▫ ▫

Disorders in this lecture are all characterized by

Disruptive, impulsive and anti social
• behaviours seen strongly violate many social
norms

Sacrifice their well-being for others

Highlights the fact that people vary in terms of
Don’t think social norms apply to them, can how cooperative they are in social norms and how
be cruel to others to help reach own goals much empathy they show to other people
• most individuals are law abiding and show
compassion, but also will break rules and can
be unkind when stressed

• Kids with oppositional defiant disorder are chronically irritable and angry, very vindictive and blame others
• Kids with conduct disorder act more antisocial and aggressive and cruel to people and animals (vandalism, theft, destroy property)
• Intermittent explosive disorder: outburst of verbal or physical aggression which is out of proportion for the situation
• Anti-social personality disorder: chronic disregard for rights of other people and these people will be cruel, aggressive and manipulative to others in order to get what
they want
CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER:
• most people say yes to hit, lie or steal,
• Many with conduct disorder would say yes to pulled a gun or knife on someone, forced someone into sexual activity, setting a fire to damage property
• Kids have chronic pattern with being unconcerned with the fundamental rights of others
Conduct Disorder
• Individuals with Conduct Disorder behave in ways that violate:
The basic rights of others
The rules of society
• often behave destructively, defiantly and cruel ways
These behaviors fall into 4 categories:
• 1) Aggression towards people and animals
• 2) Destruction of property
• 3) Deceit or theft
• 4) Serious violations of rules
• hard and challenging to manage when it persists throughout childhood and strong predictor of anti social personality disorder and violent and severe criminal behaviour
• Conduct disorder develops in childhood or adolescence, can start before age 10
These individuals are likely to experience:
• High risk for legal issues
• Poor physical health
• Comorbid psychiatric conditions
• prevalence is around 2-5% among children aged 5-12, and 5-9% of children aged 13-18
• Individuals with early onset conduct disorder are at a higher risk for persistent challenges
• Males are more likely to develop but gender difference shifts among lifespan, during adolescence, both genders tend to show high rates but males are still 2-3x more
likely to be diagnosed
• Lifetime prevalence of 12% in males and 7% in females
• Prevalence is very similar across countries
• Childhood-onset conduct disorder:
Begins before the age of 10
These individuals have behavioral issues in early elementary school that worsen with age
• more likely than adolescent-onset to engage in antisocial behaviour into adulthood
• Adolescent-onset conduct disorder:
Begins at 10 years of age or later
• around 50% of individuals diagnosed with childhood-onset engage in criminal behaviour, around 75-85% of them are chronically unemployed and have unstable personal
relationships which are often characterized by abuse
• around 35-40% are diagnosed with antisocial personality disorder
• individuals with early onset conduct disorder are at higher risk for lower quality of life, poor mental health, substance abuse, unemployment and family relationship issues
• Life-course-persistent antisocial behavior: is more likely among those with childhood-onset conduct disorder

• The DSM-5-TR includes the specifier “with limited prosocial emotions” which is applied to. children with conduct disorder who show at least 2 of the following (in multiple
relationships and settings):
Lack of remorse or guilt for actions
Lack of empathy for others
Lack of concern about performance at school, work or other important activity
Shallow or deficient emotions
• children with callas, unemotional presentations tend to be less reactive to signs of distress in other people and less sensitive to punishment, fearless and thrill-seeking (all
these align with psychopathy)
 ▫ ▫
OPPOSITIONAL DEFIANT DISORDER (ODD):
• Chronic misbehavior which is less severe than Conduct Disorder
These individuals are not aggressive towards people or animals, they do not destroy property and they do not show patterns of deception and theft
• These individuals tend to be:
Negativistic
Defiant
Disobedient
hostile
• hostility and defiance might be limited to one setting (home, school), also individuals with ODD show impaired social functioning
• Symptoms tend to begin during the toddler and preschool years, but because behaviours are so common among kids, concerns have been raised that the diagnoses of
ODD might pathologize typical behaviours in young kids, many kids will outgrow behaviours by late childhood or early adolescence
• Children with ODD are significantly more likely than those without ODD to develop:
Conduct disorder
Substance use disorders
Mood and anxiety disorders
• Males are 3x more likely than females to be diagnosed with Conduct Disorder or ODD
> this persists across cultures but gender difference narrows in adolescence
> males are 10-15x more likely to display life course persistent anti social behaviours (biological and psychosocial causes are more often present in males)
> males are more physically aggressive and cause more attention
> female aggression is more indirect and verbal instead of physical (females will more commonly engage in relational aggression like gossiping, excluding others and colluding
with others to ruin social status of others)
• Some researchers argue that antisocial behavior is equally common across the sexes but manifests in different ways
> males and females engage in stealing, lying and substance abuse to the same extent
> females show high rates of depression, anxiety, marital issues, criminal activities and unplanned pregnancies as adults

CONTRIBUTORS TO CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER:

• Biological Factors:
Children with conduct disorder are more likely to have parents who have a history of antisocial behavior
Genes seem to play an especially strong role in childhood-onset conduct disorder and ODD (particularly genes that are important in regulating dopamine, serotonin and
norepinephrine)
One gene strongly implicated is the monoamine oxidase A (MAOA) gene
> encodes an enzyme that is responsible for metabolizing serotonin, dopamine and norepinephrine and seems to be strongly implicated in both disorders
> kids with abnormal variant of the MAOA gene with combination of childhood maltreatment tend to be extremely high risk for developing aggression in general, conduct
disorders more specifically
• Biological Factors:
Children with conduct disorder may have neurological challenges which contribute to their behaviors
• These individuals tend to have high rates of comorbid ADHD
> neurological deficits tend to be in systems responsible for controlling behaviour, processing reward, punishment and planning
Abnormalities in neural activity in:
• Prefrontal cortex (responding to emotional stimuli)
• amygdala (less activity in responding to emotional stimuli)
> kids with conduct disorder might not process emotional cues in the same way healthy children do, tend to be hypersensitive to negative emotions and these might
catalyze hot tempered responses and decreased sensitivity to sad or frightened facial expressions which may impair empathy
> emotional recognition is a complex process that requires working memory and attention, individuals with both ODD and conduct disorder tend to have challenges in visual
spatial working memory, executive functioning, and these might underlie the challenges in emotional recognition

• Biological Factors:
Exposure to neurotoxins and drugs prenatally or during preschool years may impact neurological deficits
> males whose mothers smoked during pregnancy are 2.6x more likely to show oppositional behaviour during childhood and these kids higher risk for aggressive and
antisocial behaviour later
Serotonin is associated with the regulation of aggression and may be impacted among males who have a tendency towards aggression
> disrupted serotonin production is associated with aggressive and impulsive behaviour, study found that young males with high blood serotonin levels were more likely to
commit violent crime
Children with conduct disorder tend to have:
• a slower heart rate both at rest and stressor
• abnormal cortisol levels
> because these individuals tend to be less physically aroused when exposed to stressors, kids with conduct disorder might take more risks and tend to have more
difficulty learning from punishments
> kids with conduct disorder with comorbid anxiety can show more instead of less physiological activity
> testosterone levels might play a role, one study among 9-15 year old boys, higher testosterone levels were associated with more conduct disorder symptoms among
boys whose peers were involved in deviant behaviours
 ▫
CONTRIBUTORS TO CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER CONT’D:
• Social Factors:
Conduct disorder and ODD are more likely among children from
• Lower SES backgrounds
• Rural areas
• Abusive homes
> more likely to have been difficult babies, toddlers and young children
> lacking self-control and responding to frustration with aggression
> some researchers argued that kids born with a biologically based difficult temperament, that this interacts with parenting that leads to behavioural issue
> when caregivers interact with children with conduct disturbances, their interactions are hostile and contain ridicule and parents sometimes ignore behaviours but when they
misbehave they outlash
> individuals with anti social tendencies tend to choose mates with similar tendencies
> children are more likely to exhibit disruptive and delinquent behaviour if they have been physically abused
• Cognitive Factors:
Children with conduct disorder often process information about their social interactions in a manner that fosters aggression
>ex. Tend to make assumption that others will be aggressive towards them, bump into them may assume it to be intentional
> this aggression might lead to others to respond aggressively and these reactions feed children’s assumptions further
> cycle of interactions tend to maintain aggressive and antisocial
> evidence: changing aggressive behaviour patterns tend to decrease aggressive behaviour

TREATMENTS FOR CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER:

• Both psychological and social treatments are associated with reductions in:
Violent behavior
Disruptive behavior
• Medications can assist in improving emotional regulation
• Psychological and Social Therapies:
Cognitive-behavioral therapies are the most common psychotherapeutic approach for the treatment of conduct disorder
> focus: alter children’s interpersonal interactions. By teaching them to take the perspective of others and respect their viewpoints, to use self-talk to manage impulsive
behaviours and learn active ways to solve conflicts instead of aggression
• Parents are often involved in order to alter family dynamics that may be promoting the antisocial behaviours
> interventions focused on caregivers: taught to reinforce positive behaviours and discourage aggressive behaviours, provided with non-violent disciplinary techniques in order
to control their own angry responses to children’s behaviours
> these techniques tend to be particularly important in treating young kids who might not be able to assess and challenge their own thinking processes
> hard to get parents who need the most improvement in their skills to engage in therapy
> overall, these therapies do reduce aggressive and impulsive behaviours in kids and interventions are more likely to be successful long-term if they start early in childhood and
booster sessions can be used to enhance the longevity of these treatments
• Drug Therapies:
> non-pharmacological treatment is the first line treatment but some kids who show severely aggressive behaviours are prescribed drugs
Stimulants are most often prescribed since conduct disorder is typically comorbid with ADHD
> stimulants are affected in reducing ADHD symptoms in kids with conduct, and moderately effective in terms of lowering aggression
Antidepressants and antipsychotics are sometimes used (SSRI’S and SNRI’s)
> tend to reduce irritable and agitated behaviour, atypical antipsychotics are used to reduce aggressive behaviours and traditional antipsychotics do show some success but
there are too many neurological side effects for these to be perscribed

ANTISOCIAL PERSONALITY DISORDER: individuals who display chronic antisocial behaviours are often diagnosed, diagnostic criteria: duel coated as a conduct disorder in the DSM
• Key features:
Impairment in the ability to form healthy relationships with others
Engaging in behaviors that violate the fundamental rights of others
Engaging in behaviors that violate major social norms
Strong focus on the gratification of personal desires
> overall they tend to be chronically deceitful for profit or pleasure
> because of the issues with violence and criminal activity, this is the most socially destructive personality disorder
> common among criminals, they might commit violent offences (assault, murder and rape) in order to gain pleasure or what they want, when they are caught they show little
and no remorse and indifferent to the pain they caused others
• Poor impulse control is common among individuals with Antisocial Personality Disorder:
Low frustration tolerance
Propensity to take chances without considering the associated dangers
> tend to get bored easily, hard time with routine and hard to hold job or stay committed in relationship
> around 50-80% of males and 20% of females in prison are diagnosable with antisocial personality
> DSM-5 criteria and the definition of psychopathy (superficial charm, grandiose sense of self-worth, need for stimulation, tendency towards boredom, pathological lying and
lack of remorse, gain pleasure by humiliating others and can be cruel. Dogmatic opinions and when they need to be, they can be gracious and cheerful) overlap significantly
> many psychopaths end up in prison or dying young, some end up as successful professions and the successful individuals can easily give the appearance of normality
 ▫
ANTISOCIAL PERSONALITY DISORDER CONT’D:
• Lifetime prevalence:
6% among males
2% among females
> tends to be a reduction of prevalence with increasing age which may have to do with increasing age changes like personality, but also increased mortality because of the
antisocial behaviours
Within the prison population, the rate is approximately 50%
• in part antisocial personality disorder is defined in terms of behaviours that involve rule-breaking, a large proportion of prisoners meet criteria for this disorder
• Individuals with Antisocial Personality Disorder are at a significantly higher risk for substance abuse disorders
Approximately 80% of individuals with Antisocial Personality Disorder abuse alcohol and/or illicit drugs
> individuals who do have substance abuse disorder comorbid with antisocial tend to have the worst prognosis, severity of anti social symptoms tends to be positively
associated with the severity of substance abuse
> substance abuse might promote impulsive and antisocial behaviour and might reduce inhibitions that they do have which might make them more likely to engage in violent
behaviour
> individuals with antisocial disorder are at a slightly higher risk for suicide, specifically true in females
• Most adults with Antisocial Personality Disorder have demonstrated a tendency towards antisocial behavior since they were children
> most would’ve been diagnosed with conduct disorder when they were mid adolescence, around 80-90% of individual’s with antisocial have showed symptoms of conduct
disorder very early on in life
• Conduct disorder is a precursor to Antisocial Personality Disorder

