Untitled Flashcards Set

Module 7:  Anxiety Disorders

• Students’ Mental Health:

  • Students generally have poorer mental health compared to non-student peers.

  • 20-25% of undergraduates are highly test-anxious.

  • Untreated mental health issues can lead to:

    • Distress: Impacts overall quality of life (QoL).

    • Academic impact: Poor performance, integrity issues.

    • Substance abuse: As a coping mechanism.

Worry, Stress, Anxiety, and Fear

Key Differences:

Examples:

• Worry: Overthinking what might be on the exam.

• Stress: Physical tension before presenting in class.

• Anxiety: Fear of failing an exam despite being prepared.

• Fear: A dog running toward you aggressively.

Problems arise when:

• Thoughts/reactions are obsessive, irrational, or too strong for the situation.

Sources of Anxiety for Students

• Grades: Fear of failure.

• Social injustice: E.g., witnessing or experiencing discrimination.

• Fitting in: Pressure to be socially accepted.

• Balancing life: Managing school, work, and social activities.

• Financial worries: Paying tuition or rent.

• Independence: Transitioning into adulthood.

Symptoms of Anxiety

Physical:

• Increased heart rate (e.g., before a presentation).

• Nausea or sweating (e.g., during a test).

Emotional:

• Feeling nervous, frustrated, or impatient.

Behavioral:

• Avoidance of tasks (e.g., skipping classes).

• Reassurance-seeking (e.g., repeatedly asking, “Did I do okay?”).

Thoughts:

• Fear of judgment or losing control.

• Struggling with memory recall under stress.

Signs of Test Anxiety

• Frustration: “Why can’t I focus?”

• Distraction: Can’t concentrate on the paper.

• Negative self-talk: “I’m going to fail.”

• Catastrophizing: “If I fail this, my life is over.”

Post-test realization: Knowing the answers after it’s too late.

Managing Test Anxiety

1. Health Resources: Utilize counseling or wellness services.

2. Accept Normal Anxiety: A little stress improves performance.

3. Monitor Self-Talk:

   • Replace thoughts like “I’ll fail” with “I’ve prepared well.”

4. Relaxation Techniques:

   • Breathing exercises or progressive muscle relaxation.

5. Exercise: E.g., a 20-minute jog before exams.

Tips to Reduce Anxiety During a Test:

• Be prepared; don’t cram!

• Stay relaxed—breathe deeply when overwhelmed.

• Start with easy questions to build confidence.

• Focus on your pace; don’t compare with others.

Managing Stress and Anxiety

Acute Stress Disorder (ASD)

• Triggered by trauma (e.g., accident, violence).

• Duration: Stress lasts less than a month.

• If it continues, it may develop into PTSD.

PTSD (Post-Traumatic Stress Disorder)

Key Symptoms:

• Re-experiencing: Flashbacks of trauma (e.g., car crash).

• Avoidance: Refusing to drive post-accident.

• Increased Arousal: Startle response or constant alertness.

Causes:

• Direct trauma: Severe accidents or violence.

• Perceived threats: E.g., life-threatening events.

• Previous trauma: History of abuse.

Treatment of PTSD

1. Exposure Therapy:

   • Gradual exposure to triggers (e.g., driving simulations for crash survivors).

   • Learn coping mechanisms like breathing techniques.

2. EMDR:

   • Combines eye movements with revisiting traumatic memories.

   • E.g., imagining a crash while following the therapist’s hand.

3. Virtual Therapy:

   • Uses sensory cues (e.g., smells, sounds) to simulate trauma safely.

Obsessive-Compulsive Disorders (OCD)

Key Distinctions:

• Obsessions: Intrusive thoughts (e.g., “The door isn’t locked”).

• Compulsions: Repetitive actions (e.g., checking the door repeatedly).

Treatment:

• ERP (Exposure and Response Prevention):

  • Expose yourself to triggers but resist compulsions.

  • E.g., Touch a doorknob without washing hands repeatedly.

Other Disorders

1. Body Dysmorphic Disorder:

   • Obsessed with perceived flaws in appearance.

   • E.g., constantly checking a mirror.

   • Treatment: Exposure therapy.

2. Hoarding Disorder:

   • Accumulating unnecessary items.

   • Difference from OCD: Hoarders feel pleasure in collecting.

3. Trichotillomania:

   • Hair-pulling disorder seen more in females (1-5% of students).

4. Excoriation Disorder:

   • Skin-picking habit leading to scars.

   • Treatment: Habit reversal therapy.

Mindfulness Benefits

• Self-acceptance: Reduces self-criticism.

• Improved focus: Leads to better academic performance.

• Reduced anxiety: Fewer intrusive thoughts.

• E.g., Mindful breathing exercises before exams.

Module 7 Key terms:

Agoraphobia

• A type of anxiety disorder characterized by intense fear or avoidance of situations where escape might be difficult or help unavailable, often leading to avoidance of public spaces, crowds, or traveling far from home.

Animal Phobias

• A specific type of phobia involving an intense and irrational fear of animals, such as dogs, snakes, spiders, or insects. These fears can lead to avoidance behaviors.

Anxiety

• A general term describing a state of excessive worry, fear, or apprehension about future events or uncertainties. It often involves physiological symptoms like increased heart rate, sweating, and muscle tension.

Behavioral Inhibition System (BIS)

• A neuropsychological system that regulates responses to perceived threats or punishments. It is associated with feelings of anxiety and avoidance behavior in response to unfamiliar or potentially dangerous situations.

Blood-Injury-Injection Phobias

• A specific type of phobia characterized by extreme fear of blood, injuries, or medical procedures involving needles or injections. It may cause fainting due to a drop in blood pressure.

Fear

• An emotional response to an immediate and real threat, typically involving physical and psychological reactions like increased heart rate, heightened alertness, and a desire to escape the threat.

Fight/Flight System (FFS)

• A biological system that activates the body's physiological response to a perceived threat, preparing it to either fight or flee. This system involves the release of stress hormones like adrenaline.

Generalized Anxiety Disorder (GAD)

• A chronic condition characterized by excessive and uncontrollable worry about various aspects of life, often accompanied by physical symptoms like restlessness, fatigue, and muscle tension.

Natural Environment Phobias

• A specific type of phobia involving intense fear of natural elements, such as storms, water, heights, or darkness, which may lead to avoidance of these environments.

Panic

• A sudden surge of overwhelming fear or discomfort that often arises without warning. It can include physical symptoms such as a racing heart, dizziness, or shortness of breath.

Panic Attack

• A discrete period of intense fear or discomfort accompanied by physical and cognitive symptoms such as palpitations, sweating, trembling, chest pain, and fear of losing control or dying.

Panic Control Treatment (PCT)

• A therapeutic intervention for panic disorder that combines cognitive-behavioral techniques, such as exposure to feared sensations, breathing retraining, and cognitive restructuring, to reduce panic attacks.

Panic Disorder (PD)

• An anxiety disorder marked by recurrent and unexpected panic attacks, often accompanied by persistent worry about having more attacks and behavioral changes to avoid triggers.

Separation Anxiety Disorder

• A condition often diagnosed in children but can also occur in adults, characterized by excessive fear or anxiety about being separated from attachment figures, such as parents or caregivers.

Situational Phobias

• A specific type of phobia involving fear of particular situations, such as flying, driving, or being in enclosed spaces like elevators. Avoidance of these situations is common.

Social Anxiety Disorder (SAD)

• An anxiety disorder characterized by an intense fear of being judged, embarrassed, or humiliated in social or performance situations, leading to avoidance or extreme distress in these contexts.

Specific Phobia

• An intense, irrational fear of a specific object, situation, or activity, such as heights, animals, or flying. The fear is disproportionate to the actual threat and often results in avoidance behavior.

Module 8: schizophrenia disorder 

Schizophrenia Overview

• Definition: Psychotic disorder with major disturbances in thought, emotion, and behavior.

• Characteristics:

  • Disordered thinking (illogical connections).

  • Faulty perception/attention (difficulty focusing).

  • Flat or inappropriate affect (emotional responses out of context).

  • Bizarre motor disturbances (e.g., catatonia).

Prevalence (Canada) & Comorbidity

• 1% of the general population affected.

  • Half treated in the community, but 10% commit suicide.

  • Mortality rate: 3x higher than the general population.

  • Comorbid disorders:

    • Substance abuse: 37%.

    • Depression: 40%.

• Higher prevalence in Canada:

  • Related to immigration stress and high latitudes (low sunlight → less vitamin D → prenatal factors linked to schizophrenia).

Course of Schizophrenia

• Onset:

  1. Men: Late adolescence → Early 20s.

  2. Women: Early 20s → Early 30s.

  3. Can begin in childhood.

• Symptoms fluctuate between acute episodes and residual symptoms.

• Three Phases:

  1. Prodromal (Gradual deterioration, vague symptoms):

     • E.g., social withdrawal, odd speech, strange ideas, magical thinking.

  2. Acute (Apparent symptoms):

     • E.g., delusions, hallucinations, disorganized speech.

  3. Residual (Return to prodromal-like symptoms):

     • E.g., blunt affect, unclear thinking.

Symptoms of Schizophrenia

Positive Symptoms:

• Excessive or distorted behaviors:

  • Delusions (70%):

    • E.g., Persecution: “Someone is out to harm me.”

    • Grandeur: “I am a deity or have superpowers.”

    • Control: “Aliens are controlling my thoughts.”

  • Hallucinations (60-80%):

    • E.g., Auditory: Hearing voices.

    • Visual: Seeing people not present.

    • Tactile: Feeling bugs crawling on the skin.

Negative Symptoms:

• Deficits in normal behavior:

  • Alogia: Limited speech or content (e.g., vague, repetitive replies).

  • Avolition: Lack of motivation (e.g., no desire to engage in activities).

  • Blunted/Flat Affect: No visible emotion.

  • Asociality: Social withdrawal, preference for isolation.

Disorganized Symptoms:

• Inappropriate Affect: Emotions that don’t match context.

  • E.g., Laughing at tragic news.

• Disorganized Behavior:

  • E.g., Catatonia (stiff posture or erratic movements).

Etiology of Schizophrenia

Genetics:

• Inherited predisposition triggered by environmental stress.

• Multiple genes involved.

• E.g., Twin studies show higher concordance rates among identical twins.

Biochemical:

• Dopamine Hypothesis:

  • Earlier theory: Excess dopamine causes symptoms.

