“with persistent major depressive episode”) DSM-5 criteria Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years Note: in children and adolescents, mood can be irritable and duration must be at least 1 year Presence while depressed, of two (or more) of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self esteem Poor concentration or difficulty making decisions Feelings of hopelessness During the 2 year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time Criteria for major depressive disoder may be continuously present for 2 years There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder or other specified or unspecified schizophrenia spectrum and other psychotic disorder The symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg, hypothyroidism) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if: Current severity: mild, moderate, severe; with anxious distress; with mixed features; with melancholic features; with atypical features; with mood-congruent psychotic features; with mood-incongruent psychotic features; with peripartum onset; early onset: if onset is before age 21 years Late onset: if onset is at age 21 years or older; specify (for most recent 2 years of dysrhythmic disorder) With pure dysthymic syndrome: if full criteria for major depressive episode have not been met in at least the preceding 2 years With persistent major depressive episode: if full criteria for a major depressive episode have been met throughout the preceding 2 year period With intermittent major depressive episodes, with current episode: if full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode With intermittent major depressive episodes, without current episode: if full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years In full remission, in partial remission Possible courses of depressive disorders Diagnostic specifiers for depressive disorders Specifier: additional diagnostic label used by clinicians to convey extra information about symptoms Specifiers are not mandatory; only assigned if appropriate Psychotic features specifier Major depressive episodes which also include some psychotic features Hallucinations: sensory experience in the absence of sensory input Delusions: strongly held inaccurate beliefs Anxious distress specifier Depression is accompanied by several significant symptoms of anxiety Predicts poorer outcome Mixed features specifier Depressive episodes which also include several manic symptoms Melancholic features specifier Major depressive episode accompanied by additional severe symptoms such as early morning awakenings, lack of reactivity to positive stimuli Catatonic features specifier: Extremely rare muscular symptoms such as remaining in a still stupor, “waxy” limbs that remain in place when manipulated, repetitive or purposeless movement Atypical features specifier: Presence of several symptoms less common in depression, including oversleeping and overeating Peripartum onset specifier Depression occurring around the time of giving birth Seasonal pattern specifier: depression occurring primarily in certain seasons (usually winter) Sometimes called seasonal affective disorder Result of phase delayed circadian misalignment, meaning that the patient’s circadian rhythm is misaligned with the environmental day-night cycle May be treated with effectively with light therapy Onset and duration of depressive disorders Rare in childhood Risk increases in adolescence and young adulthood, decreases in middle adulthood, increases again in old age (U-shaped pattern) Depressive episodes are variable in length Usually last several months untreated but may last several years From grief to depression In previous editions of the DSM, depression could not be diagnosed during periods of mourning Now recognized that major depression may occur as part of the grieving process Acute grief: occurs immediately after loss Integrated grief: eventual coming to terms with meaning of the loss Complicated grief: persistent acute grief and inability to come to terms with loss Other depressive disorders Premenstrual dysphoric disorder Significant depressive symptoms occurring prior to menses during the majority of cycles, leading to distress or impairment Controversial diagnosis Advantage: legitimizes the difficulties some women face when symptoms are very severe Disadvantage: pathologizes can experience many consider to be normal DSM criteria At least 5 symptoms must be present final week before the onset of menses, improve after onset, and minimal/absent in week post menses Mood swings, sensitivity, etc Irritability or anger Depressed mood Anxiety and tension Decreased interests in usual activities Difficulty concentrating Lethargy Change in appetite Problems sleeping Feeling out of control Physical symptoms Disruptive mood dysregulation disorder Severe temper outbursts occuring frequently, against a backdrop of angry or irritable mood Diagnosed only in children 6-18 Criteria for manic/hypomanic episode are not met Designed in part to combat overdiagnosis of bipolar disorder in youth DSM-5 criteria Recurring temper outbursts Outbursts inconsistent with development 3 or more times a week Persistent irritability Between 6-18 years old Onset 10 years old Manic episode Elevated, expansive mood for at least one week Examples of symptoms Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors Impairment in normal functioning DSM-5 criteria for manic episode
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary) During the period of mood disturbance and increased energy or activity, three or more of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior Inflated self esteem or grandiosity Decreased need for sleep (eg, feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed Increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation (eg, purposeless non-goal-directed activity) Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indescretions, or foolish business investments) The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, other treatment) or to another general medical condition Note: a full manic episode that emerges during antidepressant treatment (eg, medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence of a manic episode and, therefore, a bipolar I diagnosis.

