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PSYC2020 EXAM
PERSONALITY DISORDERS
CLUSTER A
Personality Disorders
Persistent pattern of emotions, thoughts, and behaviours that results in enduring distress and impairment (self or others)
Typically chronic and lifelong- as opposed to coming and going
Worldwide, roughly 8% are estimated to have a personality disorder
Personality Clusters
Cluster A- Odd or Eccentric
Paranoid
Schizoid
Schizotypal
Cluster B- Dramatic, Emotional, or Erratic
Antisocial
Borderline
Histrionic
Narcissistic
Cluster C- Anxious or Fearful
Avoidant
Dependent
Obsessive-Compulsive
Ongoing Debate
Do personality disorders represents
a) extreme variations of personality ( a dimensional approach)
b) distinct personalities that are different from healthy behavioural patterns (a categorical approach)
Across diagnoses
Accosted with
Substance use
Suicide attempts
Issues at work
Relational issues- e.g. separation/divorce
Problems with the law
Paranoid Personality Disorder
What it looks like
People with this disorder tend to be thought of or describe as ‘loners’
Homelessness is prevalent due to lack of social connections
Compared to paranoid/schizotypal, lack of unusual thoughts/beliefs
More focuses on social isolation and reduced emotional range
High overlap between symptoms of autism and schizoid
Causes/ Precursors
Very little researcher, but childhood shyness appears to be Como
Additionally, absent and neglect in childhood are commonly reported
Weaker response to dopamine/less dopamine general may play a role in social aloofness
Treatment
Individuals with Schizoid Personality Disorder rarely seek out treatment unless there os a crisis
When treatment happens, it may focus on social skills training (e.g. through roleplay)
Research on outcome of treatment is limited
Schizotypal Personality Disorder
Distinctive Features
Individuals with this disorder tend to appear isolated, suspicious, and behave in a way that is odd or bizarre
Closely related to schizophrenia, but absence of hallucinations/delusions- is kind of psychosis-adjacent
May be more severe compared to other Cluster A disorders
May believe that they are clairvoyant/telepathic
Possible Causes
Seems like schizotypal may result when the genetic vulnerability to schizophrenia is present but not the additional influences to provoke full schizophrenia
May be some brain differences including damage in the left hemisphere of the brain
Interest is growing, because this disorder may be a precursor to schizophrenia for some
Treatment
When individuals seek help, it is usually for co-morbid depression or anxiety- so this is what is treated
However, treating the disorder itself may be able to delay onset of schizophrenia and reduce symptoms
e.g. thought anti-psychotic medication, treatment, and social skills training
CLUSTER B
Anti-Social Personality Disorder
A) a pervasive pattern of disregard for and violation of the rights of others- occurring since age 15 years, indicated by 3+ symptoms
B) the individual is at least 18 years old
C) evidence of conduct disorder before the age of 15
Not exclusively during schizophrenia/bipolar
Criterion A Symptoms
1. Repeatedly breaking laws in a way that is grounds for arrest
2. Deceitfulness (lying, using aliases, etc.)
3. Impulsively/ failure to plan ahead
4. Repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Consistent responsibility re- finances/work
7. Lack of remorse related to others
In real-life..
Described as irresponsible, impulsive, and deceitful
Often aggressive
Comfortable with lying/cheating
Over half with this disorder engage in substance abuse
Estimated at 3.6% of population
Criminal Behaviour
Diagnosis in significantly more common in prison settings- roughly 1/3- 2/3 of the population
Not only does Antisocial Personality Disorder predict criminal behaviour- it also predicts likelihood to reoffend
Some neurological differences
Difficulty with executive functioning and broader cognitive functioning
Low cortical arousal (essentially these people may be looking for stimulation and experience lack of fear in risky decisions)
Psychopathy
Psychopathy is not a DSM diagnosis, but falls at the high end of ASPD
People with psychopathy may be more reward/goal driven and less worried about risk/consequences
Associated with childhood physical abuse
May have learned to turn off emotions
Treatment
The best chance of success is early intervention around selfishness, callousness, and using others
Most common treatment involves parent training so that parents can reinforce positive behaviours and reduce problem behaviours
Borderline Personality Disorder
A) a pervasive pattern of instability in interpersonal relationships, self-image, and affect- along with marked impulsivity
Beginning by early adulthood and present in a variety of contexts (5+ symptoms)
Criterion A Symptoms
1. Frantic efforts to avoid real or perceived abandonment
2. Pattern of unstable and intense relationships
3. Persistently unstable self-image/sense of self
4. Impulsively in 2+ risky areas
5. Recurrent suicidal behaviour, gestures, or threats, or self-injury
6. Unstable mood- intense episodic dysphoria, irritability, or anxiety (usually lasting only a few hours)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
6. Transient, stress-related paranoid ideation or severe dissociative symptoms
What it Looks Like
Intense fluctuating moods- especially negative ones
Marked by instability and risk of suicide or self-injury
Ultimately ~10% die by suicide
Roughly 1-2% of general population
But 20-25% of psychiatric admissions
Causes & Precursors
Appears to be veritable and linked with mood disorders
Extremely high rates of childhood sexual abuse reported
Some believe BPD is a variation of PTSD and should be understood as a response to trauma
Dialectical Behaviour Therapy
The best-validated approach to treatment
Involves distress tolerance skills as well as interpersonal skills
Often very intensive with group and individual therapy, as well as on demand texting
Histrionic Personality Disorder
A) a pervasive pattern of excessive emotionally and attention seeking- beginning by early adulthood and present in a variety of contexts -5+ symptoms
Criterion A Symptoms
1. Are uncomfortable in situations where they are not the centre of attention
2. Interaction with others is often characterized by inappropriate sexual seductive or provocative behaviour
3. Displays rapidly shifting, shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Speaks vaguely and without detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion
7. Is suggestible (easily influenced)
8. Thinks relationships are more intimate than they are
Day-to day
Overly intense emotions across the board
Prefer to be centre of attention
Can be overly dramatic and seductive
Require a lot of reassurance and seek approval frequently
Difficultly delaying gratification
Overlap with Antisocial
Extremely high co-morbidity with ASPD (up to 2/3)- may indicate they are the same disorder, but typically male vs. typically female presentation
Treatment
Very little success reported
Focuses on interpersonal relationships
Narcissistic Personality Disorder
A) a pervasive pattern of grandiosity (infants or behaviour), need for admiration, and lack of empathy- beginning by early adulthood and present in a variety of contexts (5+ symptoms)
Criterion A Symptoms
1. Has grandiose sense of self-importance
2. Preoccupied with fantasies of greatness- success, brilliance, power, beauty, etc
3. Believes that he or she is ‘special’ and can only be understood by high-status people
4. Requests excessive admiration
5. Has a sense of entitlement
6. Is interpersonally exploitative (takes advantage of others)
7. Lacks empathy
8. Is often envious of others-or believes others are envious of them
9. Arrogant or haughty
What it Looks Like
Comes from Greek myth
Feel like they need the best of everything
Threatened when around others who are actually successful
Often depressed due to not meeting their own expectations
Treatment
Poorly researched
May focus on working towards attainable and meaningful goals
May also look at treating co-morbid depression
CLUSTER C
Avoidant Personality Disorder
In DSM…
A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present I a variety of contexts as indicated by 4+ symptoms
Criterion A symptoms:
1. Avoids work that involves social contact, due to fears to criticisms, rejection, or disapproval
2. is unwilling to be involved unless certain of being liked
3. Is cautious in intimate relationships due to fear of shame or ridicule
4. Preoccupied with being criticized or rejected socially
5. Inhabited in new social settings due to fear of inadequacy
6. Views self as socially inept, unappealing, or inferior
7. Is reluctant to take risks or try new activities due to fear of embarrassment
Disenting Diagnoses
Distinct from Schizoid because these individuals want social connection but fear embarrassment
Significant overlap with Social Anxiety Disorder- may be part of a spectrum- considered ore chronic/lifelong
Possible Causes
Some genetic relationship to schizophrenia
Difficult temperament was a baby
Rejection/neglect as a child, especially from parents
Behavioural inhibition (may apply to all Cluster C disorders)
***also possibly more sensitive to social rejection
Treatment
Because of overlap with social anxiety disorder- many treatments also overlap
Social skills training within a support group
Sixty medication, such as SSRIs
CBT with exposure to feared social situations
How Avoidant Personality Disorder different from Social Anxiety Disorder
Avoidant Personality Disorder is more focused on criticism and rejection over embarrassment (compared too SAD)
More chronic/lifelong
Doesn’t have a clear precursor such as bullying like SAD
Dependent Personality Disorder
In the DSM…
Similar to avoidant but the opposite (both stem from a fear of rejection)
A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts as indicated by 5+ symptoms
Criterion A symptoms:
1. Difficulty making everyday decisions without excessive advice and reassurance
2. Needs others to be responsible for most major areas of life
3. Difficulty expressing disagreement with others due to fear of disapproval
4. Difficultly initiating projects (not due to a lack of motivation)
5. Goes to excessive lengths to get support from others
6. Feels helpless when alone due to fear they can’t take care of self
7. Seeks new relationship ad soon as close relationship ends
8. Is unrealistically preoccupied with fears of being left to take care of themselves
Similar to Avoidant Personality Disorder
Feelings of inadequacy in social situations
Sensitivity to criticism
Desire for reassurance
Diffierent to Avoidant Persoanity Disorder
Instead of avoiding relationships, people with dependent personality disorder cling to relationships
Possible causes
Personality traits such as sociotropy (strong investment I positive social interaction)
Common in both avoidant and dependent
May relate to a loved history of abandonment or neglect (e.g. as a child)
Treatment
Very little research on effectiveness
People with Dependent Personality Disorder often present as ‘ideal’ patents because they want support and are happy to follow recommendations
However, therapy must focus on independence
Obsessive Compulsive Personality Disorder
In the DSM…
A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control- at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4+ symptoms
Criterion A Symptoms:
1. Preoccupied with rules, lists, order, organization, etc.
2. Shows perfectionism that interferes with finishing tasks
3. Is excessively devoted to work and productivity
4. Is overly conscientious and inflexible about morality, ethics or values
5. Is unable to discard worn-out or worthless objects
6. Is reluctant to delegate tasks or work with others unless things are been their way
7. Adopt a miserly spending style- money is hoarded for future catastrophes
8. Show rigidity and stubbornness
Extra Info
OCPD is characterized as preoccupation with doing things the ‘right way’
It is an overall mindset and approach to life- not a pattern of distinct obsessions and compulsions (as in OCD)
One of the most common personality disorders (~2-8%)
Possible Causes
Appears to be a genetic contribution
For the most people, this likely looks more like preferring structure and neatness- but does not reach the level of disorder
Treatment
Very little information on treatment of OCPD
Culturally helpful so not a big concern to researchers
Therapy is likely to work on confronting fears about things like inadequacy
Therapy is also likely to explicitly target perfectionism
What about Self-Compassion
Defined by Dr. Kristen Neff
Highlights research showing that self-criticism and shame do not produce positive change
People who are ashamed often withdraw
Can be taught within therapy or leaned about independently
3 Components
1. Choose self-kindness rather than self-judgement
2. Link failures and struggles to common humanity instead of isolating
3. Mindfully notice your ow suffering, rather than over-identifying with it
How might this be applied to Avoidant PD, Dependent PD, or OCPD?