  • Revised: Abnormal dopamine receptor activity (too sensitive/deficient).

• Brain chemicals: Glutamate transmission deficiency.

Brain Structure:

• Enlarged ventricles, loss of brain tissue.

• Hypofrontality: Reduced frontal lobe activity.

• Linked to:

  • Poor nutrition, birth complications, immune reactions.

Sociocultural Explanations:

• SES Stress:

  • E.g., Living in poverty increases schizophrenia risk.

  • Socio-genic Hypothesis: Low SES → Stress → Disorder.

  • Social-selection Theory: Schizophrenia → Poor social/economic status.

• Family Dynamics:

  • High Expressed Emotion (EE) families → Increased relapse.

Diathesis-Stress Model:

• Definition: Biological predisposition activated by stress.

• Examples:

  • Biological diathesis: Family history of schizophrenia.

  • Environmental stressor: Stressful immigration process, traumatic events.

Treatments for Schizophrenia

1. Antipsychotic Medications:

   • Reduce dopamine activity.

   • E.g., Haloperidol for managing hallucinations/delusions.

2. CBT:

   • Challenge delusions and improve coping mechanisms.

   • E.g., “The voices are not real.”

3. Family Therapy:

   • Reduces high EE to prevent relapse.

4. Social Skills Training:

   • E.g., Practicing conversational skills.

Other Psychotic Disorders

1. Schizoaffective Disorder:

   • Schizophrenia symptoms + Mood disorder (e.g., depression).

   • Example: Hallucinations and suicidal depression.

2. Delusional Disorder:

   • Persistent delusions without hallucinations or disorganized behavior.

   • Example: Believing a celebrity is secretly in love with them.

3. Brief Psychotic Disorder:

   • Sudden, short-term psychosis (less than a month).

   • Triggered by major stressor.

   • Example: Losing touch with reality after a traumatic accident.

4. Shared Psychotic Disorder (Folie à Deux):

   • Delusions shared between individuals.

   • Example: A couple believes they are being watched by the government.

Summary Table for Catatonia

Other Psychotic Disorders

• Schizophreniform disorder: This disorder includes individuals who experience the symptoms of schizophrenia for fewer than 6 months.

• Schizoaffective disorder: This disorder includes people who have symptoms of schizophrenia and who also exhibit the characteristics of mood disorders such as depression and bipolar affective disorder.

• Delusional disorder: Includes individuals with a constant belief that is the opposite of reality, in the absence of the other characteristics of schizophrenia.

• Brief Psychotic Disorder: Includes individuals with one or more positive symptoms such as delusions, hallucinations or disorganized speech or behaviour over the course of less than one month.

• Attenuated Psychosis Syndrome: Includes one or more of the symptoms associated with schizophrenia, such as hallucinations or delusions, but the person  with the disorder is aware that these are unusual experiences and that they are not normal for a healthy person.  

• Schizotypal Personality Disorder: The characteristics of this disorder to those experienced by people with schizophrenia but are less severe.

Schizophrenia: What is it

• A psychotic disorder which is characterized by major disturbances in cognitions, emotions and behaviours.

• Characterized by: 

• Disordered thinking in which their ideas are not logically related or alike.

• Faulty perception and attention.

• Flat or inappropriate affect; they have either severely restricted or nonexistent expression of emotion.

• Bizarre activity in motor skills; jerky movements, continuous spasms or muscle contractions.

Prevalence and comorbidity

Prevalence in Canada

• About 1% of the general population lives with schizophrenia.

• Treatment: Almost half are treated in the community.

• Suicide risk: Nearly 10% of individuals with schizophrenia commit suicide.

• Mortality rate: People with schizophrenia have a mortality rate three times higher then the individuals who do not have this disorder. 

• Comorbidity: about  50% of schizophrenia patients suffer another disorder which includes:

• Substance abuse (37%).

• Depression (40%).

Higher prevalence In Canada relative to Worldwide levels why?

• The higher prevalence rate in Canada is usually attributed to immigration rates and the country’s high latitude.  

Greater prevalence Observed in

• Immigrants: Individuals who move to new countries may experience more stress, which can potentially lead to the development of schizophrenia.

• High-Latitude Countries: Limited sunlight and reduced vitamin D levels are contributors that may influence the prenatal development of schizophrenia.

Course of Schizophrenia

• Onset: Schizophrenia can sometimes begin in childhood but is most commonly seen during late adolescence or early adulthood.

Symptom Pattern

• Individuals typically experience multiple episodes of acute symptoms.

• Between episodes they have less intense but still significantly impairing symptoms 

Treatment

• Most individuals with schizophrenia are treated in community settings though hospitalization is required at times.

Three common phases

• Prodromal Phase: This is the initial phase or period which is marked by a slow decline in functioning. Early warning signs can include withdrawal, lower motivation, and small changes in thought processes.

• Acute Phase: This phase is defined by the presence of severe symptoms such as delusions, hallucinations, and disorganized or illogical thinking. It’s the phase where the disorder is most noticeable and debilitating.

• Residual Phase: After an acute episode, individuals often transition  into a residual phase, where they experience a return to the prodromal level of functioning with lingering but less severe symptoms.

Clinical description of Schizophrenia Spectrum Disorders 

Schizophrenia Spectrum Disorders 

• This refers to a group of diagnoses with the field of schizophrenia, encompassing different disorders that share similar symptoms and characteristics.

DSM-5-TR Dimensional assessment of Symptoms

• Symptoms are assessed on a 0–4 scale to determine their severity:

  • 0: No symptoms.

  • 1: Equivocal evidence (uncertain or questionable symptoms).

  • 2: Present but mild.

  • 3: Present and moderate.

  • 4: Present and severe.

Types of Symptoms:

• Positive Symptoms: These involve an active display of problematic behaviours, such as hallucinations, delusions, and other distortions in perception or thinking.

• Negative Symptoms: These represent a lack or insufficiency of normal behaviours, including reduced emotional expression, lack of motivation, and social withdrawal.

• Disorganized Symptoms: This category includes symptoms that reflect disordered thinking and behaviour, such as incoherent speech, erratic actions, and confused thinking.

Positive symptoms of schizophrenia 

Definition:

• Positive symptoms refer to excesses or bizarre additions/distortions in a person’s thoughts, emotions, or behaviours. These are experiences or behaviours that are not typically present in people without the disorder.

Common Positive Symptoms:

• Hallucinations: Sensory experiences that appear real but are created by the mind. Hallucinations can involve any of the senses, though auditory hallucinations (hearing voices) are most common.

  • Prevalence: Approximately 60-80% of people with schizophrenia experience hallucinations.

• Delusions: Strongly held, false beliefs that are resistant to reasoning or contrary evidence. Common types of delusions include persecutory delusions (belief that others are out to harm them) and grandiose delusions (belief in one's exceptional abilities or importance).

  • Prevalence: Around 70% of people with schizophrenia experience delusions.\

Delusions: what are they

Definition:

• Delusions are beliefs that are strongly held despite being contrary to reality. They are resistant to logical reasoning and contrary evidence.

Common Types of Delusions:

• Delusions of Persecution: Belief that others are out to harm or harass the individual.

• Delusions of Reference: Belief that external events, objects, or people are directly related to them (e.g., thinking that a TV show is sending them personal messages).

• Delusions of Grandeur: Belief in one’s own exceptional abilities, knowledge, or importance, often unrealistic or grandiose.

• Delusions of Control: Belief that one's thoughts, feelings, or actions are being controlled by external forces.

Specific Syndromes:

• Cotard’s Syndrome: A rare delusional belief where individuals feel as though they are dead or do not exist.

• Capgras Syndrome: Belief that a close friend, family member, or significant other has been replaced by an identical impostor.

Prevalence:

• Delusions are found in more than half of individuals diagnosed with schizophrenia.

Hallucinations: What are they

Definition:

• Hallucinations are sensory perceptions that occur without any actual external stimulus. They are distortions of perception, where individuals perceive things that do not exist in reality.

Types of Hallucinations:

• Auditory: Hearing sounds or voices that are not present. This is the most common type of hallucination in schizophrenia.

• Visual: Seeing objects, people, or lights that aren’t there.

• Tactile: Feeling sensations on the skin or in the body, such as crawling or burning, that are not happening.

• Somatic: Experiencing sensations that something is inside the body, such as feeling as though organs are being moved or touched.

• Gustatory: Tasting things that are not present, often unpleasant tastes.

• Olfactory: Smelling odours that aren’t there, which can be unpleasant or disturbing.

Attentional Deficiencies 

Definition:

• Attentional deficiencies refer to challenges in filtering out irrelevant stimuli, which disrupts the ability to focus and process information effectively.

Example:

• For instance, reading requires the ability to screen out background noises and other distractions. Attention is essential for focusing on relevant information and ignoring unimportant details, which is fundamental to learning and cognitive processing.

Impact on People with Schizophrenia:

• Individuals with schizophrenia often struggle to filter out irrelevant stimuli. This makes it extremely challenging to concentrate, organize thoughts, and ignore unessential information. These difficulties can lead to disorganized thinking and hinder effective learning and daily functioning.

Negative symptoms associated with Schizophrenia

Definition:

• Negative symptoms refer to a reduction or absence of normal functions in thoughts, emotions, or behaviors. They are often harder to observe but significantly impact daily functioning.

Alogia (a negative thought disorder):

• Definition: Alogia is characterized by a lack of speech, reflecting a thought disorder where an individual has difficulty producing speech or meaningful content.

• Types:

  • Poverty of Speech: There is a reduction in the quantity of speech, leading to brief replies and limited verbal output.

  • Poverty of Content of Speech: While the amount of speech may appear normal, the information conveyed is minimal, often vague or repetitive, with little substance or clarity.

Avolition (a motivational deficit):

• Definition: Avolition refers to the inability to initiate or persist in goal-directed activities. It manifests as apathy, loss of motivation, or a lack of directedness.

• Characteristics:

  • Apathy: Lack of interest or enthusiasm in everyday activities.

  • Loss of Motivation: Difficulty starting or maintaining tasks due to a diminished sense of purpose.

  • Ambivalence: Mixed feelings or contradictory ideas that hinder decision-making and purposeful action.

Blunted & Flat Affect:

• Blunted Affect: Reduced emotional expression compared to others, with limited outward signs of emotion.

• Flat Affect: Almost complete lack of outward emotional expression, characterized by an immobile, expressionless face.