Types of mood disorders, continued “Mixed features” = term for a mood episode with some elements reflecting the opposite valence of mood Ex: depressive episode with some manic features Ex: manic episode with some depressed/anxious features The structure of mood disorders Unipolar mood disorder: only one extreme of mood is experienced Eg, only depression or only mania Depression alone is much more common than mania alone

Bipolar mood disorder: both depressed and elevated moods are experienced Eg, some depressive episodes and some manic or hypomanic episodes

Bipolar disorders DSM-5 bipolar disorders Bipolar I disorder Alternations between major depressive episodes and manic episodes Bipolar II disorder Alternations between major depressive episodes and hypomanic episodes DSM-5 criteria Criteria have been met for at least one hypomanic episode and at least one major depressive episode Criteria for a hypomanic episode are identical to those for a manic episode, with the following distinctions: 1) minimum duration is 4 days; 2) although the episode represents a definite change in functioning, it is not severe enough to cause marked social or occupational impairment or hospitalization; 3) there are not psychotic features There has never been a manic episode The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify current or most recent episode Hypomanic: if currently (or most recently) in a hypomanic episode Depressed: if currently (or most recently) in a major depressive episode Specify if With anxious distress; with mixed features with rapid cycling; with mood congruent psychotic features; with mood incongruent psychotic features; with catatonia; with peripartum onset; with seasonal pattern Specify course of full criteria for a mood episode are not currently met: In full remission, in partial remission Specify severity if full criteria for a mood episode are currently met: mild, moderate, severe Cyclothymic disorder Overview Chronic version of bipolar disorder Alternating between periods of mild depressive symptoms and mild hypomanic symptoms Episodes do not meet criteria for full major depressive episode, full hypomanic episode, or full manic episode Hypomanic or depressive mood states may persist for long periods Must last for at least two years (one year for children and adolescents) DSM-5 criteria For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode During the above 2 year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time Criteria for a major depressive, manic, or hypomanic episode have never been met The symptoms in criterion i are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder The symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition (eg hyperthyroidism) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if With anxious distress Diagnostic specifiers for bipolar disorders All of the specifiers for depressive disorders may also apply to bipolar disorders Additional specifier unique to bipolar disorders: rapid cycling specifier Moving quickly in and out of mania and depression Individual experiences at least four manic or depressive episodes within a year Occurs in between 2- and 50% of cases Associated with greater severity Prevalence of mood disorders Worldwide lifetime prevalence of MDD: 16% 6% have experienced major depression in last year Sex differences Females are twice as likely to have major depression Bipolar disorders approximately equally affect males and females Women more likely to experience rapid cycling Women more likely to be in depressive period Occurs less often in prepubertal children Rapid rise in adolescents Adults over 65 have about 50% less prevalence than general population Bipolar same in childhood, adolescence, and adults Prevalence of depression seems to be similar across subcultures Lifespan developmental influences on mood disorders 3 month olds can show depressive symptoms Young children typically don't show classic mania or bipolar symptoms mood disorder may be misdiagnosed as ADHD Children are being diagnosed with bipolar disorders at increasingly high rates Depression in elderly between 14% and 42% Co-occurrence with anxiety disorders Less gender imbalance after 65 years of age Prevalence of mood disorders Across cultures Similar prevalence among US subcultures, but experience of symptoms may very Eg, some cultures more likely to express depression as somatic concern Higher prevalence among Native Americans: four times the rate of the general population Causes of mood disorders Family studies Risk is higher if relative has a mood disorder Relatives of bipolar probands are more likely to have unipolar depression Twin studies Concordance rates are high in identical twins Two or three times more likely to present with mood disorders than a fraternal twin of a depressed co-twin Severe mood disorders have a strong genetic contribution Heritability rates are higher for females compared to males Some genetic factors confer risk for both anxiety and depression Neurobiological influences Neurotransmitter systems Serotonin and its relation to other neurotransmitters Serotonin regulates norepinephrine and dopamine Mood disorders are related to low levels of serotonin Permissive hypothesis: low serotonin “permits” other neurotransmitters to vary more widely, increasing vulnerability to depression The endocrine system Elevated cortisol Stress hormones decrease neurogenesis in the hippocampus > less able to make new neurons Sleep disturbance Hallmark of most mood disorders Depressed patients have quicker and more intense REM sleep Sleep deprivation may temporarily improve depressive symptoms in bipolar patients Psychological dimensions (stress) Stressful life events Stress is strongly related to mood disorders Poorer response to treatment Longer time before remission Context of life events matters Gene-environment correlation: people who are vulnerable to depression might be more likely to enter situations that will lead to stress The relationship between stress and bipolar is also strong Learned helplessness The learned helplessness theory of depression Lack of perceived control over life events leads to decreased attempts to improve own situation First demonstrated in research by Martin Seligman Negative cognitive styles are a risk factor for depression Depressive attributional style Internal attributions Negative outcomes are one’s own fault Stable attributions Believing future negative outcomes will be one’s fault Global attribution All three domains contribute to a sense of hopelessness Cognitive theory Negative coping styles Depressed persons engage in cognitive errors Tendency to interpret life events negatively Types of cognitive errors Arbitrary inference-overemphasize the negative aspects of a mixed situation Overgeneralization-negatives apply to all situations Cognitive errors and the depressive cognitive triad Think negatively about oneself Think negatively about the world Think negatively about the future Social and cultural dimensions Marital relations Marital dissatisfaction is strongly related to depression This relation is particularly strong in males Social support Extent of social support is related to depression Lack of social support predicts late onset depression Substantial social support predicts recovery from depression Gender differences in mood disorders Women account for 7 out of 10 cases of major depressive disorder Recall that women also have higher rates of anxiety disorders Explanations for gender differences in mood disorders Possible explanations for gender disparity Women socialized to have stronger perception of uncontrollability Parenting style makes girls less independent Women more sensitive to relationship disruptions (eg, breakups, tension in friendships) Women ruminate more than men An integrative theory Biological and psychological vulnerabilities interact with stressful life events to cause depression Biological vulnerability: eg, overactive neurobiological response to stress Psychological vulnerability eg, depressive cognitive style