Changes your though process
People who are very sensitive to criticism, CBT can feel critical to them while self compassion techniques might not be
SELF INJURY AND SUICIDE
Suicide
Ideation: thinking or voicing things like “I wish I were dead” (passive) or “I should just kill myself” (active)
Plan: knowing how and/or when one would die by suicide and/or how to access what is needed for the plan and/or having procured what is needed
Attempt: having initiated a set of actions intended to lead to one’s own death
Statistics
The global suicide rate is estimated at 9/100,000 people
However this is thought to be a rather low number due to vague deaths which could be suicides (e.g. people who drove into traffic)
In Canada, rates have dropped over the past several years but remain above the global average
Most researchers agree actual suicide rates are higher than statistics suggest
Gender Differences
Men
Die at 3.4x the rate
Choose more lethal methods
Women
Attempt more often vs. Men
Choose less violent/less lethal methods
Age Differences
Lowest amongst people aged 15 and below
Highest between ages. 45-64
Additional Statistics
Suicide is the ninth-leading cause of death overall in Canada
Second-leading between ages 15-34
Suicide is the ninth-leading cause of death overall in Canada
First Nations & Rural Areas
Highest rates of suicide in Canada are in more rural provinces/territories (highest by far in Nunavut)
Typically higher in First Nations communities, with much of this related to depression and substance abuse
Risk Factors
Lac of social support
Family history of suicide
Low levels of serotonin
Psychological disorders, especially mood disorders
Alcohol use and misuse
Past suicide attempts
Severe, stressful events (especially, if shameful)
In the DSM-5-TR
Not a diagnosis- often indicated as a symptom (e.g. of depression)
However, Suicidal Behaviour Disorder is currently a condition for further study (mostly consists of a suicide attempt within the past 24 months)
Most likely used for insurance purposes
Self- Injury
Formally, best defined as “Non-Suicidal Injury” (NSSI)
Deliberate and immediate damage of one’s own bodily tissue, in the absence of suicidal intent, for reasons not culturally or socially sanctioned
Most Common Methods of NSSI
Cutting
Scratching/carving/scraping
Hitting/bruising
Burning
Reasons for Self-Injury
Intrapersonal (about oneself)
Emotion regualtion
Self punishment
To feel something
To avoid acting on suicidal ideation/impulses
Interpersonal (related to others)
To get a response from others
To stop a consequence
Most report multiple reasons- and reason change over time
Gender Differences
Boys/Young Men
May hit/burn more
May have more injuries on hands/head (from hitting)
Girls/ Young Women
May cut more
May have more injuries on wrists/thighs
Onset & Rates
Can begin at any age
Most commonly time to begin self-injuring- in university (17-19 years)
As high ad 20% of youth and emerging adults- often particularly high in university settings (many university students have self-harmed at some point)
Risk Factors
Some evidence for family challenges- e.g. abuse, critical parents, family issues with communicating emotions
Mental illnesses such as anxiety, PTSD, eating disorders, BPD, substance abuse, and depression
Emotion regulation issues
Relational issues
In DSM-5-TR
Non-suicidal Self-Injury Disorder is also currently a condition for further study
Involves NSSI on at least 5 days over the past year
Otherwise, mostly follows standard NSSI definition
Relationship Between Suicide and Self-Injury
NSSI vs. Suicide
NSSI is by definition NOT a suicide attempt
NSSI: typically lower severity, higher frequency
Suicide: typically higher severity, lower frequency
Despite this..
NSSI is the strongest predictor of future suicide attempts and significantly elevates suicide risk
This means that NSSI response needs to include suicide risk evaluation
Remember that most people who self-injure NEVER attempt suicide
Giving & Receiving Support
Good Response to NSSI
Respond with calmness ad empathy
Show a respectful curiosity
Focus on overall wellbeing
Validate that self-injury severs a purpose
Provide resources/encourage seeking further support
Do not insist that they stop
Suicide Risk Questions
Do they have a plan?
DO they have what they need to carry out the plan?
How likely are they to carry out to plan (scale 1-10?)
National Suicide Plan: 9-8-8
If You Are Struggling
Find someone safe to talk- its ok to choose a loved one first, but you likely need professional as well
Consider Student Wellness or 9-8-8
Recognize that people who love you may have a hard time hearing how much you are struggling- but most of the time, they will want to help anyways
PSYCHOSIS
PERSONALITY DISORDERS
CLUSTER A
Personality Disorders
Persistent pattern of emotions, thoughts, and behaviours that results in enduring distress and impairment (self or others)
Typically chronic and lifelong- as opposed to coming and going
Worldwide, roughly 8% are estimated to have a personality disorder
Personality Clusters
Cluster A- Odd or Eccentric
Paranoid
Schizoid
Schizotypal
Cluster B- Dramatic, Emotional, or Erratic
Antisocial
Borderline
Histrionic
Narcissistic
Cluster C- Anxious or Fearful
Avoidant
Dependent
Obsessive-Compulsive
Ongoing Debate
Do personality disorders represents
a) extreme variations of personality ( a dimensional approach)
b) distinct personalities that are different from healthy behavioural patterns (a categorical approach)
Across diagnoses
Accosted with
Substance use
Suicide attempts
Issues at work
Relational issues- e.g. separation/divorce
Problems with the law
Paranoid Personality Disorder
What it looks like
People with this disorder tend to be thought of or describe as ‘loners’
Homelessness is prevalent due to lack of social connections
Compared to paranoid/schizotypal, lack of unusual thoughts/beliefs
More focuses on social isolation and reduced emotional range
High overlap between symptoms of autism and schizoid
Causes/ Precursors
Very little researcher, but childhood shyness appears to be Como
Additionally, absent and neglect in childhood are commonly reported
Weaker response to dopamine/less dopamine general may play a role in social aloofness
Treatment
Individuals with Schizoid Personality Disorder rarely seek out treatment unless there os a crisis
When treatment happens, it may focus on social skills training (e.g. through roleplay)
Research on outcome of treatment is limited
Schizotypal Personality Disorder
Distinctive Features
Individuals with this disorder tend to appear isolated, suspicious, and behave in a way that is odd or bizarre
Closely related to schizophrenia, but absence of hallucinations/delusions- is kind of psychosis-adjacent
May be more severe compared to other Cluster A disorders
May believe that they are clairvoyant/telepathic
Possible Causes
Seems like schizotypal may result when the genetic vulnerability to schizophrenia is present but not the additional influences to provoke full schizophrenia
May be some brain differences including damage in the left hemisphere of the brain
Interest is growing, because this disorder may be a precursor to schizophrenia for some
Treatment
When individuals seek help, it is usually for co-morbid depression or anxiety- so this is what is treated
However, treating the disorder itself may be able to delay onset of schizophrenia and reduce symptoms
e.g. thought anti-psychotic medication, treatment, and social skills training
CLUSTER B
Anti-Social Personality Disorder
A) a pervasive pattern of disregard for and violation of the rights of others- occurring since age 15 years, indicated by 3+ symptoms
B) the individual is at least 18 years old
C) evidence of conduct disorder before the age of 15
Not exclusively during schizophrenia/bipolar
Criterion A Symptoms
1. Repeatedly breaking laws in a way that is grounds for arrest
2. Deceitfulness (lying, using aliases, etc.)
3. Impulsively/ failure to plan ahead
4. Repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Consistent responsibility re- finances/work
7. Lack of remorse related to others
In real-life..