• Anhedonia: The inability to experience pleasure, leading to a general lack of enjoyment in activities that would typically be pleasurable.

Asociality (social withdrawal):

• Definition: Asociality refers to a lack of interest in social interactions, often resulting in social withdrawal and isolation.

• Characteristics:

  • Lack of Social Interest: Reduced desire to engage with others or build relationships.

  • Social Withdrawal: Avoidance of social interactions, preferring isolation.

  • Self-Absorption: Focusing mainly on personal thoughts and fantasies, with limited awareness or consideration of others.

  • Breakdown of Social Skills: Diminished ability to interact appropriately with others due to a lack of social engagement.

Inappropriate Affect:

• Emotional responses are incongruent with the context or situation.

• Examples:

  • Laughing upon hearing sad news, such as the death of a loved one.

  • Becoming enraged over a minor question, such as how a new garment fits.

• These responses may be influenced by other symptoms, such as auditory hallucinations.

• Additional Characteristics:

  • Rapid shifts between emotional states with no clear cause.

  • Although rare, inappropriate affect is diagnostically significant because it is relatively specific to schizophrenia.

:

• Includes unusual or awkward physical movements and behaviors.

• Characteristics:

  • Awkward or repetitive movements.

  • Repeated grimaces or strange facial expressions.

  • Odd or seemingly purposeless gestures.

• Catatonia: A severe form of disorganized behavior involving abnormal motor activity and responses.

  • Catatonic Stupor: Lack of movement and responsiveness to the environment.

  • Catatonic Rigidity: Maintaining a rigid posture for extended periods.

  • Catatonic Posturing: Holding bizarre or fixed postures.

  • Catatonic Excitement: Excessive and uncontrolled motor activity

Disorganised thinking and speech

Etiology of schizophrenia

Biological explanations: Genetic etiology

Genetic Predisposition:

• Some individuals inherit a biological susceptibility to schizophrenia, which can be triggered by extreme stress later in life.

• Negative Symptoms: Appear to have a stronger genetic component than positive symptoms.

Family Studies:

• Increased Risk: Relatives of individuals with schizophrenia have a higher risk of developing the disorder, with the risk increasing as genetic relatedness becomes closer.

• Related Disorders: Relatives are also at higher risk for other disorders, such as schizotypal personality disorder (a less severe form of schizophrenia).

• Inheritance: The predisposition to schizophrenia may be inherited.

Twin Studies:

• Concordance Rates: Identical twins (MZ) show a 48% concordance rate for schizophrenia, while fraternal twins (DZ) show a 17% concordance rate, supporting a genetic component.

• Genain Quadruplets: A notable case of quadruplets, all of whom developed schizophrenia, highlighting the genetic influence.

Adoption Studies:

• Children raised apart from their biological mothers with schizophrenia still show an elevated risk of developing the disorder.

• Environmental Influence: A supportive and stable environment can reduce the risk, indicating that both genetics and environment play a role.

Genetic Linkage Studies:

• Research has identified specific regions on multiple chromosomes that may contribute to schizophrenia risk.

• Multiple Gene Variants: It is believed that various gene variants combine to create vulnerability to the disorder.

Biological Explanations: Biochemical Explanations

Dopamine Hypothesis:

• Originally, it was believed that schizophrenia resulted from an excess of dopamine in the brain.

  • Historical Basis: This hypothesis emerged from the discovery that antipsychotic drugs, such as phenothiazines, which block dopamine receptors, helped reduce symptoms of schizophrenia.

  • Amphetamine Psychosis: Observations that amphetamines, which increase the release of dopamine and norepinephrine, can induce psychotic symptoms similar to schizophrenia provided further support for the dopamine hypothesis.

Updated Dopamine Hypothesis:

• Newer research suggests that it is not merely an excess of dopamine but rather abnormalities in dopamine receptors that contribute to schizophrenia.

  • Receptor Sensitivity: Excessively sensitive or deficient dopamine receptors may play a significant role.

  • Striatal Dopamine Receptors: Excessive stimulation in these receptors is associated with the disorder.

  • Prefrontal Dopamine Receptors: A deficiency in dopamine receptors in the prefrontal cortex may contribute to negative symptoms and cognitive deficits in schizophrenia.

Other Neurotransmitters:

• Glutamate: Abnormal glutamate activity, particularly in the prefrontal cortex, is thought to be involved in schizophrenia. Glutamate is another critical neurotransmitter related to cognitive processes.

• Multiple Neurotransmitters: Schizophrenia may result from abnormal interactions between several neurotransmitters, not just dopamine.

Biological explanations- Brain structure Etiology 

Brain Abnormalities:

• Brain scans of individuals with schizophrenia reveal structural and functional differences, contributing to the symptoms and progression of the disorder.

Enlarged Ventricles:

• Enlarged ventricles, which are fluid-filled spaces in the brain, are found in the majority of people with schizophrenia. This enlargement suggests a loss of brain tissue.

Frontal Lobe Abnormalities:

• Hypofrontality: Reduced activity in the frontal lobes, an area responsible for decision-making, planning, and social behavior.

• Loss of brain tissue and abnormal functioning in the prefrontal cortex can lead to difficulties in thinking, memory, and emotional regulation.

Brain Circuitry Abnormalities:

• Evidence indicates disrupted connections between the prefrontal cortex and lower brain structures, such as the limbic system, which is involved in emotion and memory regulation. This abnormal circuitry may contribute to symptoms like emotional instability and memory issues.

Possible Causes of Brain Abnormalities:

• A range of factors may contribute to the biochemical and structural abnormalities seen in schizophrenia, including:

  • Genetic Factors

  • Poor Nutrition

  • Fetal Development Issues

  • Birth Complications

  • Immune Reactions

  • Exposure to Toxins

  • Viral Infections during critical developmental periods

Sociocultural explanations 

Stress:

• Stressful life events can trigger schizophrenia in individuals with a genetic or biological predisposition. Chronic or intense stress can exacerbate symptoms or lead to the onset of the disorder.

Social Economic Status (SES):

• Increased rates of schizophrenia are observed in central city areas, often inhabited by people in the lowest socioeconomic status.

• Socio-genic Hypothesis: Suggests that the stressors associated with being in a lower social class (such as financial strain, poor living conditions, and limited access to resources) may contribute to the development of schizophrenia.

• Social-Selection Theory: Proposes that schizophrenia leads individuals to drift into lower socioeconomic classes, reversing the causality. This theory has more data support, indicating that schizophrenia may limit a person's ability to maintain or improve their socioeconomic status.

Family Functioning:

• Family theorists have identified Expressed Emotion (EE) as a key factor in schizophrenia relapse. Families high in expressed emotion—characterized by criticism, hostility, and over-involvement—can increase stress and raise the risk of relapse for individuals with schizophrenia.

Diathesis-Stress Model

Treatment of schizophrenia

Antipsychotic Medication:

• The primary approach for managing acute psychotic symptoms. Antipsychotic medications help control hallucinations, delusions, and disorganized thinking.

• Strategies are also implemented to support medication adherence, as consistent use is essential for managing symptoms and preventing relapse.

Identification and Treatment of Comorbid Disorders:

• Comorbid conditions, such as substance use and depressive disorders, are common among individuals with schizophrenia. Addressing these co-occurring disorders is crucial for improving overall outcomes.

Psychosocial Treatment Approaches:

• These approaches are used alongside medication to enhance social and vocational functioning. They have shown effectiveness in reducing symptoms, improving quality of life, and supporting community integration.

Psychosocial Treatment Strategies Supported by the APA:

• Family Interventions/Psycho-education: Educates families about the disorder, improves communication, and reduces stress within the family unit.

• Social Skills Training: Helps individuals develop the interpersonal skills needed for daily interactions and relationships.

• Cognitive Behavioral Therapy (CBT): Assists in managing symptoms, such as hallucinations and delusions, by challenging and modifying distorted thinking patterns.

• Assertive Community Treatment: A team-based approach that provides intensive, personalized support in the community to help individuals manage symptoms and daily challenges.

• Supported Employment: Offers assistance in finding and maintaining employment, which is crucial for social integration and personal empowerment.

Biological Treatments- Drug Therapies; First Generation Antipsychotics (“typical”/neuroleptics)

Purpose:

• Antipsychotics help control prominent behavioural symptoms of schizophrenia, such as delusions, hallucinations, and disorganized thinking.

• These medications primarily target positive symptoms and help prevent their recurrence, though they have limited impact on negative symptoms.

Mechanism of Action:

• Antipsychotics work by blocking dopamine receptors in the brain, which reduces dopamine activity, a key factor in psychotic symptoms.

Common Antipsychotic Medications:

• Examples include phenothiazines such as chlorpromazine, thioridazine, trifluoperazine, and fluphenazine.

Common Side Effects:

• These medications can cause side effects such as dizziness, blurred vision, restlessness, and sexual dysfunction.

Extrapyramidal Side Effects:

• These are dysfunctions in motor pathways that resemble symptoms of Parkinson’s disease, affecting movement and coordination. Common extrapyramidal symptoms include:

  • Tremors: Shaking of the fingers.

  • Shuffling Gait: Difficulty walking with a smooth motion.

  • Drooling: Uncontrolled saliva flow.

  • Dystonia: Muscle rigidity and abnormal muscle contractions.

  • Dyskinesia: Involuntary, repetitive movements, such as chewing motions and limb movements.

  • Akathisia: An inability to remain still, resulting in constant movement or fidgeting.

  • Akinesia: A state of reduced motor activity, often accompanied by a blank facial expression, slow movements, and monotonous speech.

Biological Treatments-Drug Therapies: First Generation Antipsychotics

• Tardive Dyskinesia is a condition involving involuntary muscle movements, typically occurring after prolonged use of antipsychotic medications.

Symptoms:

• Mouth Movements: Involuntary motions in the mouth muscles, such as sucking, lip-smacking, and chin-wagging.

• Severe Cases: In more advanced cases, involuntary motor movements can affect the entire body, leading to significant motor dysfunction.

Prevalence:

• Tardive Dyskinesia affects approximately 20 to 50% of individuals who are treated with antipsychotic medications for an extended period.

Treatment:

• Unfortunately, Tardive Dyskinesia is not responsive to any known treatments, making it a challenging side effect to manage once it develops.

Biological Treatments – Drug Therapies: Second Generation (Atypical) Antipsychotics

Overview:

• Second-generation or atypical antipsychotics have largely replaced first-generation antipsychotics due to their improved safety and efficacy.