Treatment of mood disorders Medication Antidepressants Selective serotonin reuptake inhibitors Called SSRIs Specifically block reuptake of serotonin so more serotonin is available in the brain Fluoxetine (prozac) is the most popular SSRI SSRIs pose some risk of suicide particularly in teenagers Negative side effects are common Some evidence that SSRI use during pregnancy lowered risk for birth complications Tricyclic antidepressants Include Tofranil, Elavil Mechanisms not well understood Block reuptake norepinephrine and other neurotransmitters Negative side effects are common (eg, drowsiness, weight gain) Discontinuation is common May be lethal in excessive doses Monoamine oxidase inhibitors Block monoamine oxidase This enzyme breaks down serotonin/norepinephrine As effective as tricyclics, with fewer side effects Dangerous in combination with certain foods Beer, red wine, cheese cannot be consumed; patients dislike dietary restrictions Also dangerous in combination with cold medicine Mixed reuptake inhibitors (eg, serotonin/norepinephrine reuptake inhibitors) Block reuptake of norepinephrine as well as serotonin Best known are venlafaxine (Effexor) and duloxetine (Cymbalta) Have fewer side effects than SSRIs Approximately equally effective Only 50% of patients benefit Only 25% achieve normal functioning Lithium Lithium carbonate = a common salt Treatment of choice for bipolar disorder Considered a mood stabilizer because it treats depressive and manic symptoms Toxic in large amounts- can be processed differently depending on different health conditions Dose must be carefully monitored Effective for 50% of patients Why lithium works is partially understood Electroconvulsive therapy (ECT) Effective for medication resisteant depression The nature of ECT Belief electrical current applied to the brain Results in temporary seizures Usually 6-10 outpatient treatments are required- can be repeated periodically as needed Side effects: Short-term memory loss which is usually restored Some patients suffer long term memory loss Mechanism for how this works is unclear Transcranial magnetic stimulation Uses magnets to generate a precise localized electromagnetic pulse Few side effects; occasional headaches Less effective than ECT for medication-resistant depression May be combined with medication Mainly used in failed trials of “first line” treatments- last resort treatment when nothing else has worked Psychosocial treatments for depression Cognitive behavioral therapy Addresses cognitive errors in thinking Also includes behavioral components including behavioral activation (scheduling valued activities) Interpersonal psychotherapy- interactions with other people Focus: improving problematic relationships Prevention Preemptive psychosocial care for people at risk Has longer-lasting effectiveness than medication Preventing relapse Research on relapse prevention is relatively less common Psychosocial and pharmacological treatments are both used Psychosocial interventions generally more effective at preventing relapse Psychosocial treatments for bipolar disorders Medication (usually lithium) is still first line of defense Psychotherapy helpful in managing the problems (eg, interpersonal, occupational) that accompany bipolar disorder Family therapy can be helpful Suicide Facts and statistics 11th leading cause of death in the USA (pre-COVID) Underreported; actual rate may be 2-3 times higher Most common among white and native Americans Particularly prevalent in young adults 3rd leading cause of death among teenagers 2nd leading cause of death in college students 12% of college students consider suicide in a given year Gender differences Males complete more suicides than females Females attempt suicide more often than males Disparity is due to males using more lethal methods Exception: suicide more common among women in China May reflect cultural acceptability; suicide is often seen as an honorable solution to problems Characteristics of suicide Reasons for suicide Suicide is often seen as a solution to unsolvable problems, and the only way to escape what is perceived as unbearable psychological pain Common emotions Hopelessness, sadness, frustration, worthlessness, guilt, and shame Cognitions Tunnel vision, unable to see the big picture or other options. Extreme pessimism about the future Behavior 80% of suicides preceded by verbal or non-verbal cues indicating intentions Why? Ambivalence Our primal instinct to want to stay alive, is a last effort to stay alive Ten common characteristics of suicide Common purpose is to seek a solution Cessation of consciousness is a common goal Stimulus is generally intolerable psychological pain Common stressor is frustrated psychological need Common emotion is hopelessness Cognitive state is one of ambivalence Cognitive state characterized by tunnel vision Common action is escape Understanding suicide Cannot ask successful suicides about their motives Psychological autopsy: case records, notes, extensive interviews with friends and family members in an attempt to reconstruct events leading up to suicide Interviewing survivors of suicide attempts