Described as irresponsible, impulsive, and deceitful
Often aggressive
Comfortable with lying/cheating
Over half with this disorder engage in substance abuse
Estimated at 3.6% of population
Criminal Behaviour
Diagnosis in significantly more common in prison settings- roughly 1/3- 2/3 of the population
Not only does Antisocial Personality Disorder predict criminal behaviour- it also predicts likelihood to reoffend
Some neurological differences
Difficulty with executive functioning and broader cognitive functioning
Low cortical arousal (essentially these people may be looking for stimulation and experience lack of fear in risky decisions)
Psychopathy
Psychopathy is not a DSM diagnosis, but falls at the high end of ASPD
People with psychopathy may be more reward/goal driven and less worried about risk/consequences
Associated with childhood physical abuse
May have learned to turn off emotions
Treatment
The best chance of success is early intervention around selfishness, callousness, and using others
Most common treatment involves parent training so that parents can reinforce positive behaviours and reduce problem behaviours
Borderline Personality Disorder
A) a pervasive pattern of instability in interpersonal relationships, self-image, and affect- along with marked impulsivity
Beginning by early adulthood and present in a variety of contexts (5+ symptoms)
Criterion A Symptoms
1. Frantic efforts to avoid real or perceived abandonment
2. Pattern of unstable and intense relationships
3. Persistently unstable self-image/sense of self
4. Impulsively in 2+ risky areas
5. Recurrent suicidal behaviour, gestures, or threats, or self-injury
6. Unstable mood- intense episodic dysphoria, irritability, or anxiety (usually lasting only a few hours)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
6. Transient, stress-related paranoid ideation or severe dissociative symptoms
What it Looks Like
Intense fluctuating moods- especially negative ones
Marked by instability and risk of suicide or self-injury
Ultimately ~10% die by suicide
Roughly 1-2% of general population
But 20-25% of psychiatric admissions
Causes & Precursors
Appears to be veritable and linked with mood disorders
Extremely high rates of childhood sexual abuse reported
Some believe BPD is a variation of PTSD and should be understood as a response to trauma
Dialectical Behaviour Therapy
The best-validated approach to treatment
Involves distress tolerance skills as well as interpersonal skills
Often very intensive with group and individual therapy, as well as on demand texting
Histrionic Personality Disorder
A) a pervasive pattern of excessive emotionally and attention seeking- beginning by early adulthood and present in a variety of contexts -5+ symptoms
Criterion A Symptoms
1. Are uncomfortable in situations where they are not the centre of attention
2. Interaction with others is often characterized by inappropriate sexual seductive or provocative behaviour
3. Displays rapidly shifting, shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Speaks vaguely and without detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion
7. Is suggestible (easily influenced)
8. Thinks relationships are more intimate than they are
Day-to day
Overly intense emotions across the board
Prefer to be centre of attention
Can be overly dramatic and seductive
Require a lot of reassurance and seek approval frequently
Difficultly delaying gratification
Overlap with Antisocial
Extremely high co-morbidity with ASPD (up to 2/3)- may indicate they are the same disorder, but typically male vs. typically female presentation
Treatment
Very little success reported
Focuses on interpersonal relationships
Narcissistic Personality Disorder
A) a pervasive pattern of grandiosity (infants or behaviour), need for admiration, and lack of empathy- beginning by early adulthood and present in a variety of contexts (5+ symptoms)
Criterion A Symptoms
1. Has grandiose sense of self-importance
2. Preoccupied with fantasies of greatness- success, brilliance, power, beauty, etc
3. Believes that he or she is ‘special’ and can only be understood by high-status people
4. Requests excessive admiration
5. Has a sense of entitlement
6. Is interpersonally exploitative (takes advantage of others)
7. Lacks empathy
8. Is often envious of others-or believes others are envious of them
9. Arrogant or haughty
What it Looks Like
Comes from Greek myth
Feel like they need the best of everything
Threatened when around others who are actually successful
Often depressed due to not meeting their own expectations
Treatment
Poorly researched
May focus on working towards attainable and meaningful goals
May also look at treating co-morbid depression
CLUSTER C
Avoidant Personality Disorder
In DSM…
A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present I a variety of contexts as indicated by 4+ symptoms
Criterion A symptoms:
1. Avoids work that involves social contact, due to fears to criticisms, rejection, or disapproval
2. is unwilling to be involved unless certain of being liked
3. Is cautious in intimate relationships due to fear of shame or ridicule
4. Preoccupied with being criticized or rejected socially
5. Inhabited in new social settings due to fear of inadequacy
6. Views self as socially inept, unappealing, or inferior
7. Is reluctant to take risks or try new activities due to fear of embarrassment
Disenting Diagnoses
Distinct from Schizoid because these individuals want social connection but fear embarrassment
Significant overlap with Social Anxiety Disorder- may be part of a spectrum- considered ore chronic/lifelong
Possible Causes
Some genetic relationship to schizophrenia
Difficult temperament was a baby
Rejection/neglect as a child, especially from parents
Behavioural inhibition (may apply to all Cluster C disorders)
***also possibly more sensitive to social rejection
Treatment
Because of overlap with social anxiety disorder- many treatments also overlap
Social skills training within a support group
Sixty medication, such as SSRIs
CBT with exposure to feared social situations
How Avoidant Personality Disorder different from Social Anxiety Disorder
Avoidant Personality Disorder is more focused on criticism and rejection over embarrassment (compared too SAD)
More chronic/lifelong
Doesn’t have a clear precursor such as bullying like SAD
Dependent Personality Disorder
In the DSM…
Similar to avoidant but the opposite (both stem from a fear of rejection)
A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts as indicated by 5+ symptoms
Criterion A symptoms:
1. Difficulty making everyday decisions without excessive advice and reassurance
2. Needs others to be responsible for most major areas of life
3. Difficulty expressing disagreement with others due to fear of disapproval
4. Difficultly initiating projects (not due to a lack of motivation)
5. Goes to excessive lengths to get support from others
6. Feels helpless when alone due to fear they can’t take care of self
7. Seeks new relationship ad soon as close relationship ends
8. Is unrealistically preoccupied with fears of being left to take care of themselves
Similar to Avoidant Personality Disorder
Feelings of inadequacy in social situations
Sensitivity to criticism
Desire for reassurance
Diffierent to Avoidant Persoanity Disorder
Instead of avoiding relationships, people with dependent personality disorder cling to relationships
Possible causes
Personality traits such as sociotropy (strong investment I positive social interaction)
Common in both avoidant and dependent
May relate to a loved history of abandonment or neglect (e.g. as a child)
Treatment
Very little research on effectiveness
People with Dependent Personality Disorder often present as ‘ideal’ patents because they want support and are happy to follow recommendations
However, therapy must focus on independence
Obsessive Compulsive Personality Disorder
In the DSM…
A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control- at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by 4+ symptoms
Criterion A Symptoms:
1. Preoccupied with rules, lists, order, organization, etc.
2. Shows perfectionism that interferes with finishing tasks
3. Is excessively devoted to work and productivity
4. Is overly conscientious and inflexible about morality, ethics or values
5. Is unable to discard worn-out or worthless objects
6. Is reluctant to delegate tasks or work with others unless things are been their way
7. Adopt a miserly spending style- money is hoarded for future catastrophes
8. Show rigidity and stubbornness
Extra Info
OCPD is characterized as preoccupation with doing things the ‘right way’
It is an overall mindset and approach to life- not a pattern of distinct obsessions and compulsions (as in OCD)
One of the most common personality disorders (~2-8%)
Possible Causes
Appears to be a genetic contribution
For the most people, this likely looks more like preferring structure and neatness- but does not reach the level of disorder
Treatment
Very little information on treatment of OCPD
Culturally helpful so not a big concern to researchers
Therapy is likely to work on confronting fears about things like inadequacy
Therapy is also likely to explicitly target perfectionism
What about Self-Compassion
Defined by Dr. Kristen Neff
Highlights research showing that self-criticism and shame do not produce positive change
People who are ashamed often withdraw
Can be taught within therapy or leaned about independently
3 Components
1. Choose self-kindness rather than self-judgement
2. Link failures and struggles to common humanity instead of isolating
3. Mindfully notice your ow suffering, rather than over-identifying with it
How might this be applied to Avoidant PD, Dependent PD, or OCPD?
Changes your though process
People who are very sensitive to criticism, CBT can feel critical to them while self compassion techniques might not be
SELF INJURY AND SUICIDE
Suicide
Ideation: thinking or voicing things like “I wish I were dead” (passive) or “I should just kill myself” (active)
Plan: knowing how and/or when one would die by suicide and/or how to access what is needed for the plan and/or having procured what is needed
Attempt: having initiated a set of actions intended to lead to one’s own death
Statistics
The global suicide rate is estimated at 9/100,000 people
However this is thought to be a rather low number due to vague deaths which could be suicides (e.g. people who drove into traffic)
In Canada, rates have dropped over the past several years but remain above the global average
Most researchers agree actual suicide rates are higher than statistics suggest
Gender Differences
Men
Die at 3.4x the rate
Choose more lethal methods
Women
Attempt more often vs. Men
Choose less violent/less lethal methods
Age Differences
Lowest amongst people aged 15 and below
Highest between ages. 45-64
Additional Statistics
Suicide is the ninth-leading cause of death overall in Canada
Second-leading between ages 15-34
Suicide is the ninth-leading cause of death overall in Canada
First Nations & Rural Areas
Highest rates of suicide in Canada are in more rural provinces/territories (highest by far in Nunavut)
Typically higher in First Nations communities, with much of this related to depression and substance abuse
Risk Factors
Lac of social support
Family history of suicide
Low levels of serotonin
Psychological disorders, especially mood disorders
Alcohol use and misuse
Past suicide attempts
Severe, stressful events (especially, if shameful)
In the DSM-5-TR
Not a diagnosis- often indicated as a symptom (e.g. of depression)
However, Suicidal Behaviour Disorder is currently a condition for further study (mostly consists of a suicide attempt within the past 24 months)
Most likely used for insurance purposes
Self- Injury
Formally, best defined as “Non-Suicidal Injury” (NSSI)
Deliberate and immediate damage of one’s own bodily tissue, in the absence of suicidal intent, for reasons not culturally or socially sanctioned
Most Common Methods of NSSI
Cutting
Scratching/carving/scraping
Hitting/bruising
Burning
Reasons for Self-Injury
Intrapersonal (about oneself)
Emotion regualtion
Self punishment
To feel something
To avoid acting on suicidal ideation/impulses
Interpersonal (related to others)
To get a response from others
To stop a consequence
Most report multiple reasons- and reason change over time
Gender Differences
Boys/Young Men
May hit/burn more
May have more injuries on hands/head (from hitting)
Girls/ Young Women
May cut more
May have more injuries on wrists/thighs
Onset & Rates
Can begin at any age
Most commonly time to begin self-injuring- in university (17-19 years)
As high ad 20% of youth and emerging adults- often particularly high in university settings (many university students have self-harmed at some point)
Risk Factors
Some evidence for family challenges- e.g. abuse, critical parents, family issues with communicating emotions
Mental illnesses such as anxiety, PTSD, eating disorders, BPD, substance abuse, and depression
Emotion regulation issues
Relational issues
In DSM-5-TR
Non-suicidal Self-Injury Disorder is also currently a condition for further study
Involves NSSI on at least 5 days over the past year
Otherwise, mostly follows standard NSSI definition
Relationship Between Suicide and Self-Injury
NSSI vs. Suicide
NSSI is by definition NOT a suicide attempt
NSSI: typically lower severity, higher frequency
Suicide: typically higher severity, lower frequency
Despite this..
NSSI is the strongest predictor of future suicide attempts and significantly elevates suicide risk
This means that NSSI response needs to include suicide risk evaluation
Remember that most people who self-injure NEVER attempt suicide
Giving & Receiving Support
Good Response to NSSI
Respond with calmness ad empathy
Show a respectful curiosity
Focus on overall wellbeing
Validate that self-injury severs a purpose
Provide resources/encourage seeking further support
Do not insist that they stop
Suicide Risk Questions
Do they have a plan?
DO they have what they need to carry out the plan?
How likely are they to carry out to plan (scale 1-10?)
National Suicide Plan: 9-8-8
If You Are Struggling
Find someone safe to talk- its ok to choose a loved one first, but you likely need professional as well
Consider Student Wellness or 9-8-8
Recognize that people who love you may have a hard time hearing how much you are struggling- but most of the time, they will want to help anyways
PSYCHOSIS
ADHD AND AUTISM
Intro to Neurodiversity
Individuals differences in brain functioning regarded as normal variations within the human population
The concept that differences in brain functioning within the human population are normal, that [neurodivergent] brain functioning should not be stigmatized
Why ADHD & Autism?
Not exactly mental health
But regularly diagnosed and supported by psychologists
Significantly impact on wellbeing- relationships, academics, etc.