Advantages:

• These medications carry fewer neurological side effects compared to first-generation antipsychotics, reducing the risk of Tardive Dyskinesia and other extrapyramidal symptoms.

Symptom Coverage:

• Atypical antipsychotics are effective in treating both positive symptoms (e.g., hallucinations, delusions) and negative symptoms (e.g., lack of motivation, social withdrawal), providing broader symptom relief.

Examples of Second-Generation Antipsychotics:

• Common atypical antipsychotics include:

  • Clozapine

  • Risperidone

  • Olanzapine

  • Quetiapine

  • Ziprasidone

  • Aripiprazole

Psychosocial/Learning-Based treatment 

Early Intervention

Module 8: personality disorders

What is personality

• Personality is defined as a set of uniquely expressed characteristics that influence our behaviours 

Personality disorders: what are they

Personality Disorders:

• PDs involve persistent patterns of emotions, thoughts, and behaviours that cause ongoing emotional distress for the person and others, often interfering with work and relationships.

• These disorders are characterized by overly rigid and maladaptive patterns of behaviour and ways of relating to others, reflecting extreme variations in personality traits, such as:

  • Undue Suspiciousness: Excessive distrust and suspicion of others.

  • Excessive Emotionality: Intense, sometimes unstable emotions.

  • Impulsivity: Acting without forethought, often leading to negative outcomes.

• Onset: PDs typically become evident in adolescence or early adulthood, with warning signs sometimes visible in childhood.

Ego Syntonic:

• Definition: Behaviours or feelings that are perceived as natural or compatible with one's self-identity.

• Relevance to PDs: Many personality disorders are ego syntonic, meaning individuals may not see their behaviours as problematic or in conflict with their self-image.

Ego Dystonic:

• Definition: Behaviours or feelings that are perceived as foreign or alien to one's self-identity.

• Relevance: Ego dystonic symptoms are typically more distressing to the individual, as they feel inconsistent with their sense of self.

Personality disorders- Categories Or Dimensions?

Categorical Model Assumptions:

• The categorical approach assumes that:

  • Problematic personality traits are either present or absent in people, with no continuum.

  • A personality disorder is either displayed or not displayed by a person, without partial or mild forms.

  • A person with a personality disorder is not significantly affected by personality traits outside of that specific disorder.

Challenges in the Categorical Approach:

• Distinguishing Personality Disorders from Other Clinical Syndromes:

  • Personality disorders often share symptoms with other mental health disorders, making clear diagnosis difficult.

• Overlap Among Disorders:

  • Many personality disorders have overlapping traits, leading to challenges in determining the exact diagnosis.

• Difficulty Distinguishing Normal from Abnormal Behaviour:

  • It can be hard to define what is "normal" versus "abnormal," as some traits associated with personality disorders exist to varying degrees in the general population.

• Confusing Labels with Explanations:

  • Diagnostic labels may be mistaken for explanations, leading to misconceptions about the cause or nature of the disorder.

Categorical Model Assumptions:

• The categorical approach assumes that:

  • Problematic personality traits are either present or absent in people, with no continuum.

  • A personality disorder is either displayed or not displayed by a person, without partial or mild forms.

  • A person with a personality disorder is not significantly affected by personality traits outside of that specific disorder.

Challenges in the Categorical Approach:

• Distinguishing Personality Disorders from Other Clinical Syndromes:

  • Personality disorders often share symptoms with other mental health disorders, making clear diagnosis difficult.

• Overlap Among Disorders:

  • Many personality disorders have overlapping traits, leading to challenges in determining the exact diagnosis.

• Difficulty Distinguishing Normal from Abnormal Behavior:

  • It can be hard to define what is "normal" versus "abnormal," as some traits associated with personality disorders exist to varying degrees in the general population.

• Confusing Labels with Explanations:

  • Diagnostic labels may be mistaken for explanations, leading to misconceptions about the cause or nature of the disorder.

Advantages of a Dimensional model

Dimensional Approach:

• Suggests that personality disorders vary in degree (severity or extent) rather than being distinct categories or kinds.

Advantages:

• Retains More Information: Provides a more comprehensive understanding of an individual's personality traits and the intensity of symptoms.

• Flexibility: Allows for both categorical and dimensional differentiation, making it adaptable to varied clinical presentations.

• Avoids Arbitrary Categorization: Reduces the need for rigid diagnostic categories, which can sometimes oversimplify or misrepresent an individual's personality traits.

Model Being Considered (APA, 2022):

• Focuses on a continuum that assesses:

  • Self Functioning: Includes self-view and the ability to be self-directed.

  • Interpersonal Functioning: Includes the ability to empathize and maintain intimate relationships with others.

Alternative Models:

• Big Five Personality Model: Some propose using the Big Five (Openness, Conscientiousness, Extraversion, Agreeableness, and Neuroticism) as a framework for assessing personality disorders, as it provides a nuanced, dimensional view of personality traits.

DSM-5TR General Personality Disorder 

A. An Enduring Pattern of Inner Experience and Behaviour:

• This pattern deviates significantly from the cultural expectations of the individual and is evident in two or more of the following areas:

  1. Cognition: Ways of perceiving and interpreting the self, other people, and events.

  2. Affectivity: Range, intensity, stability, and appropriateness of emotional responses.

  3. Interpersonal Functioning: Ability to interact effectively and form relationships.

  4. Impulse Control: Ability to manage impulses and behaviors.

B. Inflexibility and Pervasiveness:

• The enduring pattern is inflexible and affects a wide range of personal and social situations.

C. Clinically Significant Distress or Impairment:

• This pattern leads to noticeable distress or impairment in social, work, or other important areas of functioning.

D. Stability and Long Duration:

• The pattern is stable and has persisted for a long time, with an onset traceable to adolescence or early adulthood.

E. Not Better Explained by Another Mental Disorder:

• The enduring pattern is not due to or explained by another mental disorder.

F. Not Attributable to Substance Use or a Medical Condition:

• The pattern is not due to the physiological effects of a substance (e.g., drug abuse) or a medical condition.

Statistics and development of Personality disorder

Key Points:

• Prevalence: Antisocial personality disorder is the most prevalent at 3.8%, followed by borderline (2.7%), and obsessive-compulsive personality disorder (1.9%).

• Gender Differences: Gender differences vary, with some disorders more common in females (e.g., borderline, histrionic), while others like antisocial and narcissistic are more common in males.

• Course: Some disorders may improve over time (e.g., narcissistic), while others are chronic or lack sufficient information on their course.

Clusters of Personality Disorders: 3 clusters

Cluster A – Odd or Eccentric Behaviour:

• Disorders in this cluster include:

  • Paranoid Personality Disorder

  • Schizoid Personality Disorder

  • Schizotypal Personality Disorder

• Individuals with these disorders often appear unusual or peculiar in their behaviour, thinking, and interactions.

Cluster B – Dramatic, Emotional, or Erratic Behaviour:

• Disorders in this cluster include:

  • Antisocial Personality Disorder

  • Borderline Personality Disorder

  • Histrionic Personality Disorder

  • Narcissistic Personality Disorder

• Individuals with these disorders may have intense and unstable emotions and relationships, with unpredictable or attention-seeking behaviours.

Cluster C – Anxious or Fearful Behaviour:

• Disorders in this cluster include:

  • Avoidant Personality Disorder

  • Dependent Personality Disorder

  • Obsessive-Compulsive Personality Disorder

• These disorders are associated with anxiety, fearfulness, and difficulties with self-confidence and dependence on others.

Cluster A personality Disorders

Cluster A: Paranoid Personality disorder 

Characteristics:

• Suspiciousness: Individuals with PPD are highly suspicious of others.

• Expectation of Mistreatment: They believe others are likely to mistreat or exploit them.

• Reluctance to Confide: They avoid sharing personal information, fearing it may be used against them.

• Blaming Others: They often attribute their problems or challenges to others.

• Jealousy: They may be extremely jealous, seeing potential betrayal in relationships.

Differential Diagnosis and Comorbidity:

• Hallucinations and Delusions: Unlike paranoid schizophrenia, PPD does not typically involve hallucinations or full-blown delusions.

• Social and Occupational Functioning: Individuals with PPD generally experience less impairment in daily functioning compared to those with paranoid schizophrenia.

• Comorbidity: PPD often coexists with other personality disorders, such as schizotypal, avoidant, and borderline personality disorders.

Etiology & Treatment:

• Genetic and Environmental Factors: Contributing factors may include genetics, childhood trauma, underlying schemas, and cultural influences.

• Cognitive Therapy: Treatment often focuses on cognitive therapy to challenge and change mistaken assumptions about others and to reduce suspicious and paranoid thoughts.

Cluster A: Schizoid Personality Disorder 

Characteristics:

• Lack of Interest in Social Relationships: Individuals with schizoid personality disorder do not desire or enjoy close relationships, including family.

• Aloof and Detached: They often appear dull, bland, and emotionally detached.

• Minimal Emotional Expression: Rarely report experiencing strong emotions.

• Lack of Sexual Interest: Typically uninterested in sexual experiences.

• Limited Enjoyment: Few activities bring them pleasure.

• Indifference to Feedback: Unaffected by praise or criticism.

• Solitary Lifestyle: Tend to be loners with solitary interests and hobbies.

Prevalence and Comorbidity:

• Prevalence: Less than 1% of the population.

• Comorbidity: Often coexists with other personality disorders such as schizotypal, avoidant, and paranoid personality disorders.

Etiology & Treatment:

• Potential Causes: Childhood factors such as shyness, abuse, neglect, and possible low-density dopamine receptors may contribute to the disorder.

• Treatment: Social skills training, including role-playing exercises, may help individuals improve interpersonal skills.

Cluster B Personality Disorders: Borderline Personality Disorder

Characteristics:

• Core Features: BPD is marked by impulsivity and instability in relationships, mood, and self-image.

• Intense and Shifting Emotions: Individuals often experience erratic and abrupt mood swings.

• Interpersonal Turbulence: Attitudes and feelings toward others can vary dramatically, swinging from idealization to devaluation ("all good or all bad").

• Behavioral Patterns: They may be argumentative, irritable, sarcastic, and quick to take offense.

• Fear of Abandonment: They cannot tolerate being alone, often displaying clingy and demanding behaviors.

Prevalence and Comorbidity:

• Prevalence: Affects about 1 to 2% of the population and accounts for 20-25% of all psychiatric admissions.