CONTRIBUTORS TO ANTISOCIAL PERSONALITY DISORDER:

• Biological and psychosocial factors associated with Antisocial Personality Disorder are very similar to those associated with Conduct Disorder
Genetic impact:
• Heritability estimates for Antisocial Personality Disorder: 38-69%
> most studies that have addressed anti social, have focused on individuals that exhibit criminal behaviours instead of individuals specifically with antisocial personality disorder
> twin studies show a concordance rate of around 50% in monozygotic and 20% or lower in dizygotic
> adoption studies show that criminal records of adoptive sons are more similar to the criminal records of their biological father than their adoptive fathers
> genes that are more implicated in adult anti-sociality are those that play a strong role in the serotonin system (really strongly implicated in impulsivity and aggression)
• Individuals with Antisocial Personality Disorder tend to show challenges in:
Verbal skills
Executive functioning (this encompasses an individuals ability to focus, form goals, anticipate plans, self-monitor and ability to shift from maladaptive behavioural
tendencies to more adaptive)
> some researchers have found an 11% reduction in grain matter volume in the prefrontal cortex among males with antisocial
> males tend to have less volume int he prefrontal cortex, which might account for the gender differences
> research also found a decreased volume in activity in the amygdala (responsible for processing emotion, threat) and an increased volume of activity in the striatum (critically
involved in reward processing)
Low levels of arousability are associated with: risk taking, challenges in learning from punishments, fearlessness so this might promote behaviours like fighting, stealing, and
since they don’t fear punishment they might not be deterred from the fear of jail time
> can also lead to stimulation seeking, this can be in the form of prosocial things like sky diving or lead to dangerous behaviours like fighting
• Low resting heart rate
• Low skin conductance activity
• Excessive slow wave EEG reading
• Environmental factors associated with Antisocial Personality Disorder:
Childhood adversity
Childhood maltreatment
> criminal offenders tend to show high rates of childhood abuse and neglect
> physical and sexual abuse from a caregiver are most commonly associated with antisocial personality
> genetic, neurobiological and the social factors all interact which can create a cycle of violence

TREATMENTS FOR ANTISOCIAL PERSONALITY DISORDER:

• There is very minimal evidence for effective treatments among this population
Many individuals with Antisocial Personality Disorder believe that they do not need treatment
They may engage in therapy when forced but are prone to blaming others for life challenges
• Many clinicians believe that they cannot effectively treat individuals with this disorder
> ex. Might be forced to seek treatment by romantic partner via work conflicts or incarceration
> CBT can be sometimes useful for mild cases, clinicians help individuals gain control of anger, impulsive behaviours by assessing triggers and developing adaptive coping
strategies
> use of medications can be effective in terms of treating the comorbid disorders, and reducing symptoms of aggression and impulsivity
> lithium, atypical antipsychotics and anti-seizure meds can be used to decrease aggression and impulsive behaviours
 ▫ ▫
INTERMITTENT EXPLOSIVE DISORDER
• The diagnosis of Intermittent Explosive Disorder is given when individuals often display impulsive acts of aggression (they must be aged 6 or older for this diagnosis)
The aggression can be verbal or physical
The acts of aggression must be largely out of proportion for the situation
> ex. Throwing burger at waitress if served cold, outbursts are not calculated but out of control which highlights the inability for them to inhibit impulses
> onset is in late childhood or adolescents, rare to have it after 40
> chronic disorder associated with legal issues, difficulties in social relationships and difficulty keeping job
Prevalence: 3.5-7% of population

THEORETICAL PERSPECTIVE OF INTERMITTENT EXPLOSIVE DISORDER:

• Imbalance in serotonin levels may be associated with impulsive aggressive behavior
• Neuroimaging studies show:
Reduced activity in the orbitofrontal cortex (OFC)
Increased activity in the amygdala
> disorder commonly runs in families, not clear if it is due to genetic or parenting factors

TREATMENT OF INTERMITTENT EXPLOSIVE DISORDER:

• CBT can assist in:
Helping individuals to identify triggers of outbursts and subsequently avoiding these triggers
Assisting clients in appraising situations in a manner that doesn’t lead to aggression
> both individual and group CBT help in reducing anger, hostile thinking, aggression and improving anger control
• Drug treatments:
Serotonin and norepinephrine reuptake inhibitors
Mood stabilizers
 ▫
EATING DISORDERS: Normative discontent: label that researchers 30 years ago used to describe the
dissatisfaction among women and men with their bodies, particularly in developed
countries
• this has gotten worse in last 30 years
• In iceland, 64% of women of normal weight feel like they need to lose weight
• In the US, 69-84% of women show significant body dissatisfaction
• The desire for thin body shape tends to promote body dissatisfaction and
unhealthy eating patterns
• Overall, mens are less likely but in recent years men are more concerned with
body figure wanting to gain a leaner, stronger and more toned
• Kids as young as 3 show a preference for thinness (more positive
characteristics to thin figures)
• Weight bias increases with age as kids transfer into adolescence and young
adulthood
• Kids who have a strong weight bias are more likely to have depression, low
self-esteem, disordered eating and anxiety
• Obesity has numerous consequences like high blood pressure, heart disease,
diabetes
• Weight is associated with self-worth so most people care about their weight,
what people chose to eat and exercise are associated with self-worth, guilt and
merit which impact self-esteem
CHARACTERISTICS OF EATING DISORDERS:
> body image dissatisfaction is the best predictor for the development of eating disorders
> most people who meet the criteria for one of them tend to flucuate between them and tend to meet the criteria for 2 or more at different parts of lives
> show concerns with 1 or more of these without meeting a full criteria for diagnosis and are often given the diagnosis for other specified feeding or eating disorder
Anorexia Nervosa
• Individuals with anorexia nervosa (AN) starve themselves in an effort to lose weight (persist with very little amount of food for a long period of time)
> even after they lose weight, they are still convinced they need to lose more
• Eating disorders have very high mortality rates:
Most deaths occur between 16-29 years of age (around 6% is the mortality rate, and more than 25% are due to suicide but more than 50% are associated with
medical complications)
AN is the 3rd leading cause of chronic illness among adolescents
• Medical consequences associated with anorexia nervosa:
Cause of multi system organ damage which includes cardiac abnormalities, brain impairment and early onset bone disease
Bradycardia (slow heart rate)
Arrhythmia (irregular heart rate)
Heart failure
Hypotension
Electrolyte disturbances
Gastrointestinal issues
Liver problems
Low bone density (increased risk for fracture)
Acute expansion of the stomach (lead to rupturing)
• There are two types of anorexia nervosa:
Restricting type:
• These individuals will diet, fast, and/or exercise excessively to prevent weight gain
> some will go days without eating but most eat small amounts of food
> in the profile, by an individual named horbecker titled wasted, she survived months on one yogurt and 1 fat free muffin per day
Binge/purge type:
• Individuals will binge eat or purge periodically
> purging includes self-induced vomiting, overuse of laxatives
> distinct from bulimia since individuals with AN tend to be significantly below healthy body weight, individuals with bulimia nervosa are usually overweight or normal
> don’t typically engage in binges with large amounts of food, instead even if they eat a small amount they might binge and purge
> all individuals with AN are significantly below healthy body weight
• Lifetime prevalence: 1%
Higher prevalence among females
Increasing prevalence among males
> males have been historically understudied in terms of anorexia
> body dissatisfaction concerns muscularity, so focus on enhancing muscle mass
> rates of AN have increased significantly since the early 20th century and the motivations for self-starvation vary across time and culture
 ▫
ANOREXIA NERVOSA CONT’D:
• Typically begins in adolescence or young adulthood
The median number of years from onset to remission:
• 7 years for females
• 3 years for males
• more than 20 years after diagnosis, 51-76% of patients don’t meet the criteria for a diagnosis, but many continue to have eating related issues or other forms of
psychopathology (particularly depression)
• Individuals with the binge purge type of nervosa, tend to have more comorbidities than the individuals than individuals with the restricting type
> at a higher risk for suicidal and self-harming behaviours and more chronic experience of the disorder

BULIMIA NERVOSA:
• Bulimia Nervosa is characterized by:
Bingeing (uncontrolled eating)
Inappropriate compensatory behaviors to reduce weight gain
> might be self-induced vomiting, fasting, misuse of laxatives, excessive exercise
> in terms of mild presentations, individuals will have 1-3 episodes of inappropriate compensatory behaviours every week
> in terms of extreme presentations, these individuals will have 14 or more inappropriate compensatory behaviours a week
> binge will occur over specific period of time (typically 1-2 hours) involves eating significantly more than most people
> tremendous variation of binge size ranging from 1200-4000 calories in one sitting
> what makes the lesser amounts binges is that people will have a sense that they have no control over their eating but still compelled to eat in the absence of hunger

• Individuals with anorexia nervosa and bulimia nervosa:

Have self-evaluations that are very contingent upon body weight and shape
One main difference between these disorders is that individuals with bulimia nervosa don’t present with significant distortions in their body images
> a person with AN who is emaciated can look in the mirror and feel fat
> conversely, an individual with bulimia, has a realistic sense of weight and shape but dissatisfied with body and focused on losing weight
• Lifetime prevalence:
1-1.5% in adults
0.1-2% in adolescent youth
• Much more common among females
> when research studies examined disordered eating behaviour, rather than using strict DSM criteria, the prevalence is around 14-22% of adults and adolescents
> males with bulimia are more likely than females to engage in excessive exercise in order to control their weight and tend to be focused on developing a muscular look
instead of a thin one
• Onset:
typically adolescence
• Death rate:
not as high as the death rate among individuals with anorexia but double of the general population
• Medical complications are common
> serious is electrolyte imbalance which has to do with fluid loss due to vomiting, laxative use, diuretic abuse
> these imbalances can lead to heart failure
> high risk for suicide attempts, risk is around 31% for suicide attempts
• Bulimia tends to be chronic
> 15 years after diagnosis, 50% of individuals showed remission but 50% still had symptoms that qualified for diagnosis
> frequency of purging tends to be great predictor of outcomes, the more they engage in binges, the worst their outcomes tend to be

CULTURAL, ETHNORACIAL, AND HISTORICAL DIFFERENCES:

• Bulimia nervosa is significantly more common in Westernized cultures in comparison to non- Westernized cultures
In the US it is more common among White and Latinx Americans in comparison to African Americans
• Prevalence has increased dramatically in the second half of 20th century
> research has shown that in westernized cultures, a peak was reached in 1990s and remained fairly stable in the 2000s or perhaps a slight decline since the 2000s
 ▫ ▫
BINGE-EATING DISORDER:
• Binge-eating disorder (BED) is similar to bulimia nervosa with the exception that individuals do not engage in purging, fasting, or excessive exercise in order to compensate
for binges
> binges tend to result in excessive weight gain and obesity
> during binging episodes, usually report eating faster and eating until uncomfortable
> usually experience a clinically significant amount of distress
> some will eat continuously throughout day, some have discreet binges of large amounts (most often in response to stress, anxiety or depression)
• Individuals with BED are typically:
Overweight
Feel disgusted with their body
Feel ashamed of their bingeing behaviors
• Prevalence: 1-2.6%
> around 30% of individuals in weight loss programs are diagnosable with BED
> core feature: losing a sense of control during eating episodes
• There are 2 peaks of onset:
Immediately after puberty
Late adolescence
> tends to be predictor of obesity, work school and social impairment, depression, anxiety, emotional distress, substance abuse and suicidality
.> chronic, mean duration of between 8-14 years
• slightly more common among females