One of the most common referrals
In Real Life…
Not necessarily that brains working wrong- but they tend to not match up with the way society is structured
Masking
Most commonly discussed in autism
But happens in ADHD as well
Refers to attempting to cover up autistic/ADHD traits and appear neurotypical
Tends to be exhausting and can promote burnout, unhappiness, and suicidal thoughts
ADHD
“Attention-Deficit Hyperactivity Disorder
Typically involves inattention hyperactivity/impulsivity, or both
‘Deficit’ is a bit of a misnomer-not necessarily lack of attention, but difficulty regulating attention
In the DSM…
A. A persistent pattern of (1) inattention and/or (2) hyperactivity- impulsivity that infers with functioning/development
B. Several symptoms present before age 12
C. Several symptoms in 2+ settings
D. Symptoms cleat interfere with functioning
e. Not better explained by another disorder
Inattention
6+ symptomS
Presently for at least 6 months
Inconsistent with developmental level
Negative impact on social/academic/work
(2) Hyperactivity & Impulsivity
6+ symptoms
Presently for at least 6 months
Inconsistent with developmental level
Negative impact on social/academic/work
Common ADHD Myths
ADHD is a childhood disorder
people in fact do not grow out of ADHD
ADHD is wildly over diagnoses
ADHD medication turns children into zombies
there is no one size fits all medications it typically takes 3 medication before they find the right one
If someone can focus on some things, they obviously don’t have ADHD
People with ADHD are just lazy
Stats & Facts
5% of children -higher in boys
Perhaps because girls are less likely to present with hyperactivity and therefore not as big of an issue for the people around them
Highly influenced by genetics
Ca contribute to less education, poorer employment, substance abuse risky behaviours
Often co-morbid with behaviour disorder
Possible Causes
As noted, highly influenced by genetics
Appears to be related to dopamine
May involve some physical brain differences
Little to no evidence for relationship to food colourings /additives
May be related to sleep issues?
Medications
Most commonly treated using stimulants (e.g. Ritalin) which increase dopamine
Choosing a stimulant is very much trial and error -few clear predictors
Only clear predictor is if a family member was on a stimulant that worked for them
Stimulants can be addictive and harmful- for people who do not need them
One of the safest, best researched treatments
Can make it easier to function within a neurotypical system
Stays in the bay for 12 hours or less- and it is not harmful to take days off
Results show up in a day unlike SSRIs which typically take a 12 days
Same people choose to only take medication on school/work days
Other Supports
May involved behavioural strategies for child/family (e.g. routines, visual checklist, reward systems..)
May involve support in social skills
May involve academic support (e.g. tutoring)
May involve treatment of co-morbid mental health issues
Autism Spectrum Disorder (ASD)
Characterized by impairments in social communication and interaction and restricted repetitive patterns of behaviour, interest, or activities
In the DSM..
A. Persistent deficits in social communication and interaction across multiple contexts (3/3/ symptoms)
B. Restricted repetitive patterns of behaviour, interests, or activities (2+/4 symptoms
C. Symptoms present from early development
D. Clinically significant impairment across areas
E. Not better explained by something else
Specify..
Level 1: requiring support
Level 2: requiring substantial support
Level 3: requiring very substantial support
Stats & Facts
Current DSM collapsed other disorders into ASD (e.g. Asperger’s Syndrome)
More common diagnosis in recent years - multiple possible reasons
Diagnosed far more in males (4.5 to 1)
Autism and IQ
Austin’s individuals are routinely stereotyped as either intellectually disabled or geniuses
In reality, autistic people have diverse IQs
Neatly 30% have intellectual disability
Roughly 1/3 have specific ‘savant’ skills- typically looks like outstanding memory related to an area of interest
Common myths about autism
Autistic people don’t have emotions
People with autism are much more likely to freeze rather than fight or flee
Emotional responses may not match what is typical
A person can’t be autistic if they are verbal
Autistic people don’t need or want friends
Autistic people can never be independent
If autism is not visible than it is not a big deal
Support
Applied Behaviour Analysis (ABA)
Widely used and recommended intervention for autism
Used to promote language, communication, and social skills- and decrease ‘problem’ behaviours (often self soothing behaviours)
Many autistic people consider ABA to be abuse that teaches masking instead of coping
Recent study found that autistic adults who had ABA as children were 86% more likely to meet PTSD criteria
Instead..
Speech-language support
Social skills training or groups
Family supports (setting goof routines, good communication, etc)
Bri’s Favs
Run with special tress to promote social connections (e.g. love animals? Volunteer at the humane society)
Frame learning social skills as the option to access the neurotypical playbook-not as something that should be done
PSYCHOLOGY IN SCHOOL
LEARNING AND INTELLIGENCE
Psychology in Schools
School Psychologists
Typically complete a Master’s degree or PhD in School or education Psychology
Are similarly trained and have a similar job description to Clinical Psychologists but within the school system
Often includes assessments, short-term individual support, and broad school support
Individual Education Plans (IEP)
Special education plan, accommodations, and services for a student
Theoretically, anyone can have an IEP- but easier if ‘exceptional
Created by school, in cooperation with family and others
Cognitive Abilities
Thinking, reasoning and problem solving
Necessary for building academic skills
Typically stable across the lifespan
Academic Skills
Reading, writing, and math
Develop across the lifespan (with education)
Rely on underlying cognitive abilities
Specific Learning Disorders
Learning Disorder/ Learning Disability
Rough definition: when academic achievement does not match up with what is expected based on underlying cognitive abilities
More specific: according to the Ontario Psychological Association, must also identify a clear reason why the mismatch is happening
Types of Learning Disabilities
Reading (dyslexia)
e.g. issues with word reading or understanding what is read
2. Writing (dysgraphia)
e.g. issues with spelling, grammar, or organizing written ideas
3. Math (dyscalculia)
e.g. issues with number sense/ number facts or math reasoning
Involves
Challenges learning/ using specific academic skills
Academic output substantially below expected
Begin during school years, but may not be fully manifest until demands exceed capacity (e.g. under times conditions, heavy workloads, etc.)
Not better accounted for by intellectual disability, visual or auditory issues, lack of proficiency in language of instruction, etc.
Stats ad Facts
5-15% of youth across ages and cults
8.4% estimated I Canada between the age of 5-17
10.6% of males, 6.1% of females
Reading difficulties are the most common
LDs especially without support and poor employment rates
Can also be related to development of other meant health problems later
Possible Causes
Reading disorders seem to have a significant genetic component
Likely involves structural and functional brain differences
Deeply impacted by level of support received, socioeconomic status, etc.
Treatment
Tutoring or specialized school programs
Accommodations for testing
Cooperation between home and school
Intellectual Developmental Disorder (Intellectual Disability)
Significantly below average intelligence (cognitive abilities)
Significantly below average adaptive functioning (day-to-day abilities)
DSM-IV still used the term ‘mental retardation’
Experiences of ID are extremely diverse
In The DSM..
Intellectual and adaptive functioning deficits in conceptual, social, and practical domains
A) deficits in intellectual functioning, confirmed by clinical assessment and standardized testing
B) deficients in adaptive functioning resulting in failure to meet standards for personal independence and social responsibility
C) onset during the developmental period
Cut-Offs and Stats
Important that it is both cognitive and adaptives- helps make sure ID is not diagnosed just due to language issues
Roughly 1-3 percent of population have ID- with 90% of those falling in the mild range
Mild (IQ 50/55- 70)
Moderate (IQ 20/25- 35/40)
Profound (IQ below 20/25)
70/75 is two standard deviations below the mean
Diversity in functioning
Many people I the mild to moderate ID range can live independently or with only a bit of superversion/support
While institutions exist and can be a good fit for some, increasingly folks are able to have supports to live with family or on their own
Possible Causes
Many known causes exist:
Environment (e.g. abuse or neglect)
Parental (e.g exposure to drugs or disease during pregnancy)
Perinatal (e.g. difficulties during labour and delivery)
Postnatal (e.g. infant infection or head injury)
Genetics (e.g. down syndrome)
However, nearly 30% have no identifiable cause
Supports for ID
Intellectual disability typically qualifies individuals for the Ontario Disability Support Program (ODSP) meaning they can receive monthly income supplest, as well ax extra health coverage
Many programs available for supporting individuals and families-including a college program at Conestoga that prepares people for independence
Treatment and Support
Some educational accommodation and support- focus on functional academics
Support in developing adaptive skills for use in daily independent life
Support in making social connections and engaging meaningfully in community
BEHAVIOUR DISORDERS
Oppositional Defiant Disorder (ODD)
Generally looks like being irritable, argumentative, ad defiant
Most often begins in preschool
DSM Criteria
A) a pattern of angry/irritable moods augmentative/ defiant behaviours or vindictiveness
Lasting at least 6 months
Evidenced by at least 4 symptoms
Exhibited during interaction with at least one individual who is not a sibling
B) distress or impairment
C) not psychosis, substance use, or mood disorder
Symptoms
Anger/ Irritability
1. Often loses temper
2. Ofter touchy or easily annoyed
3. Often angry and resentful
Argumentative / Defiant Behaviour
1. Often argues with authrority figures
2. Often actively desires authority or refuses to comply with rules
3. Often deliberately annoys others
4. Often blames others for behaviour
Vindictiveness
1. Spiteful/vindictive 2+ times in the last 6 months
Specifiers
Mild: symptoms only in one setting (typically home)
Moderate: symptoms in two settings
Severe: Symptoms in three or more settings
Stats and Facts
Often co-morbid with ADHD and conduct disorder
Often precedes development of childhood-onset conduct disorder
Risk factors: poor emotion regulation, reciprocal relationships with harsh and inconsistent parenting, genetics don’t distinguish between ODD/CD
More likely to be bullied and to be a bully
Controversy
Lost of overlap with symptoms of other disorders
Not following directions? ADHD
Struggling with authority if instructions don’t ‘make sense’? Autism
AND many symptoms are a reasonable reaction to poor parenting/difficult home life
Should we Diagnose?
Pros
Any diagnosis can make services more accessible
May not be captured by another diagnosis
Can validate parents
Cons
Doesn’t explain the behaviours at all
Generally fails to consider environment
Labels child as ‘bad’
No clear treatment
In My Experience
Have yet to meet a child where the issue is truly ‘defiance’
Paediatrician-diagnosed ODD?
Intellectual Disability and/or ADHD x primary caregiver depression
Parents feel more validated when a good explanation for challenges with their kid is provided
Treatment
Parenting support
Especially making sure child receives attention for positive behaviour
Addressing co-morbid issues
ADHD, mental health
Parent mental health
Poverty
Conduct Disorder (CD)
Generally looks like a lack of care for others’ basic rights, and for societal norms and rules (e.g. laws)
DSM Criteria
A) a repetitive, persistent of behaviour on which the rights of others and/or societal norms/rules are violated:
At least 3/5 criteria in the past 12 months
At least 1 criterion in the past 6 months
B) clinically significant infant impairment in functioning
C) if 18 or older, criteria not met for antisocial personality disorder
Symptoms
Aversion to People and Animals
1. Often bullies, threatens, or intimidates others
2.Often initiates physical fights
3. Has used weapon that can cause serious harm
4. Has been physically cruel to people
5. Has been physically cured to animals
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity
Destruction of Property
1. Set fire with intent to cause serious damage
2. Deliberately destroyed others’ property
Deceitfulness or Theft
1. Has broken into house, building or car
2. Often ‘cos’ others
3. Stolen costly items without confrontation
Serious Rule Violations
1. Often stays out at night before age 13
2. Has run away from home at least twice (or once if long)
3. Often truant (before 13)
Specify: Onset ad Severity
Childhood onset type: 1+ symptom by age 10
Adolescent-onset type: 0 symptoms before age 10
Unspecified-onset: unclear when symptoms began
Mild: few (if any) symptoms beyond reuired- problems cause minor harm
Moderate: between ‘mild’ and ‘severe’
Severe: many symptom s beyond required and/or issues cause considerable harm to others
Specify if..