Attempters vs. Completers Characteristic Attempters Completers Sex More often female More often male Age Younger

Means Low lethality

Setting High chance of rescue

Diagnoses Dysthymia, borderline personality- highly related with suicidal gestures Mood disorder, schizophrenia, substance abuse

Degrees of suicidality Suicidal ideation: thoughts about suicide or ending one’s life Active: “I want to die” Passive: “I wish i could go to sleep and not wake up” Least severe Suicidal intent: conscios decision to act upon suicidal thoughts mid-severe Suicidal plan: specific means and setting for carrying out suicidal intent Specific means, plans, etc. Most severe Suicide risk factors Family history: suicide 6x more likely if family member has commited suicide Mental illness 90% have mental disorder 60% mood disorder Combination of substance abuse + mood disorder = high risk Alcohol use/abuse connected to 25-50% of suicides Stressful life events Real or perceived failure Rejection or loss of a loved one Humiliation- eg, unexpected arrest Personality trait- impulsivity Easy access to lethal means Sucide is most common among the elderly Suicide contagion Some research indicates that a person is more likely to commit suicide after hearing about someone else commiting suicide Media accounts may worsen the problem by sensationizionalizing/romanticizing suicide Describing lethal methods of commiting suicide Not contagious to those who are not already at risk Suicide prevention In professional mental health Clinician does risk assessment (ideation, plans, intent, means, etc) Clinician and patient develop safety plan (eg, who to call, strategies for coping with suicidal thoughts) In some cases, sign no-suicide contract Preventative programs for at risk groups CBT can reduce suicide risk Important: removing access to lethal methods If you think someone is at risk, talk to them and ensure they are getting needed support Talking to someone about suicide is not likely to place them at greater risk or “plant the idea” In contrast, the risk of not providing someone in need is huge

1. Major types of eating disorders

1. Major types of DSM-5 eating disorders

       1. bulimia nervosa and anorexia nervosa 2. Severe disruptions in eating behavior

          1. Weight and shape have disproportionate influence on self concept 2. Extreme fear and apprehension about gaining weight 3. Strong sociocultural origins- driven by Western emphasis on thinness