• Gender Differences: More common in women than in men.

• Comorbidity: Often comorbid with mood disorders, substance abuse, PTSD, eating disorders, and other Cluster A personality disorders.

Etiology & Treatment:

• Etiology: Genetic factors, links to mood disorders, and a history of early trauma may contribute to the development of BPD.

• Treatment: Treatment often includes medications like antipsychotics and antidepressants. Dialectical Behavior Therapy (DBT) is a specific and effective therapeutic approach used to address emotional regulation and interpersonal issues in BPD.

Cluster B: Borderline personality disorder- Self-mutilation

Impulsive Self-Mutilation:

• Individuals with BPD may engage in impulsive self-mutilation, such as cutting, as a way to cope with intense emotional pain. This behaviour is often a temporary escape or release from overwhelming feelings.

Expression of Anger or Manipulation:

• Self-mutilation can sometimes serve as an expression of anger or as a means of influencing or manipulating others, though not always consciously intended for that purpose.

Counteracting Feelings of Emptiness:

• These self-harming acts are often an attempt to counteract feelings of emptiness or numbness, allowing individuals to feel something tangible, even if it is pain.

Cluster B: Histrionic Personality Disorder 

Characteristics:

• Attention-Seeking Behaviour: Individuals with HPD often exhibit overly dramatic and attention-seeking behaviours.

• Appearance and Attractiveness: They may use their physical appearance to draw attention and are often overly concerned with their attractiveness.

• Exaggerated Emotions: Emotional expressions tend to be extravagant, theatrical, and shallow.

• Self-Centered: They are often self-focused and seek admiration or reassurance from others.

• Sexually Provocative: Their behaviour may be inappropriately seductive or provocative, even in professional or casual settings.

• Impressionistic Speech: Their speech style can be vague and lacking in detail, focusing more on impression than substance.

Prevalence and Comorbidity:

• Prevalence: HPD is relatively rare, with a prevalence of less than 1%.

• Gender Differences: It is more commonly diagnosed in women than in men.

• Comorbidity: HPD often co-occurs with disorders like depression and borderline personality disorder (BPD).

Etiology & Treatment:

• Sociocultural Factors: Sociocultural influences may play a role in the development of HPD.

• Co-Occurrence with Other Disorders: HPD can sometimes co-occur with antisocial personality disorder.

• Treatment Focus: Therapy may focus on improving problematic interpersonal relationships and enhancing self-awareness to reduce attention-seeking behaviours.

Cluster B: Narcissistic Personality Disorder

Characteristics:

• Grandiosity: Individuals with NPD often have an inflated sense of their own uniqueness, talents, or abilities.

• Fantasies of Success: They are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

• Need for Admiration: They require constant attention, excessive admiration, and validation from others.

• Lack of Empathy: People with NPD often struggle to recognize or identify with the feelings and needs of others.

• Envy and Arrogance: They may be envious of others, yet perceive others as being envious of them. They can be arrogant, exploitative, and have a strong sense of entitlement.

Prevalence and Comorbidity:

• Prevalence: NPD affects about 1% of the population, with indications that it may be increasing in prevalence.

• Comorbidity: NPD is often comorbid with borderline personality disorder (BPD).

Etiology & Treatment:

• Etiology: One theory suggests that NPD may stem from a failure of empathetic “mirroring” during early development, where caregivers fail to provide adequate validation.

• Treatment: Treatment strategies may include coping mechanisms and Cognitive Behavioral Therapy (CBT) to address maladaptive thinking patterns and improve empathy and interpersonal functioning.

Characteristics:

• Grandiosity: Individuals with NPD often have an inflated sense of their own uniqueness, talents, or abilities.

• Fantasies of Success: They are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

• Need for Admiration: They require constant attention, excessive admiration, and validation from others.

• Lack of Empathy: People with NPD often struggle to recognize or identify with the feelings and needs of others.

• Envy and Arrogance: They may be envious of others, yet perceive others as being envious of them. They can be arrogant, exploitative, and have a strong sense of entitlement.

Prevalence and Comorbidity:

• Prevalence: NPD affects about 1% of the population, with indications that it may be increasing in prevalence.

• Comorbidity: NPD is often comorbid with borderline personality disorder (BPD).

Etiology & Treatment:

• Etiology: One theory suggests that NPD may stem from a failure of empathetic “mirroring” during early development, where caregivers fail to provide adequate validation.

• Treatment: Treatment strategies may include coping mechanisms and Cognitive Behavioral Therapy (CBT) to address maladaptive thinking patterns and improve empathy and interpersonal functioning.

Cluster B: Anti-Social Personality Disorder 

Main Components (per DSM-5):

• Conduct Disorder: Evidence of conduct disorder symptoms before age 15, including behaviors such as truancy, running away, theft, and arson.

• Continuation into Adulthood: Pattern of antisocial behavior persists into adulthood.

Characteristics:

• Violation of Social Norms: Consistently disregards and violates the rights of others.

• Aimlessness: Often lacks long-term goals or plans, demonstrating aimless behavior.

• Impulsivity: Engages in impulsive or risky behavior without considering consequences.

• Violence: May engage in violent or aggressive acts.

• Lack of Remorse or Empathy: Shows a disregard for the feelings and needs of others, lacking remorse or empathy.

Prevalence and Comorbidity:

• Prevalence: ASPD affects approximately 1.7% to 3.7% of the general population, with a significantly higher rate (50%) in prison populations.

• Gender Differences: More prevalent in men than women.

• Comorbidity: Commonly co-occurs with substance use disorders.

Etiology & Treatment:

• Etiology: ASPD may result from a gene-environment interaction, with contributing factors including cortical under-arousal and a tendency toward fearlessness.

• Treatment: Multifaceted approaches, including Cognitive Behavioral Therapy (CBT), though prevention is often considered more effective than treatment due to the challenging nature of treating ASPD.

Cluster B: Anti-Social Personality Disorder and Psychopathy

Core Features of Psychopathy:

• Lack of remorse: Individuals with psychopathy often operate "without conscience," showing no sense of shame for harmful actions.

• Superficial charm: They can appear charming on the surface, using this to manipulate others.

• Manipulativeness: Frequently exploit others for personal gain, even resorting to violence and aggression if needed.

• Thrill-seeking behavior: Engage in impulsive, irresponsible actions, often pursuing excitement and novelty.

• Arrogant, deceitful interpersonal style: Tend to be arrogant and deceitful in social interactions.

• Deficient affective experiences: Exhibit shallow emotional responses, lacking depth in feelings.

• Early onset of antisocial behavior: Signs of diverse antisocial behaviors are often visible from an early age.

Psychopathy and APD Relationship:

• While many with psychopathy meet criteria for APD, not all individuals with APD exhibit psychopathic traits.

• APD is broader and focuses more on behavior, while psychopathy includes specific affective and interpersonal traits.

Cluster C: Avoidant Personality Disorder

Characteristics:

• Fearful in social situations: Strong apprehension around social interactions.

• Sensitive to criticism or rejection: Acutely aware of and distressed by potential negative judgments.

• Reluctant to form relationships: Avoids relationships unless assured they will be liked and accepted.

Prevalence and Comorbidity:

• Prevalence: About 1% of the population.

• Comorbidity: Often occurs alongside dependent personality disorder, depression, and generalized social phobia (social anxiety disorder).

Etiology & Treatment:

• Causes: Influences include a combination of biological and psychosocial factors. Those affected may have been born with a challenging temperament, experienced parental rejection, or been exposed to uncritical love.

• Connection to Social Anxiety: Shares a strong link with social anxiety, both in traits and treatment approaches.

• Treatment: Cognitive Behavioral Therapy (CBT), systematic desensitization, and anxiety medication are commonly used to manage symptoms.

Cluster C: Dependent Personality 

Characteristics:

• Lack of self-reliance: Struggles with making independent decisions or actions.

• Overly dependent on others: Relies heavily on others, feeling limited in autonomy.

• Intense need for care: Has a strong desire to be nurtured and supported.

• Uncomfortable when alone: Prefers to have company and assistance, feeling anxious when alone.

Prevalence and Comorbidity:

• Comorbidity: Commonly co-occurs with bipolar disorder, depression, anxiety disorders, and bulimia. Also associated with “oral” behavior problems, such as overeating or smoking.

Etiology & Treatment:

• Causes: Genetic predispositions and early childhood disruptions that may lead to fears of abandonment.

• Treatment: Focuses on building confidence and independence, ensuring that the patient does not become overly reliant on the therapist.

Cluster C: Obsessive compulsive personality disorder

Characteristics:

• Perfectionistic approach to life, often to the point of interfering with task completion.

• Preoccupied with details, rules, and schedules, leading to rigidity.

• Serious, rigid, formal, and inflexible in their approach.

• Difficulty discarding worn-out or useless items, often accumulating them.

Differential Diagnosis:

• Unlike Obsessive-Compulsive Disorder (OCD), OCPD lacks true obsessions and compulsions.

Prevalence and Comorbidity:

• Prevalence: Affects about 2% of the population.

• Comorbidity: Commonly co-occurs with OCD (20%), panic disorder, depression, generalized anxiety disorder (GAD), and avoidant personality disorder.

Etiology & Treatment:

• Genetics: A likely genetic component.

• Treatment: Includes relaxation techniques and cognitive-behavioral therapy (CBT) to reduce rigidity and perfectionism.

Key points

Definition: Personality disorders are enduring patterns of behavior and inner experiences that disrupt social and occupational functioning.

DSM-5 Clusters: Personality disorders are grouped into three clusters in the DSM-5:

• Odd/Eccentric

• Dramatic/Erratic

• Anxious/Fearful

Odd/Eccentric Cluster: This cluster includes paranoid, schizotypal, and schizoid disorders, generally considered less severe variants of schizophrenia.

Dramatic/Erratic Cluster: This cluster includes borderline, histrionic, narcissistic, and antisocial personality disorders.

Antisocial Personality Disorder (ASPD): Characterized by repeated antisocial behavior that infringes upon the rights of others.

Psychopathy vs. ASPD: While related to ASPD, psychopathy is not identical. Almost all individuals diagnosed as psychopaths meet the criteria for ASPD, but only about 20% of those with ASPD score highly on psychopathy measures.

Anxious/Fearful Cluster: This cluster includes avoidant, dependent, and obsessive-compulsive personality disorders.