With limited prosocial emotions
2+ characteristics, 12+ months, multiple settings
Lack of remorse or guilt
Callous- lack of empathy
Unconcerned about performance
Shallow or deficient affect
Stats ad Facts
Childhood onset typically is more persistent, is often preceded by OCD, involves concurrent ADHD, and involves more aggression towards others
Lifetime prevalence (US): 12% (men), 7% (women)
Usually less serious symptoms begin first- if more serious behaviours develop early- this often means a worse prognosis (may develop into anti-social disorder)
Risk Factors
Difficult infant
Below-average IQ- epically if poor verbal skills
Neglect, harsh discipline, abuse
Genetics: more common when parents have server alcohol use, mood disorders, schizophrenia, ADHD, or conduct disorders r
More likely to persist if: childhood-onset, limited prosocial emotions, ADHD, substance abuse
Gender Differences
Boys/Men
Fighting
Stealing
Vandalism
School discipline
More physical aggression
Girls/Women
Lying
Truancy
Running away
Prostitution
Less physical aggression
Treatment
Most effective earlier on
Treatment ideally is comprehensive- addressing family issues, individual issues, and broad mental health
Often includes parenting support
Often includes individuals therapy (e.g. CBT)
May involve medication to manage other diagnoses or an antipsychotic to decrease aggression
SEXUALITY IN THE DSM
In previous DSM homosexuality was categorized as sexual deviations and sociopathic personality disturbances
DSM-5-TR
Transvestic Disorder
Listed under paraphilia
“Cross-dressing” -> arousal
Distress/impairment
Gender Dysphoria
Mismatch between experience/expressed gender
Distress impairment
Overview
Tend to feel much more medical and much less like a psychological disorder
Sexual dysfunction fall into four categories
Arousal
Pain
Desire
Orgasm
Desire
Male hypoactive sexual desire disorder
6+ months of decadent or absent sexual thoughts/fantasies and desire for sexual activity
Clinically significant distress
Not better explained by another issue
Female sexual interest/arousal disorder
6+ months- but symptoms more specific
Clinically significant distress
Not better explained by another issue
What About Asexuality?
Generally involves some difference (lack) of sexual interest/attraction to others
Often involves low sexual desire
Low/absent desire does not cause distress/impairment
Arousal
Erectile Disorder
6+ months with erectile dysfunction of some kind occurring in 75-10% of sexual activities (can be general or situational)
e.g. obtaining erection, maintaining erection or reduced rigidity
Clinically significant distress
Not better explained by another issue
Orgasm
Delayed ejaculation
Marked by delay, infrequency or absence of ejaculation
Premature (Early) Ejaculation
Within 1 minute of vaginal penetration before the person wishes it
Female Orgasmic Disorder
Delay, infrequency or absence of orgasm- or reduced intensity of orgasmic sensations
Pain
Genito-Pelvic Pain/Penetration Disorder
Difficultly or pain during intercourse/attempts at penetration
Fear or anxiety about pain in anticipation of during, o as a result of vaginal penetration
Tensing/tightening of pelvic floor muscles during attempted penetration
Most common- vaginismus: involuntary spasms during attempted penetration
Paraphiliac Disorders
Overview
Typically involves
Sexual interest in an atypical target and/or atypical activity
Long-standing and necessary for sexual enjoyment
Only disordered if associated with at least one
Distress/impairment
Harm or threat to others
Voyeuristic Disorder
Involves intense sexual arousal resulting from observing unsuspecting person who is naked, disrobing, or engaging in sexual activity
Person (18+) has acted on urges or is significantly distressed by fantasies
Exhibtionistic Disorder
Involves intense sexual arousal resulting from exposure of genitals to an unsuspecting person
Person has acted on these urges or is significantly distressed by fantasies
Frotteuristic Disorder
Involves intense sexual arousal resulting from touching or rubbing against a non-consenting person
Person has acted on these urges or is significantly distressed by fantasies
Pedophilic Disorder
Involves intense sexual arousing fantasies, urges, or behaviours involving sexual activity with a prepubescent child
Person has acted on these urges or is significantly distressed by fantasies
Person is 16+ and 5 years older than specific child
Sexual Masochism Disorder
Involve intense sexual arousal resulting from being humiliated, beaten, bound or made to suffer
Person has acted on these urges or is significantly distressed by fantasies
Sexual Sadism Disorder
Involves intense sexual arousal resulting from physical or psychological suffering of another person
Person has acted on these urges with non consenting person or is significantly distressed by fantasies
Fetishistic Disorder
Involves intense sexual arousal resulting from use of nonliving objects or highly specific focus on nongential parts
Person has acted on these urges or is significantly distressed by fantasies
Fetish objects are not cross-dressing or vibrators/dildo
Transvestic Disorder
Involves intense sexual arousal resulting from cross-dressing
Person has acted on these urges or is significantly distressed by fantasies
Specify if: with fetishism or with autogyephilia (arousal based on self as woman)
Gender Dysphoria
In the DSM
Causes
No specific biological contributions identified thus far
However, evidence suggests both genetic and environmental contributions to gender dysphoria
Some research suggests higher levels of testosterone/estrogen at critical points in fetal development may have an impact
Some evidence suggest gender identity is relatively stable after 18 moths to 3 years- but this is unclear
Some gender-nonconformity is very situational
Course
Research is still very new
Studies have found persistence to be 2-39% in males, 12-50% in females
Thus, worth noting that even at the high end- many individuals who experience gender dysphoria or are gender-nonconforming end up identifying with the gender assigned at birth
Those who continue to identify with a different gender tend to be heterosexual while those who do not have gender dysphoria by adolescence tend to be gay, lesbian, or bisexual
Info
Often co-morbid with anxiety, disruptive/impulse-control disorder (e.g. ODD) and depression
Extremely high res of suicide associated with transgender individuals although often improvements after gender- affirming treatment
Autism is more prevalent in individuals with gender dysphoria
SLEEP DISORDERS
Why Sleep?
Too much or too little sleep are common symptoms
Too little sleep can cause other symptoms-e.g. lack of focus, emotional instability
Sleep is one of the first things many therapists ask about
Types of Sleep Disorders
1. Related to when and how much you sleep
e.g. narcolepsy, insomnia
2. Breathing issues during sleep
E.g. sleep apnea
3. Abnormal behavioural, experiential, or physiological events during sleep
E.g. nightmares, sleepwalking
Stages of Sleep
1. Wake
Wakefulness
drowsiness
sleep
2. NREM 1
Light sleep
Person may not think they were asleep
NREM 2
Moderately deep sleep
NREM 3
Very deep sleep
Will be disoriented if woken up
REM sleep
Brain is acting similar to wakefulness- this is when dreaming happens
Typically happens within 90 minutes
Sleeping Too Much or Too Little
Insomnia Disorder
Ongoing issues with poor sleep quantity or quality of sleep
Insomnia is extremely common-can be chronic or just for a period of time
Causes/Contributors
Other psych disorders: depression, anxiety, dementia
Substance use/abuse
Medical/physiological problems (e.g. pain, lack of daytime activity, body temperature)
Variations in light, noise, and temperature
Stress
Social media use
Who (or what) you share a bed with
Hypersomnolence Disorder
Regular, excessive sleepiness- despite sleeping 7+ hours
DSM Criteria…
A. Self reported excessive sleepiness despite main sleep period lasting 7+ hours- 1+ symptom:
1. Recurrent periods of sleep in the same day
2. Unrefreshing main sleep of 9+ hours
3. Difficultly being fully awake after abrupt awakening
B. At least 3x/week at least 3 months
C. Significant distress/impairment
D-F. Not better explained by….
Causes/Contributions
Mostly we don’t know
Some genetic influence
Some evidence exposure to a viral infection can result in this disorder
Often may actually be a different disorder- e.g. insomnia, sleep apnea
Narcolepsy
Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day
DSM Criteria
A. Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping
B. At least one of the following
1. Episodes of cataplexy
a. A sudden bilateral loss of muscle tone
b. In children, or within 6 months of onset, can also just be spontaneous grimace
2. Hypocretin deficiency measures using cerebrospinal fluid
3. Nocturnal sleep involving measurable rapid onset of REM
Associated with…
Sleep Paralysis
Brief periods after waking up where the person cannot move or speak
Hypnagogic Hallucinations
Vivid experiences that begin at the start of sleep and can include visual, touch, hearing, and movement sensations
Parasomnias
NREM Disorders
e.g. sleepwalking or sleep terrors
DSM Criteria
A. Recurrent episodes of incomplete awakening from sleep, accompanied either:
1. Sleepwalking
a. Specify if: sleep-related eating
b. Specify if: sexsomnia
2. Sleep terrors
B. No or little dream imagery is recalled
C. Amnesia for the episode is present
D. Significant distress or impairment
E-F. Not something else….
Stats and Facts
Isolated or infrequent NREM sleep arousal behaviours are very common
10-30% of kids have had at least one episode of sleepwalking
Disorder is much more common in childhood
However, violent or sexual activity during sleep I more common in adults
Highly genetic
More common in girls (childhood) but men (adulthood)
Nightmare Disorder
Multiple episodes of well-remembered, extremely stressful dreams
DSM Criteria
A. Repeated occurrences of extended, extremely dysphoric, well-remembered dreams- usually involve efforts to avoid threats of some type
B. Individually rapidly awakes and becomes alert
C. Clinically significant distress or impairment
D-E. Not something else…
Severity
Mild (Less than one/week)
Moderate (one or more/week)
Severe (nightly episodes)
Stats and Facts
Often begin between ages 3-6 - peak in severity late adolescence/ early adulthood
Most commonly appear in kids with acute or chronic psychological stressors
Treating Sleep
Medical treatment
Very common for insomnia- may be a sleep aid like benzodiazepines, or even a supplement like melatonin
Melatonin can disrupt sleep schedule if taken regularly
For hypersomnolence or narcolepsy- may prescribe a stimulant, like for ADHD
Cataplexy can also be treated with antidepressants which reduce REM sleep
Environmental Treatments
Changing sleep-wake times
Using bright light to readjust internal clock
Controlling light/noise/temperature for sleep
Harder to force yourself to sleep when you aren’t tired than waking up when you are tired
Psychological Treatment
Cognitive: e.g. supporting changing beliefs about sleep
Mindfulness: e.g. promoting relaxation to calm down for sleep
Psycho-education: sleep hygiene
Progressive Muscle relaxation
MENTAL HEALTH AND LAW
Civil Commitment
Overview
An attempt to balance individual rights and public rights (e.g. right to safety)
Falls under provincial/territorial laws
Generally commitment is allowed when:
a. Individuals have a mental disorder AND
b. Are a danger to themselves or others AND
c. Are in need of some kin of treatment
Uses parens patriae power-
Government acts as parent, in best interest of person
Strict or Not?