2. Associated Characteristics

       1. Obsessive-compulsive behaviors 2. Certain personality characteristics

          1. Restricting type- introversion, conformity, perfectionism, rigidity 2. Binge-purge type- extroverted, histrionic, volatile, impulse control problems 3. Many anorexics have a sense of pride about their diets and success in losing weight 4. Bulemia nervosa

          1. Binge eating- hallmark of bulimia nervosa and binge eating disorder

             1. Eating excess amounts of food in a discrete period of time 2. Eating is perceived as uncontrollable 3. May be associated with guilt, shame, or regret 4. May hide behavior from family members 5. Foods consumed are often high in sugar, fat, or carbohydrates 2. Defining features

             1. Compensatory behaviors- designed to make up for binge eating

                1. Most common: purging

                   1. Most common purging methods: self induced vomiting 2. May also include use of diuretics or laxatives 2. Excessive exercise 3. Fasting or food restriction 3. Diagnostic criteria

             1. recurrent episodes of binge eating 2. Recurrent inappropriate compensatory behavior in order to prevent weight gain 3. The binge eating and inappropriate compensatory behaviors both occur on average at least once a week for 3 months 4. Self-evaluation is unduly influenced by body shape and weight 5. Disturbance does not occur exclusively during anorexia  4. Associated features

             1. Associated medical features

                1. Most are within 10% of normal body weight 2. Purging methods can result in severe medical problems

                   1. Erosion of dental enamel, electrolyte imbalance 2. Kidney failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon damage 2. Associated psychological features 

                1. Most are overly concerned with body shape 2. Fear of gaining weight 3. Most have comorbid psychological disorders

                   1. 20% meet criteria for a mood disorder 2. 50-70% have met criteria for a mood disorder at some point 3. 80% have met criteria for an anxiety disorder at some point 4. Nearly two in five people abuse substances 5. Anorexia Nervosa

          1. Overview

             1. Extreme weight loss-hallmark of anorexia

                1. Restriction of calorie intake below energy requirements (sometimes defined as 15% below expected weight) 2. Intense fear of weight gain 3. Often begins with dieting 4. Subtypes 

                   1. Restricting: diet to limit calorie intake 2. Binge-eating-purging: purge to limit calorie intake  2. Diagnostic criteria

             1. Restriction of energy intake relative to requirements, leading to significantly low body weight 2. Intense fear of gaining weight or becoming fat 3. Disturbance in the way in which one’s body weight or shape is experienced 3. Defining features

             1. Most show marked disturbance in body image 2. Most have comorbid psychological disorders

                1. 70% are depressed at some point 2. Higher than average rates of substance abuse and OCD 3. Starving body borrows energy from internal organs, leading to organ damage including cardiac damage > can cause heart attack 4. Consequences

             1. Medical consequences

                1. Amenorrhea (loss of period in women) 2. Dry skin 3. Brittle hair and nails 4. Sensitivity to cold temps 5. Languo 6. Cardiovascular problems 7. Electrolyte imbalance 2. Most deadly mental disorder due to organ damage  6. Binge eating disorder

          1. Overview

             1. New disorder in DSM-5 2. Binge eating without associated compensatory behaviors  3. Associated with distress and/or functional impairment (eg, health risk, feelings of guilt) 4. Excessive concern with weight or shape may or may not be present  2. Associated features

             1. Approximately 20% of individuals in weight control programs suffer from BED 2. Approximately half of candidates for bariatric surgery suffer from BED 3. Better response to treatment than other eating disorders 4. Tend to be older than sufferers of anorexia and bulimia 5. Higher rates of psychopathology than non bingeing obsese individuals  3. Diagnostic criteria

             1. Recurrent episodes of binge eating 2. Binge eating episodes are associated with three or more of the following

                1. Eating much more than normal  2. Eating until feeling uncomfortably full 3. Eating large amounts when not hungry 4. Eating alone because embarrassed how much one is eating 5. Feeling disgusted/guilty after eating 3. Marked distress regarding binge eating 4. Binge eating not associated with bulimia 7. Bulimia and anorexia: facts and statistics