OTHER SPECIFIED FEEDING OR EATING DISORDER:

• Subclinical symptoms of eating disorders are common
• Other specified feeding or eating disorder:
Captures presentations of eating disorders that cause significant impairment but don’t meet full criteria
E.g. Partial-syndrome eating disorders:
• Individuals who meet some but not the full criteria for AN or bulimia nervosa
> might binge a few times a month
> atypical AN meet all the criteria for AN with the exception that the individuals weight is in or above the normal range
> bulimia nervosa of low frequency and or limited duration: meet all the criteria for bulimia except the frequency of binges and compensatory behaviours happen less than
once a week or less than 3 months
> night eating disorder: individuals that eat excessively into night, highly distressed that they can’t control eating behaviour, frequent insomnia and often believe they must eat
to fall asleep

UNDERSTANDING EATING DISORDERS

Migration between eating disorder diagnosis are common and risk factors are common, all disorders tend to be chronic and relapses are common
Biological Factors
• AN, BN, and BED all tend to run in families and research supports a genetic basis
> twin studies tend to show heritability estimates from 48-74%
> genetic risk interacts with biological changes at puberty (this has an impact on onset of eating disorders in females but not males)
> female changes in hormones at puberty activate the risk for these disorders
• The hypothalamus plays a pivotal role in the regulation of eating
> received messages of food consumption and nutrient levels and sends messages to stop eating when body needs are met
> these messages are carried by neurotransmitters (dopamine, serotonin, norepinephrine) and hormones (insulin and cortisol)
> disordered eating might be connected with disregulation of the neurochemicals involved with the hypothalamus or functional/structural issues within hypothalamus
> disruptions within the system can lead people to have hard time knowing when hungry or full
> individuals with AN tend to show lower functioning within hypothalamus and abnormalities in terms of dopamine and serotonin, not clear if these are the causes or the
results of the disorder
> BN, individuals will often show deficiencies in serotonin

• Gut microbiota:
Among individuals with AN, bulimia, and BED, there tends to be high levels of bacterial induced autoantibodies
> among non-human animals, inducing these autoantibodies in mice tends to have a strong impact on their food intake and anxiety

SOCIOCULTURAL AND PSYCHOLOGICAL FACTORS:

• Social media:
Exposure to traditional media (TV/magazines) is correlated with body dissatisfaction
Increased use of online social networks is correlated with:
• Low self-esteem
• Poor life satisfaction
• Depression
• Loneliness
• Image-centred digital (instagram, snapchat, tiktok) media tends to be positively associated with appearance concerns
> concern is social filtering: algorithmic processes are used on social media behaviour so that individuals that consume body idealized social media tend to receive more exposure
to body related content in future
> social media doesn’t just ideal the thin body look, but also videos posted may represent what is idealized within society
> individuals with eating disorders who frequently use image centered media tend to be more vulnerable to make physical appearance comparisons and often experience
higher symptom severity after exposure
 ▫ ▫ ▫
SOCIOCULTURAL AND PSYCHOLOGICAL FACTORS CONT’D:
• The Thin Ideal and Body Dissatisfaction:
Ideal shape for females has become significantly thinner since the mid-20th century
> pageants, barbies have been getting thinner but now changing
> women who internalize the thin ideal, tend to be at higher risk for eating disorder
> AN and BN are more common in females cause thinness is more encouraged and valued among females
> research looking at magazines, on average, female magazines have 10x the amount of diet articles than males
> body dissatisfaction that is promoted by the pressure for thinness tends to be a strong predictor of eating disorders among young women
Ideal shape for males currently emphasizes muscularity
• Boys and men are increasingly experience dissatisfaction with their bodies and an increase in disordered eating just as women have, especially when they compare
themselves to celebrities like Zac Efron
> when this is reinforced in peer groups, risks of eating disorders increase dramatically
• Turning a corner?
Body-accepting messages in the media in combination with a higher visibility of fuller-sized models and celebrities may be having a positive impact on body satisfaction
> meta-analysis regarding body dissatisfaction has shown that thinness orientated body dissatisfaction among women is starting to decrease, no comparable decrease has
been seen in males in regards to muscularity orientated body dissatisfaction
• Athletes and Eating Disorders:
Individuals engaged in sports in which weight is considered to be a critical factor for competitiveness are at a high risk of eating disorders
> sports include gymnastics, ice skating, dancing, horse racing, wrestling and body building
> individuals who participate in sports that are weight dependent or aesthetic are at a significant risk for AN and BN
> many female athletes with eating disorders report feeling physical changes that accompany puberty have a very negative impact on their competitive edge
> dieting is used to maintain pre-pubescent body weight and figure
> among males, body building is popular and have a pattern of exercising and eating that can become obsessive with a strong focus on gaining muscle
• some people with eating disorders may control their weight through excessive exercise

COGNITIVE FACTORS:
• The combination of low self-esteem, perfectionism, and body dissatisfaction tends to be predictive of the development of eating disorders
> tendency to overvalue the opinions of others and more vulnerable to social pressures that idealize thinness
• Individuals with eating disorders often have a dichotomous thinking style
> judge things as entirely good or bad, eat one chip they might think they ruined their diet and go and eat the whole bag
> often have rigid eating routines, and if these are modified, they may lose control of their eating
> anxious temperaments and perfectionistic traits tend to facilitate the development and maintenance of AN behaviours

• Emotion Regulation Difficulties:

The behaviors associated with eating disorders may serve as maladaptive strategies to manage difficult emotions
> individuals with depression are at high risk for developing anorexic, bulimic and binge eating disorders
> adolescent females who engage in emotional eating (eating when distressed to feel better are at a higher risk for developing chronic binge eating)
> two subtypes of disordered eating that involve binge eating:
1. Dieting subtype: maintain low calorie diet but will frequently relapse and binge eating
2. Depressive subtype: concerned with weight but also eat to reduce feelings of depression and low self-esteem
> tend to have more negative social and psychological outcomes over time
> tend to show more problems in relationships and more depression and anxiety disorders
• Family Dynamics:
Caregivers can directly and indirectly impact body dissatisfaction and the development of eating disorders in children and adolescents
> disordered eating attitudes are more likely with family dynamics that involve weight related teasing, pressure from care givers to be thin, low emotional expression
> families than emphasize the importance of thinness and appearance tend to be a strong risk factor for unhealthy patterns
> rigid, demanding and controlling parenting styles are a risk factor for unhealthy eating patterns
• one theory of eating disorders emphasizes the role of over-controlling families
• Family Dynamics: control
One important milestone in adolescence is individuation from family
• Individuals from overcontrolling families may fear separation since they haven’t developed the ability to live independently from their family
> at odds of individuating milestone from family
• Controlling food intake may:
Provide a sense of control (power)
Elicit concern from caregivers
> families of females with eating disorder tend to have high conflict, emphasize control and perfectionism and discourage the expression of negative emotions
> causal nature is unclear

TREATMENTS FOR EATING DISORDERS:

Psychotherapy (common) for Anorexia Nervosa
• It can be challenging to engage individuals with AN in psychotherapy
> they value thinness so much, that they must maintain control, resistant to change behaviours so therapist has to work hard to gain trust and maintain trust as patient
maintains weight
• The therapist may be forced to hospitalize the client due to life threatening weight loss
> hospitalization and force feeding is sometimes necessary and can make it hard for client to trust therapist
> since individuals with AN don’t typically seek treatment themselves, often don’t present to therapist until never malnourished, medical crisis or until families/partners seek
support for them
• Psychotherapy can be useful but it is a long process that often has many setbacks
> individuals who maintain normal weight can relapse into bulimic or anorexic
 ▫
TREATMENTS FOR EATING DISORDER CONT’D: psychotherapy
• Even after therapy, they often experience:
Self-esteem issues
Family challenges
Depression and anxiety
• CBT and family therapy tend to be useful therapeutic approaches for AN
> A clients overvaluation of thinness is challenges and rewards are used to encourage weight gain, relaxation techniques are implemented and helps to aliviate anxiety
associated with food intake
> associated with weight gain and reduction of symptoms but many patients drop out of therapy or relapse over time
> family therapy: individuals with AN and their families are treated as a unit

PSYCHOTHERAPY FOR BULIMIA NERVOSA AND BINGE-EATING DISORDER:

• CBT is the leading treatment approach for Bulimia
1) The therapist teaches the client to monitor their cognitions associated with eating (especially during bingeing and purging episodes)
2) The therapist will help the client to challenge these cognitions
3) The therapist will help the client to develop adaptive attitudes regarding body shape and weight
> behavioural components of therapy tend to involve introducing anxiety eliciting foods (ex. Providing client with bread and introducing these back into diet and confronting
irrational cognitions associated with these foods (ex. Common cognition might be: if I have this food, or one donut i am going to binge)
> client will learn to eat 3 healthy meals a day and challenges anxiety eliciting thoughts regarding weight gain
> CBT will typically last 3-6 months and will involve 10-20 sessions
• Clients who undergo CBT tend to show:
Reduced depression and anxiety
Increase in social functioning
Reduced concern about dieting
Reduced focus on weight
• CBT is more effective than medications in leading to complete cessation of bingeing and purging
> expanded CBT that target emotion regulation difficulties tend to be effective among individuals who have comorbid depression and eating disorders

BIOLOGICAL THERAPIES:
• SSRIs are sometimes prescribed for eating disorders:
They reduce binge-eating and purging behaviors
There are no medications that have been shown to be effective and safe for the treatment of AN
> SSRI’s don’t reduce over concerns regarding weight
QUESTIONS TO CONSIDER:
1) What are the implications of identifying causes for antisocial behavior?
• if we identify biological causes or strong psychosocial causes, what then?
2) How should society respond when individuals violate major social norms?
• ex. Ted bundy, earned A’s, charming, intelligent, attractive, got involved with politics and known as young JFK, kidnapped and murdered women and carefully kept
secret, got arrested 15 months later and escaped custody and kept beating and raping women, used library to gain legal skills and delayed his own execution by 10 years
• In interviews, he said the murders were a way of him to gain full possession of women, never expressed remorse, extreme example of psychopath
• Behaviours highlight tendency to engage in behaviours that violate basic rights of others and violate social norms
• Would have been diagnosed with anti-social personality disorder

Multiple pathways into eating disorders

DSM-5-TR for conduct disorders

Case study phillip

12 year old dylan case study

DSM-5-TR Oppositional defiant disorder

Integrative model of the development of anti-sociality
• biological, social and psychological factors interact across a child’s development to lead to a lifetime of anti-
sociality in some children
• Interact in ways that promote antisocial behaviours
• Antisocial parents tend to lead to genetic vulnerability toward conduct disorders and parent in ways that
promote antisocial behaviours (these kids are often exposed to maternal drug use, pre and postnatal exposure
to toxic agents, poverty, abuse and stress)
• infants and toddlers with neuropsychological issues tend to be more irritable, overreactive and slow to learn
(hard to care for and puts them at high risk of maltreatment and neglect)
• high risk of social and academic problems at school which can motivate them to turn to deviant peer
groups which can further promote anti social behaviour
• in one longitudinal study, kids were followed from age 3 to adulthood and found that combination of biological
predispositions towards cognitive deficits, difficult temperament and environment with disruptive family bonds
tended to be associated with conduct disorder that persisted into adulthood

DSM-5-TR diagnostic criteria for antisocial personality disorder

DSM-5-TR criteria for intermittent explosive disorder

Reciprocal effects between biological and psychosocial

factors in the disruptive, impulse-control, and conduct
disorders
 Profiles:

Comparison of eating disorders

DSM-5-TR criteria for anorexia nervosa

• even though they are underweight, they have a distorted image of body
and still see themselves as disgustingly fat
• Fear of gaining weight, lend to only feel good when they have complete
control of eating and losing weight
• Because of weight lose, they are chronically fatigued and typically
exercise excessively and keep up with school and work

Profiles:

Miss Y case study

• this patient did not have distorted body image but stubbornly refused to eat

DSM-5-TR criteria for bulimia nervosa

Profile:

DSM-5-TR criteria for binge-eating disorder

Case study

Table 5: rates of eating disorders in elite women athletes

Case study heidi

Case study renee:

 ▫
SEXUAL DYSFUNCTIONS:
• Sexual dysfunctions:
A set of disorders characterized by challenges:
• In responding sexually
• Experiencing sexual pleasure
• In order to be diagnosable, the challenges must be persistent and must cause significant distress or interpersonal challenges
> 7 sexual dysfunction disorders is the DSM-5-TR and these are bifurcated into disorders of arousal and orgasm and sexual pain
> in order ot be diagnosable, must occur for minimum 6 months and can’t be due to non sexual psychiatric issue like depression, a medication or substance, general medical
condition or stressors
> if caused by a substance or medication might be diagnosed with a substance-medication induced sexual dysfunction

DISORDERS OF SEXUAL INTEREST/DESIRE AND AROUSAL:

• There is tremendous variability in terms of sexual interest and sexual interest can fluctuate dramatically over time
• Male hypoactive sexual desire disorder:
Have little desire for sex
They do not fantasize about sex
They do not initiate sexual activity
They may be unresponsive when partner attempts to initiate sex
Are distressed or experience interpersonal issues
> can be life long or accquired,
> some report never having any interest in sex, either with others or privately
> these are diagnosed with life life male hypoactive sexual desire disorder
> acquired male hypoactive sexual desire disorder: males used to enjoy sex but lost interest, lack of desire might be generalized or specific to certain partners or situations
> approx. 15-20% of males tend to report frequent issues of hypoactive desire but tend to see significantly higher rates among older men
• Female Sexual interest/arousal disorder:
Among women issues with interest and arousal tend to coexist
> more than 30% of women report lack of desire for sex which occurs ocassionaly
For diagnosis, women must report at least 3 of the following (occurring for at least 6 months):
• Absent or significantly reduced interest in sexual activity, sexual fantasies, in sexual responsiveness to erotic cues, or in genital or nongenital responses to sexual activity
• Can be lifelong or acquired
> usually low sexual desire tends to occur in about 9.5% of women and 26% among post menopausal women, only 5.4% could be diagnosed with a sexual arousal disorder
> some women will experience very low among of arousal or desire but they are not distressed by it and this distress needs to be present for a diagnosis to be made
> women with low sexual desire are more likely than man to report depression, anxiety and life stress

• Erectile Disorder (ED):

Recurrent inability to have or maintain an erection or a significant decrease in erectile rigidity
> men with lifelong ED never been able to maintain erection for a period of time
> men with a acquired ED were previously able to maintain erection but no longer can
> life long dysfunction tends to be associated with psychological contributors and these tend to be receptive to treated
> acquired dysfunction tends to be associated with biological causes

• occasion challenges in achieving or maintaining erection are common with about 40% of males aged 40 and around 70% of males aged 70 having some form of ED
> advanced age and poor cardiovascular functioning tend to be predictive of ED
> increased prevalence among males who are younger than 40 and current rates might be underestimated because of underreporting
> issues in terms of the inability to have/maintain an erection aren’t considered to be a disorder unless they are persistent or cause significant distress or interfere with
relationships
> diagnostic criteria: male can’t achieve/maintain erection until the completion of sexual activity in 75-100% of occasions for a duration of at least 6 months
• ED affects:
• 8% of males (20-29 years)
• 11% of males (30-39 years)
• Approximately 15.5 - 69.1% of males (over 20 years) worldwide
 ▫ ▫
DISORDERS OF ORGASM OR SEXUAL PAIN:
• Female Orgasmic Disorder:
Reduced intensity of orgasms or absence of orgasm after the excitement phase of the sexual response cycle
> to be diagnosed, has to occur in at least 75% of sexual encounters
Can be lifelong or acquired
25% of women report occasional difficulty reaching orgasm
Prevalence of 4.7% of women
• Early Ejaculation and Delayed Ejaculation:
Early or premature ejaculation:
• Most common orgasmic disorder in men
• Persistently ejaculate with minimal sexual stimulation
• For diagnosis, a male must ejaculate within 1 minute of penetration on at least 75% of occasions for at least 6 months
> can also be diagnosed for non-penetrating sexual activities but specific criteria regarding the duration has not been specified
> prevalence is around 13% and males often try to remedy issue by wearing multiple condoms, distracting self with thoughts, masturbating before sex but tends to have
negative interpersonal impacts in relationships
• Can be lifelong or acquired
Delayed Ejaculation:
• Diagnosed in males who have significant delay or absence in orgasm after the excitement phase of the sexual response cycle
• Must be present in at least 75% of sexual encounters to be diagnosed
> men can’t ejaculate after intercourse but can with manual or oral stimulation
> prevalence around 3%

• Genito-Pelvic Pain/Penetration Disorder:

Approximately 12-39% of women report that they experience frequent pain during sexual intercourse
> due to dryness in the vagina, infection of clitoris or vulva area, injury or irritation to the vagina or tumours in the reproductive organ
> some women have involuntary contractions of the muscles that surround the around 3rd of the vagina when penetration is attempted
> women who have experienced pain or muscle tightening during sex or have a fear/anxiety about it can be diagnosed
Pain during intercourse is very rare among men and typically involves pain during erection or thrusting

CAUSES OF SEXUAL DYSFUNCTIONS:

• Biological Causes:
Medical illness can cause significant challenges in sexual functioning (ex. Diabetes can cause lower sexual drive, lower sexual enjoyment, lower satisfaction, cardiovascular
disease, hypertension, kidney disease, MS, kidney failure, vascular disease, etc.)
> around 40% of erectile dysfunction cases are caused by one of these
> males with cardiovascular disease, sexual dysfunction can be caused by disease or psychological response to the disease
> no psychological diagnoses will be applied if that dysfunction is caused exclusively by the medical condition
Common causes of sexual dysfunction in males:
• Low levels of androgens
• High levels of estrogen or prolactin
Common causes of sexual dysfunction in females:
• Low levels of estrogen (can lead to decreases in sexual desire and arousal)
• Vaginal dryness or irritation (caused by antihistamines, tampons, radiation therapy, vaginal contraceptives and infections

Prescription drugs and recreational drugs can impact sexual functioning

> prescription drugs: antihypertensive drugs, antipyshcotic, antidepressants (SSRIs), lithium tranquillizer
> recreational drugs: marijuana, alcohol, cocaine, amphetamines, nicotine
> individuals who chronically over-consume alcohol tend to have sexual dysfunctions
> when dysfunction is caused by substance use, diagnosed as substance induced sexual dysfunction
> Although many people drink alcohol to decrease their sexual inhibitions, alcohol can impair sexual performance

• Psychological Causes:
Mental disorders:
• Depression, anxiety, and schizophrenia (loss of sexual desire with anxiety and schizo) can all contribute to sexual dysfunction
> medications used to treat depression can cause issues with sexual functioning
Attitudes and cognitions:
• Performance anxiety: when individuals worry so much about if they will be aroused or have an orgasm
> individuals who have been taught that sex is sinful or bad may lack desire
> women report fear of losing control or acting in a way that will embarrass them \
> males fear that they won’t satisfy their partner and worry about the quality of erection
 ▫
• Interpersonal and Sociocultural Factors:
Interpersonal factors:
• Sexual dysfunctions are often bidirectionally associated with relationship problems leading to sexual dysfunctions and sexual dysfunctions leading to relationship problems
> communication is critical to let partners know what is arousing and what is not, what preferences are
> in sexual encounters within a male and female, males are most likely to decide when to initiate sex, how long foreplay will last, position and these might be made based on
his arousal and needs without considering hers
> most females can’t reach orgasm alone, they need oral or manual stimulation of the clitoris
> many females tend to fake orgasms in order to protect partners ego and often partners know they aren’t fully satisfied
> women who are seeking treatment are more likely to report issues in marital relationship, stress and psychological distress
Cultural factors: shaping sexual interests and activities
> traditional chinese medical systems and indian both teach that the loss of semen will affect a man’s health so masturbation is discouraged
> among women, psychological factors like emotional frustration and dissatisfaction tend to be strongly implicated in terms of sexual dysfunction
> in cultures where women’s desires for sex isn’t expected, female sexual interest, arousal disorder tends to be less prevalent
> with males, premature ejaculation tends to be common complaint across cultures

• women in western cultures tend to seek out treatment for sexual desire issues, women in non western and male centric tend to seek treatment for genital
penetration pain disorder
> individuals who are less educated and poorer tend to have more sexual dysfunctions, thought to more psychological distress, physical health, absence of proper education
on healthy social relationships
> individuals from cultural backgrounds that promote negative attitudes about sex are more likely to have sexual dysfunctions
• Sexuality is very strongly impacted by social and cultural factors
• Sexual dysfunction is more prevalent among women (43%) than men (31%)

Trends across the life span:

• Many adults are sexually active well into old age (65+)
> declines in testosterone tend to occur in their 50s and continue into life, testosterone is important in both male and female to have sexual desire
> lower testosterone and reduced blood flow and correlated with challenges in having and maintaining and erection and associated with lower intensity of orgasm
> lower estrogen levels in post menopausal tend to be associated with vaginal dryness, lack of lubrication and reduction in sexual responsively
• Both men and women require sufficient testosterone for sexual

• Biological Therapies:
if sexual dysfunction results from a medical condition: diabetes
• Treatment of that condition will often assist in restoring healthy sexual functioning
If sexual dysfunction results from medication:
• A change in dosage or a switch to a different medication can assist
> having an individual stop using recreational drugs can often assist tremendously to restore sexual functioning

TREATMENTS FOR SEXUAL DYSFUNCTIONS:

• Drug treatments for males with ED:
Viagra
Cialis
Levitra
Stenix
*These drugs do not work for approximately 1/3 men
• side effects: head aches, stomach irritation
• For premature ejaculation:
> some antidepressants (eg prozac) can be helpful
• to increase sexual desire:
> hormone therapy (effective among men with low level sexual desire due to low testosterone
> testosterone can be useful among women with low levels of arousal but tends to be most effective among post menopausal women

• Psychotherapy and Sex Therapy:

> many people only want medication and will not engage in psychotherapy to modify psychological or interpersonal issues related to sexual dysfunction
Individual and couples therapy:
• Therapist assesses personal history of the individual(s) to highlight feelings or thoughts which might contribute to sexual problems
> cognitive behavioural interventions: useful to modify attitudes and beliefs that tend to be leading to sexual challenges
> example: male fears embarrassment that he cannot maintain erection, he might be challenged to assess evidence this has happened in past, if it was common
therapist might go over thought patterns that are associated with this experience and practice more positive thought processes
> if a woman has low sexual desire because she was brought up to think sex is dirty and negative, she would learn to challenge this belief and adopt a more positive
attitude towards sex
> when one individual in the couple has a dysfunction, it may be the cause or result of relationship issues, because of this, therapists will often treat sexual dysfunctions
within the context of relationship rather than focusing on just one individual
> role playing: important during therapy to allow the therapist to understand how the couple talk about sex and how the partners view each others roles in sex

• therapists are useful in helping partners see what each of them want from sex and help negotiate mutually acceptable approaches to engage in sex
> if conflicts within relationship contains factors other than sexual practices, the therapies might put the primary focus on the conflicts then addresss exual dysfunction
( ex. Imbalance of power, distrust, hostility, disagreements of values)
> types of therapies: cognitive behavioural, psychodynamic and family systems
 ▫
TREATMENTS FOR SEXUAL DYSFUNCTIONS CONT’D:
• Sex Therapy:
Behavioral techniques of sex therapy may be used alongside many therapeutic approaches
> if sexual dysfunction is due to inadequate skill, sex therapy might focus on practicing skills
> help individuals who haven’t found out what partners want, encourage clients to masturbate for individual to explore bodies and identify what they find arousing
> another goal is to be less inhibited about sexuality and then taught to communicate desires and preferences to partners
Sensate Focus Therapy: form of sex therapies (approach is useful for challenges of desire, arousal and orgasm
• Individuals spend time gently touching each other (not around the genitals) - in early stage
> partners are instructed that they shouldn’t care about intercourse and instead should focus on pleasure
> goal: have partners spend intimate time together with healthy communication skills and no pressure
• in second phase, partners spend time directly stimulating breasts and genitals without attempting intercourse, instructed not to start intercourse until full arousal
occurs
> once the partner with the challenge regularly expresses arousal with genital stimulation, they can have sex but focusing on enhancing and maintaining pleasure instead
of reaching orgasm or performance
• They focus on sensations and communicate with each other about what feels good and what does not feel good