Strict Requirements
e.g. Ontario: mental Disorder likely to result in serious bodily harm to self or others
Pro: more protective of individual freedoms
Con: people only get help if they are a threat
Broad Requirements
E.g. BC: hospitjlizariopn to prevent substantial deterioration
Pro: support is given before things get worse
Con: right to refuse treatment is taken away
Admission for Treatment
Individuals have the right to request admission to a mental health facility
If a person does not ask for help, but commitment may occur
Civil commitment typically requires 1-2 physicians or psychiatrists to agree
Compulsory Community Treatment
If a person has previous inpatient treatment, they may be committed to compulsory community treatment (CCT)
CT tends to be a gentler, less restrictive environment
Defining Mental Illness
DSM diagnosis does not automatically mean a person has a legal mental illness
Provincial recognition of mental illness varies widely from more functional definitions (e.g. distress/impairment) to more disease/disability definitions
Dangerousness
Evidence suggest increased rate of violence is extremely small and largely related to being high in anger, recent stressors, and substance use
Inmates with serious mental illness are less likely to commit violent crime on release compared to others
Can we Assess Dangerousness?
Yes and no
Psychiatrists and psychologists are not good at assessing dangerousness without proper methodology
However, rating scales based on evidence-based predictor of violence and/or suicide risk help significantly
Best practice: professional and tool
Deinstitutionalization and Homelessness
Move towards closure of psychiatric hospitals in favour of more community treatments
However, at least in the short-term, community treatments have not been sufficient to fill the gap
This has led to significant rise in homelessness
Criminal Commitment
Overview
When people are held because:
They have been accused of committing a crime and are being detained until they are mentally fit to stand trail or
They have been found not criminally responsible on account of a mental disorder (NCRMD)
NCRMD
Has typically roughly been understood as not being responsible if:
A person does not know what they are doing or
Does not know what they are doing wrong
These people are less likely to reoffend on release
Issues with NCRMD
Often believed to be “beating the system”- avoiding jail time
In actuality, NCRMD often results in longer institutionalization compared to those convicted of a crime
Rarely used..
Fitness to Stand Trial
To be tried for a criminal offence a person must be able to:
Understand the charges and
Assist with their defence
When a person does not meet these criteria, they often are detained in a hospital-although they can also be ordered to receive treatment or conditionally discharged
Who Assesses Fitness?
Typically psychiatrists
However, forensic psychologists may be a better fir
Expanding the law foe more mental health professionals to perform fitness assessments would also reduce wait times
Expert Witnesses
Mental health professionals may be expert witnesses for reasons like:
Assessing dangerousness
Assigning a diagnosis
Bolstering or refuting mental claims
However, personal beliefs and biases likely play a role
Rights and Responsibilities
Treatment Rights
Right to treatment
Right to treatment in least restrictive setting possible
Right ti refuse treatment
Research Rights
Informed consent
Clear on risks and benefits of participation
Distribution of burden of research across the population
Eliminating deception if possible-debriefing
The Code of Ethics
Developed by the Canadian Psychological Association
Applies to more than Clinical Psychology
Goes beyond “do no harm”
Respect for the dignity of persons
Responsible caring
Integrity in relationships
Responsibility to society
Boundaries
Psychologists must avoid conflicts of interest (or at least be clear about them)
Must avoid dual relationships where possible (e.g. providing therapy to someone you know outside of therapy context)
Must avoid ay kind of intimate relationships (especially romantic/sexual) for at least a significant period post-services
Limits to Competence
Psychologists typically register with specific competencies
Psychologists must practice within their competence
While some limits are clear others require more judgement- e.g., treating someone from a culture you do not have experience with
Duty to Warn and Protect
Protecting others from credible risk of harm by client- e.g. if a client is planning to physically hurt someone
Preventing client from serious risk of harm to self (e..g suicide attempt)
May involve repairing to the pole, directly warning an intended victim, or informing a family member who can keep an eye on things
Duty to Report
Psychologists (and everyone) have a duty to report any suspected cases of child abuse
Ideally, this is done with client’s knowledge and involves the client when possible
Typically a call to Family and Children’s Services- rarely police
Timing can vary
ADHD AND AUTISM
Intro to Neurodiversity
Individuals differences in brain functioning regarded as normal variations within the human population
The concept that differences in brain functioning within the human population are normal, that [neurodivergent] brain functioning should not be stigmatized
Why ADHD & Autism?
Not exactly mental health
But regularly diagnosed and supported by psychologists
Significantly impact on wellbeing- relationships, academics, etc.
One of the most common referrals
In Real Life…
Not necessarily that brains working wrong- but they tend to not match up with the way society is structured
Masking
Most commonly discussed in autism
But happens in ADHD as well
Refers to attempting to cover up autistic/ADHD traits and appear neurotypical
Tends to be exhausting and can promote burnout, unhappiness, and suicidal thoughts
ADHD
“Attention-Deficit Hyperactivity Disorder
Typically involves inattention hyperactivity/impulsivity, or both
‘Deficit’ is a bit of a misnomer-not necessarily lack of attention, but difficulty regulating attention
In the DSM…
A. A persistent pattern of (1) inattention and/or (2) hyperactivity- impulsivity that infers with functioning/development
B. Several symptoms present before age 12
C. Several symptoms in 2+ settings
D. Symptoms cleat interfere with functioning
e. Not better explained by another disorder
Inattention
6+ symptomS
Presently for at least 6 months
Inconsistent with developmental level
Negative impact on social/academic/work
(2) Hyperactivity & Impulsivity
6+ symptoms
Presently for at least 6 months
Inconsistent with developmental level
Negative impact on social/academic/work
Common ADHD Myths
ADHD is a childhood disorder
people in fact do not grow out of ADHD
ADHD is wildly over diagnoses
ADHD medication turns children into zombies
there is no one size fits all medications it typically takes 3 medication before they find the right one
If someone can focus on some things, they obviously don’t have ADHD
People with ADHD are just lazy
Stats & Facts
5% of children -higher in boys
Perhaps because girls are less likely to present with hyperactivity and therefore not as big of an issue for the people around them
Highly influenced by genetics
Ca contribute to less education, poorer employment, substance abuse risky behaviours
Often co-morbid with behaviour disorder
Possible Causes
As noted, highly influenced by genetics
Appears to be related to dopamine
May involve some physical brain differences
Little to no evidence for relationship to food colourings /additives
May be related to sleep issues?
Medications
Most commonly treated using stimulants (e.g. Ritalin) which increase dopamine
Choosing a stimulant is very much trial and error -few clear predictors
Only clear predictor is if a family member was on a stimulant that worked for them
Stimulants can be addictive and harmful- for people who do not need them
One of the safest, best researched treatments
Can make it easier to function within a neurotypical system
Stays in the bay for 12 hours or less- and it is not harmful to take days off
Results show up in a day unlike SSRIs which typically take a 12 days
Same people choose to only take medication on school/work days
Other Supports
May involved behavioural strategies for child/family (e.g. routines, visual checklist, reward systems..)
May involve support in social skills
May involve academic support (e.g. tutoring)
May involve treatment of co-morbid mental health issues
Autism Spectrum Disorder (ASD)
Characterized by impairments in social communication and interaction and restricted repetitive patterns of behaviour, interest, or activities
In the DSM..
A. Persistent deficits in social communication and interaction across multiple contexts (3/3/ symptoms)
B. Restricted repetitive patterns of behaviour, interests, or activities (2+/4 symptoms
C. Symptoms present from early development
D. Clinically significant impairment across areas
E. Not better explained by something else
Specify..
Level 1: requiring support
Level 2: requiring substantial support
Level 3: requiring very substantial support
Stats & Facts
Current DSM collapsed other disorders into ASD (e.g. Asperger’s Syndrome)
More common diagnosis in recent years - multiple possible reasons
Diagnosed far more in males (4.5 to 1)
Autism and IQ
Austin’s individuals are routinely stereotyped as either intellectually disabled or geniuses
In reality, autistic people have diverse IQs
Neatly 30% have intellectual disability
Roughly 1/3 have specific ‘savant’ skills- typically looks like outstanding memory related to an area of interest
Common myths about autism
Autistic people don’t have emotions
People with autism are much more likely to freeze rather than fight or flee
Emotional responses may not match what is typical
A person can’t be autistic if they are verbal
Autistic people don’t need or want friends
Autistic people can never be independent
If autism is not visible than it is not a big deal
Support
Applied Behaviour Analysis (ABA)
Widely used and recommended intervention for autism
Used to promote language, communication, and social skills- and decrease ‘problem’ behaviours (often self soothing behaviours)
Many autistic people consider ABA to be abuse that teaches masking instead of coping
Recent study found that autistic adults who had ABA as children were 86% more likely to meet PTSD criteria
Instead..
Speech-language support
Social skills training or groups
Family supports (setting goof routines, good communication, etc)
Bri’s Favs
Run with special tress to promote social connections (e.g. love animals? Volunteer at the humane society)
Frame learning social skills as the option to access the neurotypical playbook-not as something that should be done
LEARNING AND INTELLIGENCE
Psychology in Schools
School Psychologists
Typically complete a Master’s degree or PhD in School or education Psychology
Are similarly trained and have a similar job description to Clinical Psychologists but within the school system
Often includes assessments, short-term individual support, and broad school support
Individual Education Plans (IEP)
Special education plan, accommodations, and services for a student
Theoretically, anyone can have an IEP- but easier if ‘exceptional
Created by school, in cooperation with family and others
Cognitive Abilities
Thinking, reasoning and problem solving
Necessary for building academic skills
Typically stable across the lifespan
Academic Skills
Reading, writing, and math
Develop across the lifespan (with education)
Rely on underlying cognitive abilities
Specific Learning Disorders
Learning Disorder/ Learning Disability
Rough definition: when academic achievement does not match up with what is expected based on underlying cognitive abilities
More specific: according to the Ontario Psychological Association, must also identify a clear reason why the mismatch is happening
Types of Learning Disabilities
Reading (dyslexia)
e.g. issues with word reading or understanding what is read
2. Writing (dysgraphia)
e.g. issues with spelling, grammar, or organizing written ideas
3. Math (dyscalculia)
e.g. issues with number sense/ number facts or math reasoning
Involves
Challenges learning/ using specific academic skills
Academic output substantially below expected
Begin during school years, but may not be fully manifest until demands exceed capacity (e.g. under times conditions, heavy workloads, etc.)