          1. Bulimia

             1. Majority are female- 90%  2. Some binge eating symptoms are relatively common in med 3. Incidence among males is increasing, 0.8 % bulemia, 2.9% BED 4. 6-7% of college women suffer from bulimia at some point 5. Onset typically in adolescence 6. Tends to be chronic if left untreated  2. Anorexia

             1. Majority are female and white 2. From middle to upper middle class families 3. Usually develops around early adolescence 4. More chronic and resistant than bulemia  5. Lifetime prevalence approximately 1% 6. Cross cultural factors

                1. Develop in non-western women after moving to western countries 

2. Causes of eating disorders

1. Social dimensions

       1. Media and cultural factors

          1. Media portrayals: thinness linked to success, happiness 2. Cultural emphasis on dieting 3. Standards of ideal body size

             1. Frequently changing and difficult to achieve 4. Using dietary supplements can lead to other serious problems such as drinking or other drug addictions  2. Dietary restraint

          1. Adolescent dieting leads to an 8x greater risk of developing an eating disorder 2. Adolescents tend to internalize the standards of friendship groups (eg, a teenager is more likely to diet if her friends also diet) 3. May paradoxically cause weight gain

             1. Produces stress and withdrawal symptoms that increase cravings for food 4. During periods of restricted food intake, people become preoccupied with food and eating

             1. Classic study conducted during WWII: volunteers placed on strict diets started thinking, writing, and reading more about food 3. Family influences

          1. Parents with distorted perception of food and eating may restrict children’s intake too (eg, put chubby toddlers on unnecessary diets) 2. Families of individuals with with anorexia are often

             1. High achieving 2. Concerned with external appearances 3. Overly motivated to maintain harmony > leads to poor communication and denial of problems 3. Disordered eating also strains family relationships

             1. Causes parental guilt and frustration and is associated with poorer outcomes 

2. Biological dimensions

       1. Some genetic component 

          1. Relatives of people with eating disorders are 4-5 times more likely to develop an eating disorder 2. Not clear what is inherited

             1. May be nonspecific traits like emotional instability or impulsivity 3. Low levels of serotonergic activity often found in eating disorders 4. Hormones may influence eating behavior

3. Psychological dimensions 

       1. Low sense of personal control and self confidence 2. Perfectionistic attitudes 3. Distorted body image 4. Preoccupation with food 5. Mood intolerance

3. Treatment of eating disorders

1. Psychotropic drugs-primarily antidepressants

       1. Generally ineffective for anorexia nervosa 2. SSRIs show increased efficacy for bulimia

2. Psychological treatments- usually cognitive behavioral therapy

       1. Emphasis on core pathological mechanism: distorted body image

3. Medical and psychological treatment of bulimia nervosa

       1. Cognitive behavioral therapy (CBT-E) 2. Medical and drug treatments

          1. Antidepressants

             1. Can help reduce binging and purging behavior 

4. Medical and psychological treatment of binge eating disorder

       1. Previously used medications for obesity are now not recommended 2. Psychological treatment

          1. CBT- effective 2. Interpersonal psychotherapy- equally effective as CBT 3. Self help techniques- effective 4. IPT was effective for both rapid and non rapid responders 

5. Psychological treatment of anorexia nervosa

       1. General goals and strategies

          1. Weight restoration

             1. First and easiest goal of achieve 2. Psychoeducation 3. Behavioral and cognitive interventions

             1. Target food, weight, body image, thought, and emotion 4. Treatment often involves the family 5. Family based treatment (FBT) has the most support from clinical trials for treating adolescents with anorexia 

4. Preventing eating disorders

1. Often focuses on promoting body acceptance in adolescent girls
2. Identify specific targets

       1. Early weight concerns

3. Screening for at risk groups (eg sororities)
4. Provide education

       1. Normal weight limits 2. Effects of caloric restriction

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5. Obesity

1. Background and overview 

       1. Considered BMI of 30+ 2. Not DSM disorder, but may be a consequence 3. Statistics

          1. In 2008, 33.8% of adults in the united states were obese; 37.5% in 2010 2. Mortality rates

             1. Close to those associated with smoking 3. Increasing more rapidly in childrens/teens 4. Obesity also growing rapidly in developing countries