• Techniques for treating early ejaculation:

1) Stop-Start technique:
• Can be performed via masturbation or with a partner
> first phase: male is asked to stop stimulating self or ask partner to stop stimulating him just before ejaculation, then relaxation and concentration of body is used till
arousal declines then stimulation can resume
> if stimulation stops too late and ejaculation does occur, male encouraged not to feel disappointed

> second phase: man lies on back and have partner on top, goal is for male to enjoy the sensation of penetration with no ejaculation, encouraged to maintain position for
10-15 minutes
> most males with premature ejaculation have intercourse only when on top position when using quick and short thrusting, hard to have control over ejaculation and tends to
be common with early ejaculation

> third phase: partner creates a thrusting motion while on top but uses slow and long movements

2) Squeeze technique: partner stimulates male to erection, when ejaculation evident, partner applies firm squeeze at head or base for 3-4 seconds (results in reduction
of the erection)
> then the partner can stimulate again to the point of ejaculation and squeeze
> goal: for male with premature ejaculation to learn what point ejaculation inevitability feels like and to learn to control arousal at that point
• More difficult to teach partners

• Techniques for Treating Pelvic Muscle Tightening:

Deconditioning techniques to reduce woman’s automatic tightening are used
> in a safe environment, woman is taught to insert fingers into vagina to examine vagina in mirror and practice relaxation exercises
> silicon dilators might be inserted and over time, woman will be able to insert large dilators while maintaining relaxation
> if woman has partner, partner can use their fingers instead of dilator
> if woman has male partner, she can guide his penis into her vagina while remaining relaxed

CONSIDERATIONS FOR GAY, LESBIAN, BISEXUAL, AND TRANSGENDERED PEOPLE:

• Individuals who are gay, lesbian, bisexual or transgendered tend to have the same rates of sexual dysfunctions as heterosexual people
LGBTQI individuals face additional stressors associated with sexuality due to stigma and discrimination
• This can impact both sex and health
> having a healthy sex life in important for psychological well-being and this can be difficult for individuals who are transgendered (higher risk for sexual violence,
transphobia, and tend to have negative impact on sexual satisfaction)
> often report difficulties in seeking sexual contact and difficulties having an orgasm
> hypoactive sexual desire disorder tends to be common condition among transgendered women
 ▫
PARAPHILIC DISORDERS: sexual experiences are an important aspect of human experiences but they are often secretive
> para means around or beside, philia is a greek word for love
> individuals vary in what sexual activities they enjoy and sexual attitudes tend to change a bit over time
• There is significant variability in sexual activities
Paraphilias: atypical sexual preferences
Can be categorized as:
• 1) Those involving the consent of others (e.g. some sadomasochistic practices)
• 2) Those that involve nonconsenting others (e.g. voyeurism)
• They are also categorized depending upon whether they involve contact with others (e.g. pedophilia) or not (eg. Some fetishes)
• Paraphilic disorder: atypical sexual activity, which causes an individual significant distress or causes harm (or a risk of harm) to the individual or others
> tend to have recurrent sexual arousing fantasies or urges that involve non human objects, non consenting adults, suffering or humiliation or self or partner or children

FETISHISTIC DISORDER AND TRANSVESTIC DISORDER

• Fetishistic disorder:
Repetitive and significant sexual arousal from nonliving objects or a strong focus on nongenital body parts
> common: feet, toes, hair
> arousal might be achieved from smelling or licking fabrics (leather) for the individual with the desire (this is for desire for object - ex. Man might be aroused by partner
wearing high heel but requires that object for arousal)
> whereas individuals without fetish might have a preference
> because of the associated secrecy, the prevalence is largely unknown but exclusively noticed among men in clinical samples
• Transvestic disorder:
Individuals who fantasize about dressing in clothes that are specific to the opposite sex which results in sexual arousal and MUST result in significant emotional
distress and dysfunction in order to be considered an issue
• Different from transvestism which is cross-dressing (which may or may not be associated with sexual arousal) that is not causing distress
> prevalence: not known, thought to be rare among men under 3% and extremely rare in women
> most men identify as heterosexual and are married with kids, some men are sexually aroused in being a woman or having traditional female roles or tasks

SEXUAL SADISM AND SEXUAL MASOCHISM DISORDERS: separate but often considered together as sadomasochism
• Sexual sadism disorder:
Sexual fantasies, behaviors, and urges involve the infliction of pain and humiliation upon sex partner
> acts of cruelty tend to produce sexual arouse like orgasm
> for a diagnosis, urges need to cause the individual significant distress or cause impairment in functioning or person must have acted on them with a non consenting
individual
> diagnosis quite low reliability and validity
> dominance and feelings of power might lead to this, associated with criminal offensives, diagnosable in around 10% of individuals who have convicted rape
> present in about 29-36% of sexual homocide perpetrators
> approx. 22% of pop report sadistic sexual fantasies but thought to be underreported
> mostly found among men and tends to positively associated with anti social behaviours

Sexual masochism disorder:

Sexual fantasies, behaviors, and urges involve
suffering pain or humiliation during sex
For a diagnosis, this must cause an individual significant distress or significantly impair their functioning
> in both, distress might manifest as guilt, shame, frustration or loneliness and uncommon for them to seek treatment
> some engage in mild or moderately sadistic or masochistic behaviours during sex without carrying through with suffering
> when done in trusting relationship where boundaries are set (safety words), not seen to be problematic
• 4 main sexual rituals in sadism and masochism:
1. Physical restriction
> bondage, chains, handcuffs
2. Administration of pain
> beating, whippings, electrical shocks, strangulating, mutilation
3. Hyper-masculinity practices
> aggressive use of fists or dildos
4. Humiliation
> one partner will verbally or physically humiliate partner directly during sex

• men are more likely to enjoy sadomasochistic sex in the roles of either the sadist or masochist, some women enjoy but many consent to please partner or paid to do
so
 ▫
VOYEURISTIC, EXHIBITIONISTIC, AND FROTTEURISTIC DISORDERS:
• Voyeurism:
Becoming sexually aroused by watching an unsuspecting individual who is:
• Naked
• Undressing
• Engaging in sexual activities
• Engaging in private activities
• The most common illegal paraphilia
> around 12% of men and 4% of women have engaged in at least 1 act of voyeurism by spying on individuals engaging in sexual activities
> to be diagnoses, behaviour but be repeated by at least 6 months and behaviour must be compulsive, urges must lead to significant distress or impaired functioning
• Exhibitionism:
When an individual is sexually gratified by exposing their genitals to involuntary observers (typically strangers)
For a diagnosis of exhibitionistic disorder:
• The individual must have acted on these urges
• The behavior must cause significant impairment or distress
• this behaviour is typically compulsive and impulsive
> around 4% of women and 2% of women have reported in engaging in at least 1 act
> most exhibitionists tend to be males and their targets tend to be women kids or adolescents
> those to target kids, might also have cooccurring pedophilic disorder
> behaviour is typically in public (park, bus) and arousal stems from observation of the involuntary observers disgust, fear or from fantasying that the victim is aroused
> fear of getting caught tends to increase arousal, likely to continue behaviour even after getting caught
• Frotteurism:
Individual experiences sexual gratification from rubbing against a nonconsenting individual or from fondling parts of the body of a nonconsenting individual
• Often occurs in crowded places like subway, train, elevator, and target might not realize it is sexual
> during this behaviour, the affected person will fantasize that they are in an intimate partnership with the victim, most cases involve men inappropriately touching
females
> diagnosis, individual must have intense and reoccurring sexual arousal from non consenting rubbing or touching for more than 6 months (can be manifested in thoughts,
behaviours, or urges)
> fantasies can cause significant distress and dysfunction in relationships but also in daily activities
> tend to reduce in older age, common among other paraphilic disorders
> women in many cultures rarely report events of sexual harassment when it occurs on public transportation, many countries have adopted female only transportation
and taxi services (ex. Brazil, India, Indonesia) for the purpose of protecting women
PEDOPHILIC DISORDER:
• Pedophilic disorder:
Individuals with this disorder are adults (16 years and older)
They have recurrent and uncontrollable sexual fantasies and behaviors focused on sexually immature children (who are typically 13 years of age and younger)
In order to be diagnosed:
• The individual must have acted on their urges involving children or child sexual exploitation materials
OR
• the individual must experience significant distress because of their urges

• The impact on child victims is often severe.

• Children who have been sexually abused often experience:
Fear
Shame
Depression
Complex PTSD
Conduct disorder
Hyperactivity
Sexualized behaviors (inappropriate for their age)
 ▫ ▫
CAUSES OF PARAPHILIAS:
• Behavioral theories:
Initial classical pairing of a stimulus with early sexual arousal
• This is followed by operant conditioning where the stimulus is present during masturbation
• Social Learning Theory:
The child’s home and culture can impact deviant sexual behavior
• Kids whose caregivers often use corporal punishment or engage in aggressive acts with each other are more likely to engage in impulsive and aggressive acts
• Child abuse and family dysfunction is more common among sex offenders

TREATMENTS FOR PARAPHILIC DISORDERS:

• Most individuals with a paraphilic disorder do not seek treatment
Treatment is typically forced upon those who have been arrested for illegal acts (e.g. pedophilia, voyeurism)
• Sex offenders are sometimes treated with chemical castration
• SSRIs are sometimes useful in reducing paraphilic behaviour and sexual drive
• Behavior modification therapies:
Aversion therapy: can be used to extinguish sexual responses to objects or situations
Desensitization procedures: can reduce anxiety about having normal sexual encounters with others
• Cognitive interventions:
Role playing:
• Can help to provide the individual with practice approaching others and negotiating positive sexual encounters in relationships
Identification of thoughts and situations that trigger their behaviors

GENDER DYSPHORIA:
• Diagnosis of gender dysphoria requires:
Significant distress or impairment that is associated with the gender incongruence
*The incongruence in and of itself is NOT viewed as a disorder
• Rates of suicide and nonsuicidal self-injury are very high in this group
• Rejection by others is associated with:
Low self-esteem
Psychological distress
 ▫
GENDER DYSPHORIA CONT’D:
• Individuals who identify as transgender may or may not be diagnosed with gender dysphoria.
This is based upon whether or not this incongruence causes them impairment or distress
• Biological factors:
In genetic females:
• Female-to-male gender dysphoria is associated with prenatal exposure to very high levels of androgens
In genetic males:
• Male-to-female gender dysphoria is associated with prenatal exposure to very low levels of androgens

TREATMENTS FOR GENDER DYSPHORIA:

• In combination with psychotherapy, 3 other approaches are typically used in the treatment of gender dysphoria:
1) Cross-sex hormone therapy
2) Social transition to full-time real-life experience in the desired gender role
3) Gender-affirming surgery
• Gender-affirming surgery:
Is controversial largely because it is irreversible
• Post operative regret can occur and this tends to be associated with an insufficient psychiatric assessment
• Most clinicians argue that cross-hormone therapies and surgeries are not acceptable for children and adolescents
Outcome studies:
• Show good levels of sexual functioning and high
 ▫

SUBSTANCE USE AND GAMBLING DISORDERS:

DEFINING SUBSTANCE USE DISORDERS:

• 4 conditions are critical in determining
substance use:
Intoxication
Withdrawal
Abuse and dependence

DEPRESSANTS;
• Depressants:
Cause a slowing within the central nervous system
Moderate doses:
• Associated with relaxation, sleepiness, reduced concentration, impaired thinking, judgement, and motor skills
Heavy doses:
• Associated with stupor and possibly death
 ▫
STIMULANTS:
• Stimulants:
Result in the activation of the central nervous system
Symptoms:
• Feelings of energy, power, happiness • Decreased desire for sleep
• Reduced appetite