Module 8 Key Terms
 

Antisocial Personality Disorder

A personality disorder characterized by a disregard for and violation of the rights of others, often including deceitfulness, impulsivity, irritability, aggression, and lack of remorse for harmful actions.

Avoidant Personality Disorder

A personality disorder marked by extreme sensitivity to rejection, feelings of inadequacy, and social inhibition, leading to avoidance of interpersonal interactions despite a desire for connection.

Borderline Personality Disorder

A personality disorder characterized by instability in mood, self-image, and interpersonal relationships, along with impulsivity and difficulty regulating emotions.

Dependent Personality Disorder

A personality disorder involving an excessive need to be cared for, leading to submissive and clinging behaviors, fears of separation, and difficulty making independent decisions.

Histrionic Personality Disorder

A personality disorder defined by excessive emotionality and attention-seeking behavior, often including a need for approval and inappropriate seductiveness.

Narcissistic Personality Disorder

A personality disorder involving a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy for others, often coupled with a sense of entitlement.

Obsessive-Compulsive Personality Disorder

A personality disorder characterized by preoccupation with orderliness, perfectionism, and control, often at the expense of flexibility, openness, and efficiency.

Paranoid Personality Disorder

A personality disorder marked by pervasive distrust and suspicion of others, often leading to interpretive biases, grudges, and a reluctance to confide in others.

Personality Disorder

A category of mental health disorders characterized by enduring, maladaptive patterns of behavior, cognition, and inner experience that deviate significantly from cultural expectations and cause distress or impaired functioning.

Psychopathy

A construct involving traits such as lack of empathy, superficial charm, manipulativeness, and impulsivity, often overlapping with but distinct from antisocial personality disorder.

Schizoid Personality Disorder

A personality disorder characterized by detachment from social relationships, limited emotional expression, and a preference for solitary activities.

Schizotypal Personality Disorder

A personality disorder involving social and interpersonal deficits, cognitive or perceptual distortions, and eccentric behaviors, often including unusual beliefs or magical thinking.
Alogia

A negative symptom of schizophrenia characterized by a significant reduction in speech output or fluency, reflecting a lack of thought or diminished verbal expression.

Anhedonia

The inability to experience pleasure from activities that are typically enjoyable, often associated with depression and negative symptoms of schizophrenia.

Asociality

A lack of interest in or motivation for social interaction, often seen in negative symptoms of schizophrenia.

Associative Splitting

A term describing the fragmented and disconnected thought processes often observed in schizophrenia, where associations between ideas are disrupted.

Attenuated Psychosis Syndrome

A condition involving subthreshold psychotic symptoms, such as mild delusions or hallucinations, that are distressing but not severe enough to meet criteria for a psychotic disorder.

Avolition

A negative symptom of schizophrenia characterized by a lack of motivation to initiate or sustain goal-directed activities.

Brief Psychotic Disorder

A psychotic disorder lasting less than one month, marked by sudden onset of delusions, hallucinations, disorganized speech, or catatonic behavior, with eventual full recovery.

Catatonia

A state of psychomotor disturbance seen in some psychotic disorders, characterized by abnormal motor activity, including immobility, excessive movement, or peculiar movements.

Catatonic Immobility

An extreme form of catatonia where an individual maintains a rigid, fixed posture for extended periods, often resisting attempts to be moved.

Delusion

A false belief that is strongly held despite evidence to the contrary, commonly found in psychotic disorders.

Delusional Disorder

A psychotic disorder characterized by persistent delusions without other major symptoms of schizophrenia, such as hallucinations or disorganized thinking.

Dementia Praecox

An outdated term for schizophrenia, introduced by Emil Kraepelin, emphasizing the early onset and progressive cognitive decline associated with the disorder.

Disorganized Speech

Speech that is incoherent or lacks logical flow, often characterized by tangentiality, loose associations, or word salad, and is a hallmark of disorganized symptoms in schizophrenia.

Disorganized Symptoms

Symptoms of schizophrenia that include erratic behavior, disorganized thinking, inappropriate affect, and difficulty maintaining logical connections between thoughts.

Double Bind

A communication style theorized to contribute to the development of schizophrenia, involving contradictory messages or demands that create a no-win situation.

Expressed Emotion (EE)

A measure of family environment, involving high levels of criticism, hostility, or emotional over-involvement, which has been linked to relapse in schizophrenia.

Flat Affect

A negative symptom of schizophrenia characterized by diminished or absent emotional expression, such as reduced facial expressions or voice modulation.

Folie à Deux (Shared Psychotic Disorder)

A rare condition where two or more individuals share delusions, often due to a close relationship with one person who has a primary psychotic disorder.

Hallucination

A sensory perception without external stimuli, such as hearing voices or seeing things that are not present, commonly seen in psychotic disorders.

Hebephrenia

A historical term for disorganized schizophrenia, characterized by inappropriate affect, erratic behavior, and fragmented thinking.

Inappropriate Affect

Emotional expressions that are incongruent with the context or situation, often observed in schizophrenia.

Negative Symptoms

Symptoms of schizophrenia that involve deficits in normal functioning, such as flat affect, alogia, avolition, anhedonia, and asociality.

Paranoia

An intense and irrational mistrust or suspicion of others, often accompanied by persecutory delusions.

Positive Symptoms

Symptoms of schizophrenia involving the presence of abnormal behaviors, such as hallucinations, delusions, and disorganized speech or behavior.

Prodromal Stage

The period before the full onset of schizophrenia, during which subtle symptoms, such as social withdrawal or odd behaviors, may emerge.

Psychosis

A mental state involving a loss of contact with reality, characterized by hallucinations, delusions, and disorganized thinking or behavior.

Psychotic Disorder Due to Another Medical Condition

A condition where psychotic symptoms, such as delusions or hallucinations, are directly caused by a medical illness or neurological condition.

Schizoaffective Disorder

A mental health condition combining symptoms of schizophrenia, such as psychosis, with mood disorder symptoms, such as mania or depression.

Schizophrenia

A chronic and severe mental disorder characterized by disturbances in thought, perception, emotion, and behavior, including hallucinations, delusions, disorganized thinking, and negative symptoms.

Schizophreniform Disorder

A psychotic disorder with symptoms similar to schizophrenia but lasting between one and six months.

Schizophrenogenic

An outdated term suggesting that certain parental behaviors or family dynamics might contribute to the development of schizophrenia.

Schizotypal Personality Disorder

A personality disorder involving social and interpersonal deficits, eccentric behaviors, and cognitive or perceptual distortions, often considered part of the schizophrenia spectrum.

Shared Psychotic Disorder (Folie à Deux)

A condition in which two or more people develop shared delusions, often due to a close relationship with someone who has a primary psychotic disorder.

Substance-Induced Psychotic Disorder

A psychotic disorder caused by the use of or withdrawal from substances, such as drugs or alcohol, resulting in symptoms like hallucinations or delusions.

Token Economy

A behavioral therapy technique often used in psychiatric settings where patients earn tokens for desirable behaviors, which can be exchanged for privileges or rewards.

Module 9: Sexual dysfunctions and Paraphilic Disorders 

What are sexual dysfunctions?

• Sexual dysfunctions are persistent or recurrent issues with sexual interest, arousal, or response.

What is the prevalence rate of this disorder?

• For women is 40-45% in life time

• For men is 20-30% in lifetime 

What are the different types?

• Lifetime vs acquired; eg. A woman who has never experienced an orgasm since becoming sexually active (lifetime), A man who previously had no difficulty achieving an erection but starts experiencing erectile dysfunction after a traumatic event (acquired).

• Situational vs generalized; eg. A woman who experiences arousal issues while only under stress or pressure (situational), a man who consistently experiences premature ejaculation in all sexual activities (generalized).

What are the human sexual response phases

• Five phases:

• Desire phase: Sexual urges in response to cues/fantasies.

• Arousal phase: Physiological sexual arousal (eg., penile tumescence, Vaginal lubrication).

• Plateau phase: Brief period before orgasm.

• Orgasm phase: Ejaculation (men) Vaginal contractions (women).

• Resolution phase: Decreased arousal post-Orgasm.

What are the Categories of Sexual Dysfunctions 

• 1. Sexual desire disorders:

• Male Hypoactive Sexual Desire Disorder: Low or no sexual fantasies/interest (`20-30% of men suffer from this disorder).

• Female Sexual Interest/Arousal Disorder: Low interest and arousal (`20% of women suffer from this disorder).

• 2. Sexual Arousal Disorders

• Male Erectile Disorder: Difficulty becoming aroused; increases with age (~7-70% of men)

• 3. Orgasmic Disorders:

• Female Oorgasmic Disorder: Absence of orgasm (~16-46% ;~10% never experienced orgasm).

• Male Orgasmic Disorder: 

• Delayed ejaculation (~3%).

• Premature ejaculation (~40% of men experience at some point).

Sexual Pain Disorders

• Genito-Pelvic pain/Penetration Disorder:

• Vaginismus: Involuntary Vaginal spasms; Arousal/organsm, possible via other stimulation.

• Dyspareunia: Pain during intercourse; linked to low desire/arousal.

What are the different explanations for Sexual Dysfunctions

• 1. Biological:

• Hormonal imbalances (testosterone, estrogen).

• Medical issues (diabetes, circulatory problems).

• Medications (SSRIs, antihypertensives).

• 2. Psychological:

• Performance anxiety, poor body image, trauma.

• Depression/anxiety, relationship conflicts

• 3. Sociocultural:

• Gender norms, sexual scripts, religious beliefs, taboos.

What are the available treatments for Sexual Dysfunction Disorders?

• 1. Psychosocial:

• CBT, anxiety reduction, directed masturbation, couples therapy. 

• 2. Medication:

• Testosterone, Slidenafil (Viagra), SSRIs.

• 3. Physical/Surgery:

• Treat underlying conditions, penile prosthesis, vaginal dilators

Paraphilic Disorders

What are paraphilic disorders?

• Paraphilia: Unusual/deviant sexual attractions or behaviours.

• Paraphilic Disorder: Must last 6+ months and cause significant impairment/distress or involve harm to others.

What are the distinguishing features of these disorders?

• Uncommon and atypical.

• Involves non-consenting/mature partners or objects.

• Persistent/recurrent method of sexual gratification.

What are the common types listed in the DSM-5

• 1. Voyeurism: Watching non-consenting individuals undress/ engage in sexual acts.

• Example: “peeping tom”.