2. Obesity and disordered eating patterns

       1. Obesity and night eating syndrome

          1. Occurs in 7-19% of treatment seekers 2. Occurs in 55% of individuals seeking bariatric surgery 3. Consume ⅓+ of daily calories after dinner 4. Get up during the night to eat 5. Patients are wide awake and do not binge eat 6. Often not hungry, skip breakfast the next morning  2. Causes

          1. Obesity is related to technological advancement

             1. Promotes inactive, sedentary lifestyle 2. Genetics account for about 30% of obesity cases 3. Psychological factors contribute as well

             1. More likely to be obese if people in close social circles are also obese 

3. Obesity treatment

       1. Efficacy

          1. Moderate success with adults 2. Greater success with children and adolescents 3. Recent study suggests that the combination of restricted calorie intake, increased physical activity, and behavior therapy tends to lead more weight loss than any of these components on their own  2. Treatment progression- from least to most intrusive options 3. Steps of obesity treatment

          1. First step

             1. Self directed weight loss programs 2. Second step

             1. Commercial self help programs 3. Third step

             1. Behavior modification programs 4. Last step

             1. Bariatric surgery

6. Sleep-wake disorders: the major dyssomnias

1. The importance of sleep

       1. Just a few hours’ sleep deprivation decreases immune functioning 2. Sleep deprivation affects all aspects of daily functioning- energy, mood, memory, concentration, attention 3. Sleep loss may bring on feelings of depression in non-depressed individuals

          1. Paradoxically, can have antidepressant effects in depressed individuals 

2. Overview

       1. Polysomnographic (PSG) evaluation of sleep

          1. Electroencephalograph (EEG)- brain waves  2. Electrooculography (EOG)- eye movements 3. Electromyography (EMG)- muscle movements 4. Detailed history, assessment of sleep hygiene and sleep efficiency 2. Actigraph

          1. Portable wearable device sensitive to movement- can detect different stages of wakefulness/sleep 3. Two major types of sleep disorders

          1. Dyssomnias

             1. Difficulties in amount, quality, or timing of sleep 2. Parasomnias

             1. Abnormal behavioral and physiological events during sleep

3. The dyssomnias: overview and defining features of insomnia

       1. Insomnia disorder

          1. One of the most common sleep disorders 2. Microsleeps 3. Problems initiating/maintaining sleep (eg, trouble falling asleep, waking during the night, waking too early in the morning) 4. 15% of adults report daytime sleepiness 5. Only diagnosed as a sleep disorder if it is not better explained by a different condition (eg, generalized anxiety disorder) 6. Diagnostic criteria

             1. Dissatisfaction with sleep quantity or quality 2. Sleep disturbance causes significant distress 3. Sleep difficulty occurs 3 nights per week or more at least 2 months 4. Difficulty occurs even when there is possibility for sleep 5. No other physiological, medical, or mental disorders better explain symptoms  2. Insomnia

          1. Facts and statistics

             1. Often associated with medical and/or psychological conditions

                1. Anxiety, depression, substance use 2. Affects females twice as often as males 2. Associated features

             1. Unrealistic expectations about sleep 2. Believe lack of sleep will be more disruptive than it usually is 3. Causes

             1. Pain, physical discomfort 2. Delayed temperature rhythm (body temperature doesnt drop until later, leading to delayed drowsiness) 3. Light noise, temperature influence ability to sleep 4. Other sleep disorders cause secondary insomnia

                1. Apnea 2. Periodic limb movement disorder 5. Stress and anxiety 6. Parental effects on children’s sleep

                1. Parents’ negative beliefs about sleep linked to more infant waking during the night 2. Some kinds learn to fall asleep only with a parent present 3. Hypersomnolence disorder

          1. Overview

             1. Sleeping too much or excessive sleep

                1. May manifest as long nights of sleep or frequent napping 2. Experience excessive sleepiness as a problem 2. Defining features

             1. Causes are not well understood due to limited research 2. Often associated with other medical and/or psychological conditions 3. Only diagnosed if other conditions does not adequately explain hypersomnia, which should be the primary complaint 4. Associated features

                1. Complain of sleepiness throughout the day 2. Able to sleep through the night  4. Narcolepsy 

          1. Overview

             1. Principal symptom: recurrent intense need for sleep, lapses into sleep, or napping 2. Also accompanied by at least one