Not better accounted for by intellectual disability, visual or auditory issues, lack of proficiency in language of instruction, etc.
Stats ad Facts
5-15% of youth across ages and cults
8.4% estimated I Canada between the age of 5-17
10.6% of males, 6.1% of females
Reading difficulties are the most common
LDs especially without support and poor employment rates
Can also be related to development of other meant health problems later
Possible Causes
Reading disorders seem to have a significant genetic component
Likely involves structural and functional brain differences
Deeply impacted by level of support received, socioeconomic status, etc.
Treatment
Tutoring or specialized school programs
Accommodations for testing
Cooperation between home and school
Intellectual Developmental Disorder (Intellectual Disability)
Significantly below average intelligence (cognitive abilities)
Significantly below average adaptive functioning (day-to-day abilities)
DSM-IV still used the term ‘mental retardation’
Experiences of ID are extremely diverse
In The DSM..
Intellectual and adaptive functioning deficits in conceptual, social, and practical domains
A) deficits in intellectual functioning, confirmed by clinical assessment and standardized testing
B) deficients in adaptive functioning resulting in failure to meet standards for personal independence and social responsibility
C) onset during the developmental period
Cut-Offs and Stats
Important that it is both cognitive and adaptives- helps make sure ID is not diagnosed just due to language issues
Roughly 1-3 percent of population have ID- with 90% of those falling in the mild range
Mild (IQ 50/55- 70)
Moderate (IQ 20/25- 35/40)
Profound (IQ below 20/25)
70/75 is two standard deviations below the mean
Diversity in functioning
Many people I the mild to moderate ID range can live independently or with only a bit of superversion/support
While institutions exist and can be a good fit for some, increasingly folks are able to have supports to live with family or on their own
Possible Causes
Many known causes exist:
Environment (e.g. abuse or neglect)
Parental (e.g exposure to drugs or disease during pregnancy)
Perinatal (e.g. difficulties during labour and delivery)
Postnatal (e.g. infant infection or head injury)
Genetics (e.g. down syndrome)
However, nearly 30% have no identifiable cause
Supports for ID
Intellectual disability typically qualifies individuals for the Ontario Disability Support Program (ODSP) meaning they can receive monthly income supplest, as well ax extra health coverage
Many programs available for supporting individuals and families-including a college program at Conestoga that prepares people for independence
Treatment and Support
Some educational accommodation and support- focus on functional academics
Support in developing adaptive skills for use in daily independent life
Support in making social connections and engaging meaningfully in community
BEHAVIOUR DISORDERS
Oppositional Defiant Disorder (ODD)
Generally looks like being irritable, argumentative, ad defiant
Most often begins in preschool
DSM Criteria
A) a pattern of angry/irritable moods augmentative/ defiant behaviours or vindictiveness
Lasting at least 6 months
Evidenced by at least 4 symptoms
Exhibited during interaction with at least one individual who is not a sibling
B) distress or impairment
C) not psychosis, substance use, or mood disorder
Symptoms
Anger/ Irritability
1. Often loses temper
2. Ofter touchy or easily annoyed
3. Often angry and resentful
Argumentative / Defiant Behaviour
1. Often argues with authrority figures
2. Often actively desires authority or refuses to comply with rules
3. Often deliberately annoys others
4. Often blames others for behaviour
Vindictiveness
1. Spiteful/vindictive 2+ times in the last 6 months
Specifiers
Mild: symptoms only in one setting (typically home)
Moderate: symptoms in two settings
Severe: Symptoms in three or more settings
Stats and Facts
Often co-morbid with ADHD and conduct disorder
Often precedes development of childhood-onset conduct disorder
Risk factors: poor emotion regulation, reciprocal relationships with harsh and inconsistent parenting, genetics don’t distinguish between ODD/CD
More likely to be bullied and to be a bully
Controversy
Lost of overlap with symptoms of other disorders
Not following directions? ADHD
Struggling with authority if instructions don’t ‘make sense’? Autism
AND many symptoms are a reasonable reaction to poor parenting/difficult home life
Should we Diagnose?
Pros
Any diagnosis can make services more accessible
May not be captured by another diagnosis
Can validate parents
Cons
Doesn’t explain the behaviours at all
Generally fails to consider environment
Labels child as ‘bad’
No clear treatment
In My Experience
Have yet to meet a child where the issue is truly ‘defiance’
Paediatrician-diagnosed ODD?
Intellectual Disability and/or ADHD x primary caregiver depression
Parents feel more validated when a good explanation for challenges with their kid is provided
Treatment
Parenting support
Especially making sure child receives attention for positive behaviour
Addressing co-morbid issues
ADHD, mental health
Parent mental health
Poverty
Conduct Disorder (CD)
Generally looks like a lack of care for others’ basic rights, and for societal norms and rules (e.g. laws)
DSM Criteria
A) a repetitive, persistent of behaviour on which the rights of others and/or societal norms/rules are violated:
At least 3/5 criteria in the past 12 months
At least 1 criterion in the past 6 months
B) clinically significant infant impairment in functioning
C) if 18 or older, criteria not met for antisocial personality disorder
Symptoms
Aversion to People and Animals
1. Often bullies, threatens, or intimidates others
2.Often initiates physical fights
3. Has used weapon that can cause serious harm
4. Has been physically cruel to people
5. Has been physically cured to animals
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity
Destruction of Property
1. Set fire with intent to cause serious damage
2. Deliberately destroyed others’ property
Deceitfulness or Theft
1. Has broken into house, building or car
2. Often ‘cos’ others
3. Stolen costly items without confrontation
Serious Rule Violations
1. Often stays out at night before age 13
2. Has run away from home at least twice (or once if long)
3. Often truant (before 13)
Specify: Onset ad Severity
Childhood onset type: 1+ symptom by age 10
Adolescent-onset type: 0 symptoms before age 10
Unspecified-onset: unclear when symptoms began
Mild: few (if any) symptoms beyond reuired- problems cause minor harm
Moderate: between ‘mild’ and ‘severe’
Severe: many symptom s beyond required and/or issues cause considerable harm to others
Specify if..
With limited prosocial emotions
2+ characteristics, 12+ months, multiple settings
Lack of remorse or guilt
Callous- lack of empathy
Unconcerned about performance
Shallow or deficient affect
Stats ad Facts
Childhood onset typically is more persistent, is often preceded by OCD, involves concurrent ADHD, and involves more aggression towards others
Lifetime prevalence (US): 12% (men), 7% (women)
Usually less serious symptoms begin first- if more serious behaviours develop early- this often means a worse prognosis (may develop into anti-social disorder)
Risk Factors
Difficult infant
Below-average IQ- epically if poor verbal skills
Neglect, harsh discipline, abuse
Genetics: more common when parents have server alcohol use, mood disorders, schizophrenia, ADHD, or conduct disorders r
More likely to persist if: childhood-onset, limited prosocial emotions, ADHD, substance abuse
Gender Differences
Boys/Men
Fighting
Stealing
Vandalism
School discipline
More physical aggression
Girls/Women
Lying
Truancy
Running away
Prostitution
Less physical aggression
Treatment
Most effective earlier on
Treatment ideally is comprehensive- addressing family issues, individual issues, and broad mental health
Often includes parenting support
Often includes individuals therapy (e.g. CBT)
May involve medication to manage other diagnoses or an antipsychotic to decrease aggression
SEXUALITY IN THE DSM
In previous DSM homosexuality was categorized as sexual deviations and sociopathic personality disturbances
DSM-5-TR
Transvestic Disorder
Listed under paraphilia
“Cross-dressing” -> arousal
Distress/impairment
Gender Dysphoria
Mismatch between experience/expressed gender
Distress impairment
Overview
Tend to feel much more medical and much less like a psychological disorder
Sexual dysfunction fall into four categories
Arousal
Pain
Desire
Orgasm
Desire
Male hypoactive sexual desire disorder
6+ months of decadent or absent sexual thoughts/fantasies and desire for sexual activity
Clinically significant distress
Not better explained by another issue
Female sexual interest/arousal disorder
6+ months- but symptoms more specific
Clinically significant distress
Not better explained by another issue
What About Asexuality?
Generally involves some difference (lack) of sexual interest/attraction to others
Often involves low sexual desire
Low/absent desire does not cause distress/impairment
Arousal
Erectile Disorder
6+ months with erectile dysfunction of some kind occurring in 75-10% of sexual activities (can be general or situational)
e.g. obtaining erection, maintaining erection or reduced rigidity
Clinically significant distress
Not better explained by another issue
Orgasm
Delayed ejaculation
Marked by delay, infrequency or absence of ejaculation
Premature (Early) Ejaculation
Within 1 minute of vaginal penetration before the person wishes it
Female Orgasmic Disorder
Delay, infrequency or absence of orgasm- or reduced intensity of orgasmic sensations
Pain
Genito-Pelvic Pain/Penetration Disorder
Difficultly or pain during intercourse/attempts at penetration
Fear or anxiety about pain in anticipation of during, o as a result of vaginal penetration
Tensing/tightening of pelvic floor muscles during attempted penetration
Most common- vaginismus: involuntary spasms during attempted penetration
Paraphiliac Disorders
Overview
Typically involves
Sexual interest in an atypical target and/or atypical activity
Long-standing and necessary for sexual enjoyment
Only disordered if associated with at least one
Distress/impairment
Harm or threat to others
Voyeuristic Disorder
Involves intense sexual arousal resulting from observing unsuspecting person who is naked, disrobing, or engaging in sexual activity
Person (18+) has acted on urges or is significantly distressed by fantasies
Exhibtionistic Disorder
Involves intense sexual arousal resulting from exposure of genitals to an unsuspecting person
Person has acted on these urges or is significantly distressed by fantasies
Frotteuristic Disorder
Involves intense sexual arousal resulting from touching or rubbing against a non-consenting person
Person has acted on these urges or is significantly distressed by fantasies
Pedophilic Disorder
Involves intense sexual arousing fantasies, urges, or behaviours involving sexual activity with a prepubescent child
Person has acted on these urges or is significantly distressed by fantasies
Person is 16+ and 5 years older than specific child
Sexual Masochism Disorder
Involve intense sexual arousal resulting from being humiliated, beaten, bound or made to suffer
Person has acted on these urges or is significantly distressed by fantasies
Sexual Sadism Disorder
Involves intense sexual arousal resulting from physical or psychological suffering of another person
Person has acted on these urges with non consenting person or is significantly distressed by fantasies
Fetishistic Disorder
Involves intense sexual arousal resulting from use of nonliving objects or highly specific focus on nongential parts
Person has acted on these urges or is significantly distressed by fantasies
Fetish objects are not cross-dressing or vibrators/dildo
Transvestic Disorder
Involves intense sexual arousal resulting from cross-dressing
Person has acted on these urges or is significantly distressed by fantasies
Specify if: with fetishism or with autogyephilia (arousal based on self as woman)
Gender Dysphoria
In the DSM
Causes
No specific biological contributions identified thus far
However, evidence suggests both genetic and environmental contributions to gender dysphoria
Some research suggests higher levels of testosterone/estrogen at critical points in fetal development may have an impact
Some evidence suggest gender identity is relatively stable after 18 moths to 3 years- but this is unclear
Some gender-nonconformity is very situational
Course
Research is still very new
Studies have found persistence to be 2-39% in males, 12-50% in females
Thus, worth noting that even at the high end- many individuals who experience gender dysphoria or are gender-nonconforming end up identifying with the gender assigned at birth
Those who continue to identify with a different gender tend to be heterosexual while those who do not have gender dysphoria by adolescence tend to be gay, lesbian, or bisexual
Info
Often co-morbid with anxiety, disruptive/impulse-control disorder (e.g. ODD) and depression
Extremely high res of suicide associated with transgender individuals although often improvements after gender- affirming treatment
Autism is more prevalent in individuals with gender dysphoria
SLEEP DISORDERS
Why Sleep?