OPIODS:
• Common opioids:
Morphine
Heroin
Codeine
Methadone

HALLUCINOGENS AND PCP:

• Substances that produce significant perceptual illusions and distortions:
Lysergic acid diethylamide (LSD)
Phencyclidine (PCP)
Peyote
Mescaline
Psilocybin mushrooms
Ecstasy (MDMA or Molly)
Ketamine
• Symptoms:
Severe anxiety
Paranoia
Loss of control

• Disorders are diagnosed when individuals:

Frequently can’t fulfill their major obligations at home, work, or school because of their intoxication
 ▫ ▫
CANNABIS:
• Intoxication:
Is associated with a feeling of well-being and relaxation

INHALANTS:
• Volatile substances that produce chemical vapors that can be inhaled:
These depress the central nervous system
Examples:
• Nitrous oxide
• Gasoline
• Spray paint
• Aerosol sprays

THEORIES OF SUBSTANCE USE AND DISORDERS:

• Biological Factors:
The brain has a “pleasure pathway” that impacts how we experience reward
• Drugs can have a strong impact upon this pathway
Genetics plays a strong role in determining who is at risk for substance use disorders
• Psychological Factors:
Social learning theorists argue that kids and adolescents may model substance use behavior that they see in:
• Caregivers
• Important role models in their culture
Cognitive theories:
• Focus on expectations of substance use and beliefs concerning the appropriateness of using substances as a coping mechanism for stress
Personality characteristics can play a role
• Sociocultural Factors:
Reinforcing effects of substances might be more appealing to individuals who experience chronic stress
 ▫
TREATMENTS FOR SUBSTANCE USE AND DISORDERS:
• Biological Treatments:
Antianxiety drugs, antidepressants, and drug antagonists
Methadone maintenance programs
Based on aversive classical conditioning
• Can be used in isolation or in conjunction with biological or psychosocial therapies
• Cognitive Treatments:
CBT for the treatment of both drug and alcohol use disorders has gained significant empirical support

GAMBLING DISORDER:
• The DSM-5-TR widened substance-related and addictive disorders to include gambling disorder
• Pathological gambling is associated with:
Substance use
Depression
Anxiety
Family history of substance use
Family history of gambling issues
 Sexuality and gender along the continuum— occasional challenges in terms of
sexual functioning like lack od desire or inability to reach orgasm are common
• if people have challenges with sexual functioning that is consistent and
causes significant amounts of interpersonal challenges, then they might be
diagnosed with sexual dysfunction
• Around 40-45% of women and 20-30% of men often experience
• Stimuli find arousing tend to be variable, when they focus sexual activity on
stimuli considered to be inappropriate within society (prepubescent children,
non living objects, suffering, humiliation) then they might be diagnosed with a
paraphilic disorder
• More than half people tend to report at least one paraphilic fantasy (ex.
Voyerism, fetishism, insatism)
• Rate fantasies tend to be common among males and females and many who
report the fantasies, report not wanting to act out these fantasies
• erotic themes of insect and violence are common themes of sexual
fantasies
• Fantasy is considered to be a healthy outlet in terms of sexual thoughts
• people vary dramatically in gender identity • Individuals who have a paraphilia disorder will often feel compelled to engage
• male, female, other gender, or no gender in paraphilia even when the behaviours will cause significant stress or social
Gender identity are distinct from gender roles or legal problems
> gender roles are societal expectations concerning how males and females should act
• gender dysphoria: when people believe they were born in the wrong gendered
body and experiences significant distress
> formally known as gender identity disorder
David Reimer
• social vs biological contributors to self-concept as being male
female, another gender, or without gender
• Biology, social norms, psychological factors all interact to
impact sexual disorders and health

Masters and Johnson

• most of what we know about the human body during sexual activity is
largely based on their work who published largely in the 1970s
• They observed people engaging in sexual practices in a lab and recorded
physiological changes that occured

The sexual response cycle: Masters and Johnson divided the sexual response cycle into five phases
(physical and emotional)
1. Desire phase
> includes fantasy
2. Arousal phase
> engorgement occurs (erection in penis)
> enlargement of labia and clitoris
> myotonia
> alot of muscles in body become tense and this leads to muscular contractions involved in orgasm
3. Plateau phase
> try to extend phase as long as they can
4. Orgasm phase
> discharge of neuromuscular tension that has been built up during the excitement and plateau
stages
> males have rhythmic contractions of the prostate, penis and urethra and ejaculation
> refractory period of a few minutes or hours when they can’t reach another erection or orgasm
> females have rhythmic contractions of the vagina, females don’t have a refractory period so
can experience more orgasms immediately after following one
5. Resolution phase
> people significantly in terms of length and distinctiveness of each phase and women’s responses
tend to be more variable than men
> occasional difficulties with one or more stages are common (stress, medication or issues in
relationship, persistent challenges that cause distress might be diagnosed with sexual dysfunction
DSM-5-TR sexual dysfunction
• when evaluate whether someone has a sexual dysfunction, it is important to
assess partner factors (partner has health issues, sexual challenges,
relationship factors (conflict, communication), vulnerability (history of abuse),
cultural or religious beliefs and relevant medical conditions)

Bill and Margaret case study

A model showing how anxiety and cognitive interference can produce erectile
dysfunction and other sexual disorders

Murry case study

The kinds of sexual practices people find appealing

Paraphilic disorders
• definition and disorders themselves are controversial
• Presence of paraphilia does not constitute a disorder, diagnosis is only
given when the behaviours cause the individual to have distress,
impairment or causes or leads to strong risk of harm to others
• Why are some variations in sexual behaviours, mental disorders while
others are not?
• Most research literature regarding paraphilic disorders is limited and
inconsistent and provides little information about how assess the degree
of pathology
 ▫

psychology
The context is important to how we label as normal or abnormal and the culture they belong to
LOOKING AT ABNORMALITY: • we tend to be experts in abnormal because of the way we were socialized
NORMAL :Behaviours, thoughts, and feelings are the following:
• Typical for the social context
• Not distressing to the individual
• Not interfering with social life or work/school
• Not dangerous
Example: College students who are self confident and happy, performed to the capacity in school, and have good friends)
SOCIALLY ESTABLISHED DIVISION BETWEEN NORMAL AND ABNORMAL: Behaviours, thoughts, and feelings are one or more of the following:
• somewhat unusual for the social context
• distressing to the individual
• Interfering with social or occupational functioning
• Dangerous
example college students who are often unsure and self critical, occasionally abuse, prescription, drugs, fail some courses, and avoid friends who disapprove of their drug use)
ABNORMAL: Behaviours, thoughts, and feelings are one or more of the following:
• highly unusual for the social context
• The source of significant individual distress
• Significantly interfering with social or occupational functioning
• Highly dangerous to the individual or others
Example college students who are hopeless about the future, our self loathing, chronically abuse, drugs, fail, courses, and have alienated all their friends
Defining Abnormality Abnormal psychology is also known as psychopathology, abnormal behaviour is not the same as psychological disorder (need certain things met)
• The four dimensions of abnormality:
Dysfunction - dysfunctional when they start to interfere with peoples ability to function, forming relationships, or studying or holding a job
Distress - cause distress to individual themself and to the people around them
Deviance- deviant from the social norm, vary across cultures
Dangerousness - harm to individual (cutting, burning) and to others through aggression
The Disease Model of Mental Illness the focus is identifying what is wrong with the individual to provide treatment
• No biological test is available to diagnose the psychological disorders that we will discuss in this course
Mental disorders consist of issues concerning cognition, emotional responses/regulation, and social behavior (biologically and enviornmentally understood)
• ex. Patient with schizophrenia
CULTURAL RELATIVISM oppsite from the disease model of mental illness
• Cultural relativism: the perspective that no universal standards exist for labelling behaviors as abnormal
Abnormality exists only relative to cultural norms
Opponents of cultural relativism: argue that it can be dangerous when cultural norms are allowed to dictate abnormality
Thomas Zaz:psychiatrist societies often label people as abnormal to justify the control of the group (ex. Hitler saying jews were abnormal, slavery in the US, only in 1973 that
the American Psychiatric removed homosexuality as abnormal)
HISTORICAL PERSPECTIVES ON ABNORMALITY:
• 3 types of theories have been used to explain abnormal behavior:
1) Biological Theories - abnormal behaviour is similar to physical diseases, treatments surround restoring bodily health
2) Supernatural Theories- abnormal behaviour is because of divine intervention, sins, curses, demonic, treatment involves rituals, atomics, confessions and exorcism
3) Psychological Theories- abnormal behaviour is because of physiological processes like beliefs, coping styles, and life events (trauma) treatment = rests, relaxation, changing
environment and thought processes
• the way we see an abnormal individual is impacted by our theoretical position
ANCIENT THEORIES:
• Many historians speculate that prehistoric people had a concept of insanity likely tied to supernatural beliefs (treatment was exorcism sometimes killed)
• Treatment for abnormality during Stone Age and into Middle Ages: drilling holes in skull of the individual displaying abnormal behavior using a trephine (trephination)
Purpose: to allow evil spirits to depart
• holes in the skulls date back to half a mill year ago, and sections were cut away
• Individuals who heard things that weren’t real or who were chronically ill often faced this
• Some believed it was to treat blood clots so still a matter of debate
• Ancient China: human body has a positive force (yang) and a negative force (yin) which both confront and complement each other. If forces are not balanced, insanity can
result
• with the rise of Buddhism and dowism, this led to the evil ghosts being blamed
• Ancient Egypt, Greece, and Rome
Strong reliance on biological theories
“Wandering uterus”: (quite common) when women experienced unexplainable aches, sadness, apathy, it was thought that the uterus would wander around the body and
create ailments when it was hungry for semen (e.g. if stuck in the rib cage may lead to chest pain)
- Greeks named this disorder hysteria (hystera means uterus)
- Treatments: vaginal fumigations, fragrances, vaginal inserts made of wool
- The ultimate treatment for issues with the womb: marriage, sexual intercourse, and pregnancy
• shows how mental disorders can be misinterpretated and can lead to
}
 ▫