• 2. Exhibitionism: Exposing oneself to non-consenting individuals.

• Example: Flashing.

• 3. Frotteurism: Rubbing genitals on non-consenting individuals. 

• Example: Crowded public spaces.

• 4. Sexual Sadism: Arousal from inflicting pain/humiliation.

• Example: spanking someone and hearing them scream. 

• 5. Sexual Masochism: Arousal from experiencing pain/humiliation

• Example: erection from being choked.

• 6. Transvestism: Sexual arousal from cross-dressing (not linked to gender identity).

• 7. Fetishism: Arousal from non-sexual objects (e.g shoes) or body parts (e.g. feet).

• 8. Pedophilia: Attraction to pubescent children; distinct from acting on acting on attraction.

What are some other Paraphillias?

• Somnophilia: Sleeping people.

• Necrophilia: Corpses.

• Zoophilia: Animals.

• Urophilia/Coprophilia: Urine/feces.

What are some explanations for Paraphilic disorders?

• 1. Behavioural: Classical/operant conditioning, modelling early experiences.

• 2. Cognitive: Distortions in thoughts, poor social skills.

• 3. Biological: Hormonal imbalances, brain activity changes (mainly in frontal or temporal regions of the brain).

What are some treatments for Paraphilic Disorders?

• 1. Psychosocial:

• CBT  aversion therapy, Orgasmic reorientation, relapse prevention.

• Good Lives Model (GLM), Risk/Need/Responsibility Model (RNR).

• 2. Medication:

• Antiandrogens (“chemical castration”), SSRIs.

Key notes

• Paraphilias are more common in men (3-5%) then women (1-6%).

• High comorbidity among paraphilias (eg. Voyeurism and exhibitionism).

• Some behaviours (e.g BDSM) are consensual and are not disorders.  

Module 9: Gender Dysphoria 

Key Concepts

• Gender Identity: Psychological sense of one's gender (e.g., male, female, non-binary).

• Gender Dysphoria (GD): Significant distress or impaired functioning due to a mismatch between sex assigned at birth and gender identity.

• Transgender Identity: Gender identity/expression differs from assigned sex at birth, not the same as Transvestic Disorder (paraphilia).

Patterns of Gender Dysphoria

1. Cisgender:

   • Identify with the gender assigned at birth (e.g., a female assigned at birth identifies as female).

2. Female-to-Male (FTM):

   • Assigned female at birth but identify as male (trans man).

3. Male-to-Female (MTF):

   • Assigned male at birth but identify as female (trans woman).

Explanations of Gender Dysphoria

1. Biological:

   • Genetic: GD runs in families (e.g., concordance in identical twins).

   • Hormonal: Abnormal testosterone/estrogen levels during critical fetal development.

     • Example: Excess testosterone exposure may masculinize a female-assigned fetus.

   • Structural Brain Differences: Variations in regions linked to sexuality and consciousness.

     • Example: Insula, hypothalamus, anterior cingulate cortex, and BST (bed nucleus of stria terminalis).

2. Psychological:

   • Internal conflict about gender identity can cause distress.

3. Cultural:

   • Societal and cultural expectations shape experiences of gender identity and dysphoria.

Treatment Options

1. Hormone Treatments:

   • Puberty Blockers: Prevent development of secondary sexual characteristics.

   • Hormone Replacement Therapy (HRT):

     • MTF (Male-to-Female): Estrogen.

     • FTM (Female-to-Male): Testosterone.

2. Surgery:

   • Gender-Affirming Surgery: Adjust physical characteristics to align with gender identity.

     • MTF: Vaginoplasty (create clitoris/vagina).

     • FTM: Chest masculinization, hysterectomy, phalloplasty (prosthetic or reconstructed penis).

3. Other Supports:

   • Facial surgeries.

   • Speech Therapy: Adjusting voice pitch to match identity.

Important Notes

• Not All Trans People Experience GD: Many transgender individuals do not experience gender dysphoria but may still seek support to align their identity and physical appearance.

• Not All Trans People Pursue Medical Interventions: Hormones/surgeries are personal choices and do not invalidate their identity.

Quick Recap with Examples

• Cisgender Example: Assigned female at birth and identifies as female.

• FTM Example: Assigned female at birth, identifies and lives as male, may undergo testosterone therapy.

• MTF Example: Assigned male at birth, identifies as female, may seek estrogen therapy and vaginoplasty.

• Biological Example: A study finds structural differences in the hypothalamus of people with GD compared to cisgender individuals.

• Cultural Example: Stigma in society exacerbates distress in someone with GD.

Key Terms for Module 7-9 

Module 7 key terms:

• Here are definitions for the key terms related to anxiety and phobic disorders:

• Agoraphobia: An anxiety disorder characterized by intense fear and avoidance of situations where escape might be difficult or help unavailable during a panic attack. Commonly includes fears of open spaces, crowds, or being outside alone.

• Animal Phobias: A type of specific phobia involving an excessive and irrational fear of animals, such as spiders (arachnophobia), snakes (ophidiophobia), or dogs (cynophobia).

• Anxiety: A general state of apprehension or unease about potential future threats or dangers, often accompanied by physical symptoms like increased heart rate and muscle tension.

• Behavioural Inhibition System (BIS): A neuropsychological system that regulates aversive motives, leading individuals to avoid potentially threatening situations. It is sensitive to signals of punishment, non-reward, and novel stimuli.

• Blood-Injury-Injection Phobias: A specific phobia characterized by an intense fear of blood, injuries, or injections, often leading to fainting due to a vasovagal response—a sudden drop in heart rate and blood pressure.

• Fear: An emotional response to an immediate and identifiable threat, triggering physiological changes that prepare the body for a fight or flight response.

• Fight/Flight System (FFS): A physiological response to perceived harmful events, attacks, or threats to survival, preparing the body to either confront or flee from the threat.

• Generalized Anxiety Disorder (GAD): A mental health disorder characterized by chronic and excessive worry about various aspects of daily life, accompanied by symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances.

• Natural Environment Phobias: Specific phobias involving fear of natural phenomena, such as heights (acrophobia), storms (astraphobia), or water (aquaphobia).

• Panic: A sudden surge of overwhelming fear or anxiety, often without an obvious cause, leading to physical symptoms like heart palpitations, sweating, trembling, and shortness of breath.

• Panic Attack: An abrupt episode of intense fear or discomfort that peaks within minutes, accompanied by physical and cognitive symptoms such as chest pain, dizziness, fear of losing control, or fear of dying.

• Panic Control Treatment (PCT): A cognitive-behavioral therapy designed to treat panic disorder by exposing individuals to the physical sensations of panic in a controlled environment, helping them to understand and manage their symptoms.

• Panic Disorder (PD): An anxiety disorder characterized by recurrent unexpected panic attacks and persistent concern about having more attacks or their consequences, leading to significant behavioral changes.

• Separation Anxiety Disorder: A condition where an individual experiences excessive fear or anxiety about separation from home or attachment figures, beyond what is developmentally appropriate.

• Situational Phobias: Specific phobias involving fear of particular situations, such as flying (aviophobia), driving, or being in enclosed spaces (claustrophobia).

• Social Anxiety Disorder (SAD): Also known as social phobia, it involves intense fear of social situations where one might be scrutinized or judged by others, leading to avoidance of such situations.

• Specific Phobia: An anxiety disorder marked by a significant and irrational fear of a specific object or situation, leading to avoidance behavior and significant distress or impairment in functioning.

Schizophrenia and Related Disorders:

• Alogia: A negative symptom of schizophrenia characterized by reduced speech output and limited spontaneous conversation.

• Anhedonia: Inability to experience pleasure from activities usually found enjoyable.

• Asociality: Lack of interest in social interactions, often seen in schizophrenia.

• Associative Splitting: Disruption in the logical connection between thoughts, leading to disorganized thinking.

• Attenuated Psychosis Syndrome: A condition involving mild psychotic symptoms that are less severe and more transient than those in full-blown psychosis.

• Avolition: Decreased motivation to initiate and sustain purposeful activities.

• Brief Psychotic Disorder: A sudden onset of psychotic symptoms lasting more than a day but less than a month, with eventual full return to premorbid functioning.

• Catatonia: A state of psycho-motor immobility and behavioral abnormality manifested by stupor.

• Catatonic Immobility: Maintaining a rigid posture for extended periods, resisting movement.

• Delusion: A firmly held false belief not aligned with reality, resistant to contrary evidence.

• Delusional Disorder: A psychiatric condition characterized by persistent delusions without other significant psychotic symptoms.

• Dementia Praecox: An outdated term once used to describe what is now known as schizophrenia.

• Disorganized Speech: Speech that is incoherent, tangential, or illogical, reflecting disorganized thinking.

• Disorganized Symptoms: Symptoms including disorganized speech, behavior, and inappropriate affect.

• Double Bind: A situation where a person receives conflicting messages, leading to a no-win scenario.

• Expressed Emotion (EE): A measure of the family environment based on how family members speak about the patient, indicating levels of criticism, hostility, and emotional over-involvement.

• Flat Affect: A lack of emotional expression, often observed in schizophrenia.

• Folie à Deux (Shared Psychotic Disorder): A rare condition where two individuals share the same delusional beliefs.

• Hallucination: Perception-like experiences without an external stimulus, such as hearing voices or seeing things that aren't there.

• Hebephrenia: A subtype of schizophrenia characterized by disorganized behavior and shallow or inappropriate emotional responses.

• Inappropriate Affect: Emotional expressions that are incongruent with the context or situation.

• Negative Symptoms: Symptoms that reflect a decrease or loss of normal functions, such as alogia, avolition, and anhedonia.

• Paranoia: An irrational and persistent feeling of being persecuted or targeted.

• Positive Symptoms: Excess or distortion of normal functions, including hallucinations and delusions.

• Prodromal Stage: The early phase of a disorder, marked by subtle symptoms preceding full-blown illness.

• Psychosis: A mental state characterized by a disconnection from reality, including delusions and hallucinations.

• Psychotic Disorder Due to Another Medical Condition: Psychotic symptoms directly resulting from a medical condition, such as a brain injury or illness.

• Schizoaffective Disorder: A mental health condition featuring symptoms of both schizophrenia and mood disorders (depression or bipolar disorder).

• Schizophrenia: A chronic mental disorder involving distortions in thinking, perception, emotions, language, sense of self, and behavior.