Too much or too little sleep are common symptoms
Too little sleep can cause other symptoms-e.g. lack of focus, emotional instability
Sleep is one of the first things many therapists ask about
Types of Sleep Disorders
1. Related to when and how much you sleep
e.g. narcolepsy, insomnia
2. Breathing issues during sleep
E.g. sleep apnea
3. Abnormal behavioural, experiential, or physiological events during sleep
E.g. nightmares, sleepwalking
Stages of Sleep
1. Wake
Wakefulness
drowsiness
sleep
2. NREM 1
Light sleep
Person may not think they were asleep
NREM 2
Moderately deep sleep
NREM 3
Very deep sleep
Will be disoriented if woken up
REM sleep
Brain is acting similar to wakefulness- this is when dreaming happens
Typically happens within 90 minutes
Sleeping Too Much or Too Little
Insomnia Disorder
Ongoing issues with poor sleep quantity or quality of sleep
Insomnia is extremely common-can be chronic or just for a period of time
Causes/Contributors
Other psych disorders: depression, anxiety, dementia
Substance use/abuse
Medical/physiological problems (e.g. pain, lack of daytime activity, body temperature)
Variations in light, noise, and temperature
Stress
Social media use
Who (or what) you share a bed with
Hypersomnolence Disorder
Regular, excessive sleepiness- despite sleeping 7+ hours
DSM Criteria…
A. Self reported excessive sleepiness despite main sleep period lasting 7+ hours- 1+ symptom:
1. Recurrent periods of sleep in the same day
2. Unrefreshing main sleep of 9+ hours
3. Difficultly being fully awake after abrupt awakening
B. At least 3x/week at least 3 months
C. Significant distress/impairment
D-F. Not better explained by….
Causes/Contributions
Mostly we don’t know
Some genetic influence
Some evidence exposure to a viral infection can result in this disorder
Often may actually be a different disorder- e.g. insomnia, sleep apnea
Narcolepsy
Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day
DSM Criteria
A. Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping
B. At least one of the following
1. Episodes of cataplexy
a. A sudden bilateral loss of muscle tone
b. In children, or within 6 months of onset, can also just be spontaneous grimace
2. Hypocretin deficiency measures using cerebrospinal fluid
3. Nocturnal sleep involving measurable rapid onset of REM
Associated with…
Sleep Paralysis
Brief periods after waking up where the person cannot move or speak
Hypnagogic Hallucinations
Vivid experiences that begin at the start of sleep and can include visual, touch, hearing, and movement sensations
Parasomnias
NREM Disorders
e.g. sleepwalking or sleep terrors
DSM Criteria
A. Recurrent episodes of incomplete awakening from sleep, accompanied either:
1. Sleepwalking
a. Specify if: sleep-related eating
b. Specify if: sexsomnia
2. Sleep terrors
B. No or little dream imagery is recalled
C. Amnesia for the episode is present
D. Significant distress or impairment
E-F. Not something else….
Stats and Facts
Isolated or infrequent NREM sleep arousal behaviours are very common
10-30% of kids have had at least one episode of sleepwalking
Disorder is much more common in childhood
However, violent or sexual activity during sleep I more common in adults
Highly genetic
More common in girls (childhood) but men (adulthood)
Nightmare Disorder
Multiple episodes of well-remembered, extremely stressful dreams
DSM Criteria
A. Repeated occurrences of extended, extremely dysphoric, well-remembered dreams- usually involve efforts to avoid threats of some type
B. Individually rapidly awakes and becomes alert
C. Clinically significant distress or impairment
D-E. Not something else…
Severity
Mild (Less than one/week)
Moderate (one or more/week)
Severe (nightly episodes)
Stats and Facts
Often begin between ages 3-6 - peak in severity late adolescence/ early adulthood
Most commonly appear in kids with acute or chronic psychological stressors
Treating Sleep
Medical treatment
Very common for insomnia- may be a sleep aid like benzodiazepines, or even a supplement like melatonin
Melatonin can disrupt sleep schedule if taken regularly
For hypersomnolence or narcolepsy- may prescribe a stimulant, like for ADHD
Cataplexy can also be treated with antidepressants which reduce REM sleep
Environmental Treatments
Changing sleep-wake times
Using bright light to readjust internal clock
Controlling light/noise/temperature for sleep
Harder to force yourself to sleep when you aren’t tired than waking up when you are tired
Psychological Treatment
Cognitive: e.g. supporting changing beliefs about sleep
Mindfulness: e.g. promoting relaxation to calm down for sleep
Psycho-education: sleep hygiene
Progressive Muscle relaxation
MENTAL HEALTH AND LAW
Civil Commitment
Overview
An attempt to balance individual rights and public rights (e.g. right to safety)
Falls under provincial/territorial laws
Generally commitment is allowed when:
a. Individuals have a mental disorder AND
b. Are a danger to themselves or others AND
c. Are in need of some kin of treatment
Uses parens patriae power-
Government acts as parent, in best interest of person
Strict or Not?
Strict Requirements
e.g. Ontario: mental Disorder likely to result in serious bodily harm to self or others
Pro: more protective of individual freedoms
Con: people only get help if they are a threat
Broad Requirements
E.g. BC: hospitjlizariopn to prevent substantial deterioration
Pro: support is given before things get worse
Con: right to refuse treatment is taken away
Admission for Treatment
Individuals have the right to request admission to a mental health facility
If a person does not ask for help, but commitment may occur
Civil commitment typically requires 1-2 physicians or psychiatrists to agree
Compulsory Community Treatment
If a person has previous inpatient treatment, they may be committed to compulsory community treatment (CCT)
CT tends to be a gentler, less restrictive environment
Defining Mental Illness
DSM diagnosis does not automatically mean a person has a legal mental illness
Provincial recognition of mental illness varies widely from more functional definitions (e.g. distress/impairment) to more disease/disability definitions
Dangerousness
Evidence suggest increased rate of violence is extremely small and largely related to being high in anger, recent stressors, and substance use
Inmates with serious mental illness are less likely to commit violent crime on release compared to others
Can we Assess Dangerousness?
Yes and no
Psychiatrists and psychologists are not good at assessing dangerousness without proper methodology
However, rating scales based on evidence-based predictor of violence and/or suicide risk help significantly
Best practice: professional and tool
Deinstitutionalization and Homelessness
Move towards closure of psychiatric hospitals in favour of more community treatments
However, at least in the short-term, community treatments have not been sufficient to fill the gap
This has led to significant rise in homelessness
Criminal Commitment
Overview
When people are held because:
They have been accused of committing a crime and are being detained until they are mentally fit to stand trail or
They have been found not criminally responsible on account of a mental disorder (NCRMD)
NCRMD
Has typically roughly been understood as not being responsible if:
A person does not know what they are doing or
Does not know what they are doing wrong
These people are less likely to reoffend on release
Issues with NCRMD
Often believed to be “beating the system”- avoiding jail time
In actuality, NCRMD often results in longer institutionalization compared to those convicted of a crime
Rarely used..
Fitness to Stand Trial
To be tried for a criminal offence a person must be able to:
Understand the charges and
Assist with their defence
When a person does not meet these criteria, they often are detained in a hospital-although they can also be ordered to receive treatment or conditionally discharged
Who Assesses Fitness?
Typically psychiatrists
However, forensic psychologists may be a better fir
Expanding the law foe more mental health professionals to perform fitness assessments would also reduce wait times
Expert Witnesses
Mental health professionals may be expert witnesses for reasons like:
Assessing dangerousness
Assigning a diagnosis
Bolstering or refuting mental claims
However, personal beliefs and biases likely play a role
Rights and Responsibilities
Treatment Rights
Right to treatment
Right to treatment in least restrictive setting possible
Right ti refuse treatment
Research Rights
Informed consent
Clear on risks and benefits of participation
Distribution of burden of research across the population
Eliminating deception if possible-debriefing
The Code of Ethics
Developed by the Canadian Psychological Association
Applies to more than Clinical Psychology
Goes beyond “do no harm”
Respect for the dignity of persons
Responsible caring
Integrity in relationships
Responsibility to society
Boundaries
Psychologists must avoid conflicts of interest (or at least be clear about them)
Must avoid dual relationships where possible (e.g. providing therapy to someone you know outside of therapy context)
Must avoid ay kind of intimate relationships (especially romantic/sexual) for at least a significant period post-services
Limits to Competence
Psychologists typically register with specific competencies
Psychologists must practice within their competence
While some limits are clear others require more judgement- e.g., treating someone from a culture you do not have experience with
Duty to Warn and Protect
Protecting others from credible risk of harm by client- e.g. if a client is planning to physically hurt someone
Preventing client from serious risk of harm to self (e..g suicide attempt)
May involve repairing to the pole, directly warning an intended victim, or informing a family member who can keep an eye on things
Duty to Report
Psychologists (and everyone) have a duty to report any suspected cases of child abuse
Ideally, this is done with client’s knowledge and involves the client when possible
Typically a call to Family and Children’s Services- rarely police
Timing can vary
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