psychology
ANCIENT THEORIES CONT’D:
• Ancient Egypt, Greece, and Rome
Hippocrates: believed removing pateitn from difficult family could help restore mental health
- Regarded as the father of medicine
- Abnormal behavior is akin to other bodily diseases
- Body is composed of 4 basic humors: blood, phlegm, yellow bile, and black bile
- Diseases are caused by imbalances in these humors
• categorized into 4 main categories: epilepsy, mania, melancholia and brain fever (treatment to restore the balance of the humors, bleeding patient, rest, relaxation, change
in diet) non medical and same as modern except for blood
Plato- belief that insanity occured when irrational mind was overcome by impluse, passion or appetite (treatment was discussion with individual with intention with restoring
rational control over emotions)
• Medieval Views:
Middle Ages (400-1400CE): strong dependence upon supernatural explanations of abnormal behavior (particularly in the late Middle Ages)
- Most laypeople believed in demons/curses as cause of abnormal behavior.
- Physicians and government officials acknowledged physical causes or trauma as underlying cause of abnormal behaviour
• during 11th century, individuals practicing witchcraft were targeted known as renaissance
ASYLUMS: harsh and inhumane conditions
• 12th century: Europe started to take responsibility for housing/care of individuals considered to be mentally ill
• 11th-12th century: general hospitals started to include special facilities for individuals who showed abnormal behavior
• Act for Regulating Madhouses in England:
Passedin1774
Purpose: to assist in improving conditions of hospitals and madhouses and protect individuals from being unjustly jailed for insanity
• the mentally ill were basically inmates, patients were exhibited to public for fee, chained to a wall, locked in small boxes
TREATMENT IN 18TH-19TH CENTURIES: industrial revolution
• Mental hygiene movement:
New treatment approach based on the view that individuals developed psychological issues because of:
- separation from nature
- stress associated with rapid social changes
Treatment: prayers, incantations, rest, relaxation (in a serene and physically appealing location)
• Dorothia dicks, retired school teacher visited a jail and found poor and brutality, she allowed laws to improve institutions
• In the 19th century, increasing of patients in asylums and prejudice to foreigners and quality of care went back down, effective treatments developed in 20th century
and those who couldn’t afford got no treatment
EMERGENCE OF MODERN PERSPECTIVES:
BEGINNINGS OF MODERN BIOLOGICAL PERSPECTIVES:
Late 19th century:
Knowledge of anatomy, physiology, neurology, and chemistry of the body increased significantly
- Increasing focus on the biological underpinnings of abnormality
• Richard craft: sphyillis can be a cause of insanity and helped push forward that biological factors can lead to abnormal behaviours
- Wilhelm Griesinger (1945): published The Pathology and Therapy of Psychic disorders
- Argued that all psychological disorders are due to brain pathology
- Emil Kraepelin (1856-1926): published a similar text and developed a system for classifying symptoms into discrete disorders
Why is it important to have a classification system? This can be very critical for researchers to have a common set of terms and criteria to distinguish between disorders and
to advance studies of tjem
THE PSYCHOANALYTIC PERSPECTIVE:
• Franz Mesmer (1734-1815): believed that distribution of magnetic fluid in one person could be impacted by others and alignment of planets
Austrian physician who applied animal magnetism to treat diseases the focus was among those with hysteric disorders where they would lose feeling in body and used iron
rods to realign magnetic force (changes occured due to hypnosis)
Held the belief that individuals have a magnetic fluid in their body that must be distributed in a specific pattern to maintain health
• Sigmund Freud (1856-1939): said hypnosis could lead to catharsis
Viennese neurologist
Argued that a significant portion of mental life is unconscious
- Worked with Josef Breuer (1842-1925)
- Physician interested in hypnosis/unconscious processes
THE ROOTS OF BEHAVIOURISM:
• Ivan Pavlov (1849-1936): unconditioned stimulus = food, unconditioned response = salvation, conditioned stimulus = footsteps with person with food
Russian physiologist
Discovered classical conditioning:dogs could be conditioned to salivate if presented with stimuli previously paired with food.
• John Watson (1878-1958):
Used classical conditioning principles in order to understand human behaviors (e.g. phobias) passing by same intersection you had accident, says that fear could be reduced by
exposure while maintaining relaxation
• Thorndike (1874-1949) and Skinner (1904-1990):
Studied how the consequences of behaviors can impact their likelihood of recurring
- Operant/instrumental conditioning
• behaviours followed by pos consequence are more likely to be repeated and vice versa
 ▫

psychology
THE COGNITIVE REVOLUTION:
• 1970’s saw a significant shift towards the study of cognitions
Focus on thought processes which mediate the association between stimulus and response
Cognitions: thought processes which impact behavior and emotion
- Encompass attention, beliefs, and interpretations of events
- Pioneers in the cognitive revolution:
- Alberta Bandura- argued self advocacy (a persons beliefs regarding their ability to execute behaviours required to control an event) beliefs are
imporant in determining sense of well-being
- Albert Ellis - individuals who are prone to psychologiclal diorders are prone to having negative assumptions about themselves and world (developed
rational emotive therapy - considered to be controversial as patients had to challenge their irrational belief systems
- Aaron Beck - irrational thought who had psychological disorders and beck cognitive therapies is the most used for depressive and anxiety based
disorder
MODERN MENTAL HEALTH CARE
• 1950s saw significant breakthroughs in drug treatments
This was associated with deinstitutionalization: meaning the patients prescribed the drugs no longer need to be institutionalized b/c their symptoms were controlled
• Between 1955 and 2016 the number of patients in psychiatric hospitals went from 500,000 to 38000, seen in US, europe and Canada
• 1960’s patients’ rights movement:
Advocates argued that patient recovery was supported if individuals were integrated into the community rather than being institutionalized in asylums and hospitals
- More satisfying lives could be achieved with the support of community-based treatment facilities: represented positive change
MODERN MENTAL HEALTH CARE CONT’D:
• Community mental health centers:
Typically include multidisciplinary teams of therapists,social workers, and physicians
- Halfway houses: offer individuals with long-term mental health issues to live in a supportive and structured environment
- Day treatment centers: partial hospitalization programs (PHP) provide more intensive therapy for those with greater needs: less intense than patient or resident
placements
- When is hospitalization necessary? Necessary for individuals who have acute psychiatric symptoms, average stay is 3-10 days, once the acute symptoms have
subsided, they are usually released to a community based center for continued care, to treat serious mental health problems, more time is necessary
• Many people who are chronically ill are re-hosptialized every week
• Pros and cons of deinstitutionalization:
In some cases, (primary benefit if enough primary resources are available) can enhance the quality of life for individuals
Cons:
- Because of the underfunding of community mental health programs: Many individuals left institutions only to become victims of poverty and neglect
• limited access to impatient treatment is associated with higher risk suicide, homelessness, premature mortality, violent crime and incarceration
DEINSTITUTIONALIZATION AND CRIME:
• Because of the lack of accessible treatment:
Many individuals with severe mental illness (SMI) end up in hospitals for short durations with inadequate treatment and others become part of the criminal justice
system
Individuals with SMI are increasingly becoming transinstitutionalized ( process where people who previously have been deinstitionalized become institutionalized in a diff
setting - from hospital to jail) to the criminal justice system
• Research conducted among prison inmates: suggests that 2/3 of inmates had some form of diagnosable mental health disorder in their lifetime.
Approximately 60% of inmates reported having symptoms of a mental health disorder within the year preceding their incarceration.
• Despite the high rates, about 83% did not receive mental health care after being in jail
• Trend seen around the world,prisons replacing hospitals
TREATMENT UTILIZATION:
• Many individuals with psychological disorders do not receive treatment
Approximately 33% of adults with a mental illness and 41% of adults with a serious mental illness have received treatment in the past year (majority of the people
who need help, they don’t get the help they need)
Treatment barriers:
- Structural barriers: cost, not knowing where to get help, not being able to get an appointment
- Attitudinal barriers: perceived stigma, perception of treatments to be ineffective
PROFESSIONS WITHIN ABNORMAL PSYCHOLOGY:
• Psychiatrists: can perscribe meds
Have an MD degree
Have specialized training in treatment individuals with
psychological disorders
• Clinical Psychologists: can conduct psychotherapy but not give meds
Usually have a PhD in psychology
Specialize in treating/researching psychopathology
PsyD degree: doctoral degree from a graduate program emphasizing clinical training more heavily than research training
• Master’s-level career options:
Marriage and family therapists (MFT)
Clinical social workers (masters degree)
Mental health counsellors
Psychiatric nurses (degree and specialization
 ▫

psychology
THEORETICAL PERSPECTIVES:
• Theory: set of ideas which provide a framework to ask questions regarding a phenomenon and for collecting/interpreting information about that phenomenon
The vast majority of theories of psychological challenges have searched for one factor: one gene, etc which is the cause of psychological symptoms
Therapy: a treatment which is typically based upon a theory of a phenomenon
• Targets the factors that (the theory asserts) cause the phenomenon of interest
- Many contemporary theorists adopt a biopsychosocial approach (recognizes the development of psychological symptoms is due to the combination of
biological, cultural and sociocultural factors - all collectively referred to as risk factors
RISK FACTORS:
• Typically risk factors create an increased risk for numerous different issues
Transdiagnostic risk factors: factors which increase the risk of many types of psychological issues ex. Severe stress from childhood trauma
Some risk factors may lead to very specific symptoms
• psychological risk: difficulty staying calm
• Sociocultural: growing up with stress of discrimination
DIATHESIS-STRESS MODEL
Diathesis: means risk factor
diathesis-stress model: agrues that onlu when
you have risk factor and stress (trigger) thats
when you have a disorder
TREATMENTS:
• Proponents of biological, psychological, and sociocultural theoretical perspectives tend to adopt different treatment approaches
• Biological: prescribe meds, socio: psycho therapy using therapist and discuss symptoms and factors
• Both have proven to be effective and often used together, meds alone has increased
• sociocultural might try to change social conditions to improve mental health
BIOLOGICAL APPROACHES:
BRAIN DYSFUNCTION:
• The brain is divided into 3 main areas:
Hindbrain: includes all posterior parts of brain, closest to spinal cord (important for basic life function,
Midbrain: located in middle brain
Forebrain: front part of brain
FOREBRAIN:
• Subcortical structures: are located just under the cerebrum
Thalamus: directing info from sensory to cerebrum: vision, hearing Relaying sensory info and
Hypothalamus: regulating eating, drinking, sexual behaviour, basic emotions movement
Pituitary gland: endocrine system Regulates responses to
Limbic system: set of structures critical for instinctive behaviour: eating, drinking, response to stress rewards
- Amygdala: processing emotions *fear Control breathing and reflex
- Hippocampus: consolidating memories Timing of sleep and attention, network
of neurones that controls arousal
BRAIN DYSFUNCTION:
• Causes of brain dysfunction:
Controls coordination of movement
Injury (e.g. head injury from contact sports)
Diseases (e.g. Alzheimer’s disease)
Alternation to size and activity of frontal cortex are associated with schizophrenia, depression, ADHD
Particular areas of the brain are associated with a range of psychological functions
BIOCHEMICAL IMBALANCES:
• Neurotransmitters: biochemicals which act as messengers by carrying impulses from one neuron to another in the brain and in other areas of the nervous system
BIOCHEMICAL THEORIES OF PSYCHOPATHOLOGY:
• Psychological symptoms may be associated with:
The amount of neurotransmitters available within synapses. This is impacted by: both processes happen naturally, but when malfunction can have low or high
neurotransmitter
- Reuptake: happens when neuron releasing neurotransmitter absorbs the neurotransmitter and decreases what it available in synapse
- Degradation: happens when receiving/ releasing neuron releases an enzyme in the synapse and break down neurotranmitter
The number of receptors for neurotransmitters (on dendrites)
The functioning of receptors for neurotransmitters (on dendrites)
SEROTONIN:
• Travels through many areas of the brain:
Dysfunction in the system which regulates serotonin is a transdiagnostic risk factor associated with psychopathology
• emotional wellbeing, depression and anxiety, abnormal behaviours like aggressive impulses
DOPAMINE:
• Critical neurotransmitter in regions of the brain associated with:
Experience of reinforcements/rewards: impacted by substances (alcohol)
Functioning of muscle systems(ex. Strong role in disorders that involve disorders that control muscles, ex parkisons)
Dopamine dysfunction is a transdiagnostic risk factor
 ▫