• Schizophreniform Disorder: A disorder with schizophrenia-like symptoms lasting more than one month but less than six months.

• Schizophrenogenic: A term historically used to describe factors thought to contribute to the development of schizophrenia.

• Schizotypal Personality Disorder: A personality disorder characterized by acute discomfort in close relationships, cognitive or perceptual distortions, and eccentric behavior.

• Shared Psychotic Disorder (Folie à Deux): A condition where a delusion develops in an individual in the context of a close relationship with another person who has an established delusion.

• Substance-Induced Psychotic Disorder: Psychosis directly caused by substance use, such as drugs or alcohol.

• Token Economy: A behavioral therapy system where individuals earn tokens for desired behaviors, which can be exchanged for rewards.

Personality Disorders:

• Antisocial Personality Disorder: A pattern of disregard for, and violation of, the rights of others, often involving deceit and manipulation.

• Avoidant Personality Disorder: A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

• Borderline Personality Disorder: A pattern of instability in interpersonal relationships, self-image, and affects, with marked impulsivity.

• Dependent Personality Disorder: A pattern of submissive and clinging behavior related to an excessive need to be taken care of.

• Histrionic Personality Disorder: A pattern of excessive emotionality and attention-seeking behavior.

• Narcissistic Personality Disorder: A pattern of grandiosity, need for admiration, and lack of empathy.

• Obsessive-Compulsive Personality Disorder: A pattern of preoccupation with orderliness, perfectionism, and control.

• Paranoid Personality Disorder: A pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent.

• Personality Disorder: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, and leads to distress or impairment.

• Psychopathy: A personality disorder indicated by persistent antisocial behavior, impaired empathy and remorse, and bold, disinhibited, and egotistical traits.

• Schizoid Personality Disorder:
  A pattern of detachment from social relationships and a limited range of emotional expression in interpersonal settings.

• Schizotypal Personality Disorder:
  A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentric behaviors or thoughts.

Sexual and Gender Disorders

Sexual Dysfunctions

• Delayed Ejaculation:
  Difficulty or inability to ejaculate despite adequate sexual stimulation and desire.

• Erectile Disorder:
  Difficulty achieving or maintaining an erection during sexual activity.

• Exhibitionistic Disorder:
  Sexual arousal from exposing one’s genitals to non-consenting individuals.

• Female Orgasmic Disorder:
  Delay in, infrequency of, or absence of orgasm following normal sexual excitement.

• Female Sexual Interest/Arousal Disorder:
  Low sexual desire or difficulty becoming aroused during sexual activity.

• Fetishistic Disorder:
  Sexual arousal involving non-living objects or specific body parts not typically associated with sexual arousal (e.g., feet, shoes).

• Frotteuristic Disorder:
  Sexual arousal from touching or rubbing against a non-consenting person.

• Genito-Pelvic Pain/Penetration Disorder:
  Difficulty with vaginal penetration, pain during intercourse, or fear of pain associated with penetration.

• Male Hypoactive Sexual Desire Disorder:
  Persistent or recurrent deficiency of sexual fantasies and desire for sexual activity.

• Male Orgasmic Disorder:
  Delayed ejaculation or inability to reach orgasm during sexual activity.

• Paraphilic Disorders:
  Sexual arousal involving atypical objects, situations, or individuals (e.g., voyeuristic, exhibitionistic, pedophilic disorders).

• Pedophilic Disorder:
  Sexual attraction to prepubescent children; may or may not involve acting on these attractions.

• Premature Ejaculation:
  Ejaculation that consistently occurs within one minute of penetration and before the individual wishes it.

• Sexual Masochism Disorder:
  Sexual arousal from being humiliated, beaten, or made to suffer.

• Sexual Sadism Disorder:
  Sexual arousal from inflicting physical or psychological suffering on others.

• Transvestic Disorder:
  Sexual arousal from cross-dressing, typically unrelated to gender identity.

• Vaginismus:
  Involuntary spasms of the vaginal muscles that interfere with penetration.

• Voyeuristic Disorder:
  Sexual arousal from observing an unsuspecting person who is naked, undressing, or engaging in sexual activity.

Gender Disorders

• Gender Dysphoria:
  Distress or impairment resulting from a mismatch between one’s assigned sex at birth and gender identity.

• Gender Nonconformity:
  Behavior or gender expression that does not align with societal expectations of one’s assigned sex.

• Gender-Affirming Surgery:
  Medical procedures to modify physical characteristics to align with gender identity (e.g., vaginoplasty, phalloplasty).

Module 10: Mental health services Legal and Ethical Issues

Charter Rights and Freedom for Mental Ill Individuals 

• 1. Key Sections of the Charter:

• Section 1-Guarantee of Rights and Freedoms:

• Guarantees rights and freedoms, subject only to reasonable limit.

• Section 7: Rights to life, liberty, and security of the person.

• Section 9: Right to not be arbitrarily detained.

• Section 12: Protection from cruel and unusual treatment.

• Section 15: Equality before the law (includes protection for mental and physical disabilities

Examples:

• A person with schizophrenia cannot be detained arbitrarily without proper justification. 

• Freedom of expression applies unless it breaches reasonable limits.

Types of commitment 

• 1. Civil commitment:

• Governed by Provincial jurisdiction.

• Involves placing someone in a mental health facility for their safety or the safety of others.

• Conditions: Danger to self/inability to care for oneself.

Examples:

• Someone experiencing severe psychosis may be hospitalized temporarily for assessment under the Ontario Mental Health Act.

• Criminal Commitment:

  • Governed by Federal Jurisdiction.

  • Applied when a person commits a crime but is found not criminally responsible (NCRMD) due to a mental illness.

• Examples:

  • A defendant with severe delusions during a criminal act may use the NCRMD defense.

Patients’ Rights

1. Right to Treatment:

   • Individuals committed involuntarily must receive treatment to address their condition in the least restrictive environment.

2. Example:

   • Outpatient therapy instead of hospitalization.

3. Right to Refuse Treatment:

   • Involuntary patients can refuse treatment unless:

     • They are deemed incapable of informed decision-making.

     • A substitute decision-maker provides consent.

4. Example:

   • A patient refusing antipsychotics may have their prior consent through a substitute decision-maker used.

Prediction of Dangerousness

• Predicting violent behavior is central to civil commitments but is challenging due to:

  • Base Rate Problem: Rare events (e.g., suicide) are hard to predict.

  • Actuarial Prediction: Uses statistical models.

Examples:

• Predicting suicide in clinical populations often misses rare cases.

• Specific threats are more predictive of danger than vague statements.

Criminal Commitment & NCRMD

1. Insanity Defense (NCRMD in Canada):

   • Based on Section 16 of the Criminal Code.

   • Applies when mental illness prevents understanding the nature or wrongfulness of an act.

2. Examples:

   • M'Naghten Rules: Not understanding the act was wrong due to mental illness.

   • Case: Vince Li was found NCRMD for a high-profile crime, later treated and integrated into a group home.

3. Fitness to Stand Trial:

   • Defendants must comprehend charges and assist in their defense.

4. Example:

   • A defendant with severe cognitive impairment may be declared unfit and hospitalized until competency is restored.

Ethics in Therapy & Research

1. Informed Consent:

   • Participants in research must be informed of risks and can withdraw.

2. Example:

   • A participant in a clinical drug trial is informed about potential side effects like drowsiness.

3. Confidentiality & Privileged Communication:

   • Therapist-client communications are confidential, except for safety concerns.

4. Example:

   • Therapists must warn authorities if a client threatens identifiable harm (Tarasoff case).

Ethical Dilemmas

1. Duty to Warn & Protect:

   • Breaching confidentiality to prevent imminent danger to others.

2. Example:

   • Warning a specific individual about a threat posed by a client.

3. Challenges in Research:

   • Balancing benefits with ethical standards like informed consent and confidentiality.

4. Example:

   • Psychologists follow Tri-Council guidelines in Canada.

Key Legal Cases

• M'Naghten Rules: Established insanity defense criteria.

• Regina v. Swain (1991): Led to reforms in criminal commitment laws (Bill C-30).

• Winko v. British Columbia (1999): Required discharge unless significant risk to public safety.

Example:

• Bill C-30 ensures review boards assess NCRMD cases annually for appropriate decisions.

Practical Considerations

• Actuarial models improve dangerousness prediction but cannot eliminate risk.

• Therapists must navigate confidentiality and ethical dilemmas, balancing legal and professional obligations.

Module 10: key terms 

Civil Commitment Laws: Legal statutes that allow for the involuntary hospitalization and treatment of individuals with severe mental illnesses when they are deemed unable to care for themselves or pose a danger to themselves or others.

Clinical Efficacy: The effectiveness of a clinical intervention or treatment in achieving the desired therapeutic outcome under controlled conditions.

Clinical Utility: The practical usefulness of a clinical intervention in real-world settings, considering factors like feasibility, cost-effectiveness, and applicability to diverse populations.

Criminal Commitment: The legal process of confining an individual to a mental health facility as a result of criminal behavior, typically when the person is found not guilty by reason of insanity or deemed incompetent to stand trial.

Dangerousness: The potential of an individual to cause harm to themselves or others, often assessed in legal and clinical settings to determine the necessity of interventions like involuntary commitment.

Deinstitutionalization: The policy and process of reducing the population of mental health institutions by transitioning individuals to community-based treatment settings, aiming to improve quality of life and integration into society.

Duty to Warn: The legal and ethical obligation of mental health professionals to inform potential victims or authorities if a client poses a credible threat of harm to others.

Expert Witnesses: Individuals with specialized knowledge or expertise who provide testimony in legal proceedings to assist the court in understanding complex issues, such as psychological evaluations in criminal cases.

Fitness to Stand Trial: An assessment of a defendant's mental capacity to understand the nature of the legal proceedings and to participate adequately in their own defense.

Informed Consent: The process by which a patient or research participant is fully informed about the procedures, risks, benefits, and alternatives before agreeing to undergo a treatment or participate in a study.

Malingering: The intentional fabrication or exaggeration of physical or psychological symptoms for external incentives, such as avoiding work, obtaining financial compensation, or evading criminal prosecution.

Mental Illness: A broad range of mental health conditions characterized by alterations in thinking, mood, or behavior associated with distress and impaired functioning.

Transinstitutionalization: The phenomenon where individuals with mental illnesses are moved from psychiatric hospitals to other institutions, such as prisons or nursing homes, often due to inadequate community-based services.