                1. Cataplexy 2. Hypocretin deficiency 3. Going into REM sleep abnormally fast (>15 min), as evidenced by polysomnographic measures  2. Defining features

             1. Facts and statistics- rare condition

                1. Affects about .03% to .16% of the population 2. Equally distributed between males and females 3. Onset during adolescence 4. Typically improves over time  5. Breathing-related sleep disorders

          1. Overview 

             1. Include three different disorders previously classified as parts of the same disorder

                1. Obstructive sleep apnea hypopnea

                   1. Airflow stops, but respiratory system works 2. Central sleep apnea (CSA)

                   1. Respiratory systems stop for brief periods 3. Sleep related hypoventilation: decreased breathing during sleep not better explained by another sleep disorder 2. Facts

             1. Obstructive sleep apnea occurs in 10-20% of population  2. More common in males  3. Associated with obesity and increasing age 3. Features associated with breathing related sleep disorders

             1. Persons are usually minimally aware of apnea problem 2. Often snore, sweat during sleep, wake frequently 3. May have morning headaches  4. May experience episodes of falling asleep during the day (due to poor sleep quality at night) 4. circadian rhythm sleep-wake disorders

             1. Disturbed sleep (eg either insomnia or excessive sleepiness leading to distress and/or functional impairment (eg significantly decreased productivity at work) 2. Specifically due to brain’s inability to synchronize day and night 3. Ex

                1. Shift work type- job leads to irregular hours 2. Familial type- associated with family history of dysregulated rhythms 3. Delayed or advanced sleep phase type- person’ s biological clock is naturally set earlier or later than a normal bedtime 

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7. Treatment of sleep disorders 

1. Insomnia

       1. Benzodiazepines and over the counter sleep medications 2. Prolonged use

          1. Can cause rebound insomnia, dependence  2. Best as short term solution 

2. Hypersomnia and narcolepsy

       1. Stimulants (ie, Ritalin) 2. Cataplexy usually treated with antidepressants

3. Breathing related sleep disorders

       1. Many include medications, weight loss, or mechanical devices

4. circadian rhythm sleep wake disorders

       1. Phase delays

          1. Moving bedtime later (best approach) 2. Phase advances

          1. Moving bedtime earlier (more difficult) 3. Use of very bright light

          1. Trick the brain’s biological clock

5. Cognitive behavioral therapy for insomnia (CBT-I)

       1. Psychoeducation about sleep 2. Changing beliefs about sleep  3. Extensive monitoring using sleep diary 4. Practicing better sleep related habits 5. Changing assumptions that they cant function well on little sleep

6. Psychological treatments for sleep disorders

       1. Relaxation and stress reduction 

          1. Reduces stress and assists with sleep  2. Modify unrealistic expectations about sleep 2. Stimulus control procedures

          1. Improved sleep hygiene-bedroom is a place for sleep 2. For children- setting a regular bedtime routine

8. Preventing sleep disorders

1. Best approach: practice healthy “sleep hygiene” (behaviors that lead to adequate quality and quantity of sleep)
2. Also helpful to educate parents about good sleep habits for children
   9. Parasomnias

1. Overview

       1. Nature of parasomnias

          1. The problem is not with sleep itself 2. Problem is abnormal events during sleep, or shortly after waking 2. Two classes of parasomnias

          1. Those that occur during REM (ie, dream) sleep 2. Those that occur during non-REM (ie, non-dream) sleep 

2. non-REM Sleep arousal disorders

       1. New DSM-5 diagnosis 2. Recurrent episodes of either/or

          1. Sleep terrors

             1. Recurrent episodes of panic like symptoms during non-REM sleep 2. Sleepwalking 3. Individual has no memory of the episodes 

3. More about sleep terrors

       1. Facts and associated features

          1. More common in children (~6%) than adults 2. Child cannot be easily awakened during the episode 3. Child has little memory of it the next day

4. More about sleep walking

       1. Sleepwalking disorder- somnambulism

          1. Occurs during non-REM sleep 2. Usually during first few hours of deep sleep 3. Person must leave the bed 2. Facts and associated features 

          1. More common in children than adults 2. Problem usually resolves on its own without treatment 3. Seems to run in families 4. May be accompanied by nocturnal eating