psychology
NOREPINEPHRINE (NORADRENALINE)
• Neurotransmitter which is primarily produced by neurons within the brain stem(drugs like cocaine can prolong norepinephrine by slowing down the reuptake process)
• too little found in brain, individuals can get depressed
GABA: Interaction within
Genotype S/s S/l L/l
• Inhibits the action of other neurotransmitters interaction and
Many drugs have a tranquilizing effect on the body because they increase the activity of GABA genes
• disfunction associated with anxiety symptoms Individuals with at
THE ENDOCRINE SYSTEM: important for psychological disorders least 1 short had
• The endocrine consists of a system of glands which are responsible for producing hormones. higher chance of
depression but only
These hormones (chemicals that carry messages throughout the body and can have impact on mood, reactivity level and
if they had a
reaction to stress) are released directly into the blood
history of
GENETIC ABNORMALITIES:
maltreatment as
• Behavioral genetics: the study of the genetic basis of personality and abnormality kids
• Serotonin transporter gene: impacts the functioning of serotonin systems in the brain
Research suggests that the presence of at least 1 short allele on the serotonin transporter gene can increase risk for developing depression
- Polygenic: Importantly, a combination of genetic abnormalities likely contribute to depression (ex. Diabetes, epilepsy, coronary heart disease)
• combination of abnormalities likely contribute to depression
INTERACTIONS BETWEEN GENES AND ENVIRONMENT: there is a bi directional association within genes and enviornment
• Genes: impact the environments we choose
These environments can reinforce our genetically influenced interests/personalities
• children with aggression and impulses choose friends who support the impulses behaviours and give anti-social interactions
INTERACTIONS BETWEEN GENES AND ENVIRONMENT:
• Epigenetics: environmental factors can impact the expression of genes, focuses on heritable changes and the expression of genes with no change in the actual genetic
sequence
• diet, exercise, seasonal changes, financial status can have neg or pos impact on development by impacting the expression of genes
• cells, tissues, can be altered in development as a cause of enviornment
DRUG THERAPIES:
• Drug therapies: improve the functioning of neurotransmitter systems and as a result, can relieve psychological symptoms
• the standard first line treatment for the majority of psychiatric disorders include both medications and psychotherapy
• Antipsychotic drugs:
Reduce symptoms of psychosis (hallucinations and delusions)
Phenothiazines: the first group of antipsychotic drugs
- Helpful in reducing psychotic symptoms
- Side effects: severe sedation, visual disturbances, and tardive dyskinesia
• tardive dyskinesia: neurological disorders resulting in involuntary movements of the face
tongue, mouth and jaw
Atypical antipsychotics:
- Effective in treating psychosis with fewer side effects
• Antidepressant drugs:
Reduce symptoms of depression: sadness, low motivation, disturbances in appetite and sleep
- Selective serotonin reuptake inhibitors (SSRIs): most frequently used antidepressants
- Selective serotonin-norepinephrine reuptake inhibitors (SNRIs): target both serotonin and norepinephrine (side effects of both: nausea, diarrhea, headache, tremor,
sexual disfunction and agitation
• Lithium: side effects: nausea, vomitting, diarrhea, blurred vision, toxicity (organ damage) and tremor
Used as a mood stabilizer
Has been prescribed for bipolar disorder for more than 60 years (prescription rate is declining due to the side effects)
Prevents/treats mania
• Antianxiety drugs: SSRI are often prescribed due to the withdrawal symptoms
Barbiturates:
- Induce relaxation and sleep
- Highly addictive and can lead to dangerous withdrawal symptoms (life threatening - a significant rate in heart rate, delirium and convulsions)
Benzodiazepines (tranquilizers) about 80% of those who take this for 6 weeks or longer tend to show withdrawal symptoms
- Used in the treatment of anxiety, insomnia, seizures, and neuropathic pain
- E.g. Xanax, Klonopin, Valium, Ativan
- Highly addictive and show significant withdrawal symptoms (heart rate increase, irritability and sweating)
ELECTROCONVULSIVE THERAPY (ECT) 1 million people get it yearly
Introduced in early 20th century
Used to treat severe mood disorders
Treatment involves passing an electrical current (70-150 V) through a patient’s brain:
- This induces a seizure for about 1 min
- Anesthesia and muscle relaxants are administered before the procedure
- Has been shown to be effective in the treatment of:
- Depressive disorders
- Bipolar disorder
- *Potentially OCD
 ▫ ▫

psychology
ALTERNATIVE APPROACHES TO STIMULATE THE BRAIN:
• Repetitive Transcranial Magnetic Stimulation (rTMS): treatment resistant depression
Noninvasive technique to stimulate the brain
- Exposes patients to high-intensity magnetic pulses that are focused on specific brain regions
• Deep Brain Stimulation (DBS):
Electrodes are surgically implanted into particular areas of the brain (deliver stimulation to certain neural areas)
• Vagus Nerve Stimulation (VNS):
Electrodes are surgically implanted in the vagus nerve (vagas nerve: transports info to the brain)
This approach provides superior outcomes in terms of effectiveness and mortality among patients with chronic, and treatment resistant depression, can also reveal auditory
hallucinations
PSYCHOSURGERY: main issue:we don’t know what part of the brain is causing symptoms, and numerous parts of the brain are likely
Controversial approach to treatment
• Trephination:
prehistoric form of crude brain surgery to release evil spirits
• Prefrontal lobotomy: later seen as cruel and not effective, side effects were severe and permanent (side effects: inability to control impulses, iniate actitivy, seizures and
sometimes death)
Procedure was introduced in 1935
For treatment of individuals experiencing psychosis
• By the 1950s:
use of psychosurgery had declined significantly
• Today:
Psychosurgery is used, but rarely
ASSESSING BIOLOGICAL APPROACHES:
• PRO:
Many find the biological approach appealing
- It promotes the view that mental disorders ought to be viewed as medical diseases (eliminates blame)
• CON:
Not everyone responds well to drugs or other biological treatments available
Most of these therapies have significant side effects
• critiques worry these individuals will become dependent on the meds instead of confronting the issues
• Those who rely more on biological approaches are more pessimistic
PSYCHOLOGICAL APPROACHES: Behavioural approaches
BEHAVIOURAL APPROACHES
• Classical Conditioning:
Ivan Pavlov discovered this phenomenon
Behavioral Approaches
• Operant Conditioning:
E.L. Thorndike:
- The Law of Effect: behaviors that are followed by a reward are strengthened. Those that are followed by a punishment are weakened
Operant conditioning: shaping behaviors by
- providing rewards for desired behaviors
- providing punishments for undesired behaviors
- B.F. Skinner promoted research in this domain (stated that birds could press bars if bars were associated with delivery of food, pigeon would avoid if it was associated
with electrical shock)
• Operant conditioning reinforcement schedules:
Continuous reinforcement schedule (reward or punishment every time the behaviour occurs)
Partial reinforcement schedule (reward or punishment happens sometimes the behaviour occurs)
• Extinction: elimination of a learned behavior (Extinction is more difficult if behaviour was learned through partial reinforcement
• Hobart Mowrer’s (1939) two-factor model (shows how combinations of classical and operant conditioning can explain how fears persist)
• Initially individuals develop fears through classical conditioning (ex. Woman may fear malls as she was assaulted in one a year ago), second stage is they develop
behaviours to help them avoid triggers for that fear (Ex, woman would avoid mall) extinction cannot happen if she doesn’t expose herself
• Modeling and Observational Learning:
Albert Bandura:
- Social Learning Theory: people learn to engage in behaviors by watching others
- Modeling (people learn by imitating influential people (caregivers)) - more common if the person who they are imitating is see an an authority figure or the
individual modelling behaviour is be like oneself (kids are more likely to look at the same-sex caregiver as them)
- Observational learning (people observes the rewards or punishments another person gets for their behaviour and acts accordingly (observing consequences
of others behaviour ex sibling getting in trouble
- Some researchers argue that observational learning can be used to explain violence and criminal activity
 ▫

BEHAVIOURAL THERAPIES:
psychology
• Focus:
Identify reinforcements and punishments that impact a person’s maladaptive behaviors
- Try to alter specific behaviors
- Requires a behavioral assessment of the client problem
• ex( what are the triggers, when are the likely to use drugs, what are the circumstances)
• Systematic desensitization therapy:
Gradual approach for the extinction of anxiety responses to stimuli AND the maladaptive behavior associated with that anxiety
• clients will learn relaxation and fear stimuli, therapist helps by using least feared to most feared stimulus while doing relaxation exercises
• good treatment the most for anxiety, and often combined with modelling (watching the therapist)
ASSESSING BEHAVIOURAL APPROACHES: limitations are unclear, doesn’t recognize the impact of free will
• The effectiveness of behavioral therapies has been strongly supported in controlled studies
COGNITIVE APPROACHES:
• Causal attributions:
The attributions that we make for events that occur in our lives can have an impact upon our behavior
The attributions we make for our behavior can have an impact upon our emotional responses and self- concept
Global assumptions: broad beliefs that we have about ourselves, our relationships, and the world.
- Can be positive/helpful or negative/destructive
• albert elis and aaron beck made the arguement that the vast majority of maladaptive behaviours result from disfunction global assumptions
• disfunctional assumptions: rigid rules for living that tend to be unrealistic (“i should be loved by everyone” or “its better to avoid problems than to face them”
individuals who hold onto these will react to situations with irrational thoughts and behaviours
• example: if we act rude to another person we attribute that to situational factors (not having a good sleep), and not feel as guilty, however if you attribute that to
personal factors (not being a nice person) you are more likely to feel guilty
• Cognitive therapies: this approach is designed to be short-term (12-20 sessions, 1-2 a week)
Assist clients in identifying and challenging negative/dysfunctional beliefs
Goal: collaborate with clients to define issues and teach them effective problem-solving techniques to more adaptively cope with their challenges
Main goals to therapy: 1. To help clients identify maladaptive thoughts (ex, diary of thoughts) 2. Teach the clients to challenge their maladaptive thoughts so they will be
encouraged and 3. Encourage clients to face their fears and understand how to cope effectively
• Cognitive-Behavioral Therapy (CBT): very common,
Cognitive techniques combined with behavioral techniques
Focus: problem-oriented, emphasis on the present
ASSESSING COGNITIVE APPROACHES:
• Maladaptive cognitions are common among individuals with:
Mood disorders
Anxiety disorders
Sexual disorders
Eating disorders
Substance use disorders
• limitation: hard to prove that maladaptive cognitive being the cause rather the consequence
*Cognitive therapy tends to be useful in the treatment of these disorders
PSYCHODYNAMIC APPROACHES
• Freud developed psychoanalysis (collaborated with Jospeh Brewer in order to understand a client named Anna Oh, used hypnosis on her)
Catharsis: release of emotions connected to unconscious memories, hysteria that anna oh had were from repressed memories
Repression: motivated forgetting of a distressing experience (symptoms can still become manifested, so it doesn’t eliminate the emotion with the memory
PSYCHODYNAMIC THEORIES: 3-4 session per week for years, symptom relief over focus on past
• Ego psychology: emphasizes the importance of a person’s ability to regulate their defense mechanisms in a way that facilities healthy functioning within a society
• Object relations (Klein, Mahler, Kernberg): our early relationships create unconscious representations of ourselves and others
• these are carried with us for our entire life and cause expectations for future relationships (ex. Early relationship with care givers can effect future relationships)
PSYCHODYNAMIC THERAPIES: goal: help clients understand the maladaptive coping strategies they use and the sources of unconscious conflucts
• Focus: uncovering and resolving unconscious factors responsible for psychological symptoms
• Free association: a client talks about whatever comes to mind without censoring themselves
• Client’s resistance: material that the client is resistant to talking about
• Transference (happens when clients responds to therapist like father or mother) and countertransference (therapist builds emotions and feelings for clients): can be
important sources of insight and can be used as a tool in psychotherapy
Most threatening conflicts are the ones that our ego tries to repress
• Comparing classical psychoanalysis vs modern psychodynamic theory
• Interpersonal therapy (IPT):
Emerged from modern psychodynamic theory
Focus on the client’s pattern of relationships with individuals in their life
• therapist is structuring and directive, often therapist will provide interpretations early on with strong focus on how the client can change their current relationship
ASSESSING PSYCHODYNAMIC APPROACHES:
• Psychodynamic approaches have played a strong role in shaping psychology and psychiatry (primarily in highlighting the importance of the unconscious mind)
• Limitations:
Difficulty in testing fundamental assumptions in this approach using valid/reliable methods b/c key factors are unconscious
Generalizability is questionable
Financially inaccessible to many (since it tends to be long-term)
 ▫

HUMANISTIC APPROACHES
• Carl Rogers (1951):
psychology
Developed humanistic theory
Believed that people naturally move in the direction of personal growth, self- acceptance, and self- actualization (self-actualization is defined as fulfillment of our potential
for our creativity, meaning and love in our lives)
- Pressure from others can interfere with this (can have distorted perspective of ourself)
HUMANISTIC THERAPY: hold the belief that if they can provide the client with a supportive environment and relationship, that the client will grow and gain insight
• Purpose: assist clients in discovering their greatest potential through the process of self-exploration
• Client-centered therapy (CCT):
Developed by Carl Rogers
Therapist communicates:
- Genuineness
- Unconditional positive regard
- Empathetic understanding
- * Primary strategy to communicate these elements is reflection
• the therapist will express an attempt to understand what the client is trying to say
ASSESSING HUMANISTIC APPROACHES:
• has helped with individuals diagnosed with depression, alcoholism, schizophrenia, anxiety, and personality disorders (good for those partially distressed, not for severely
distressed)
• This approach gained significant traction in the 1960s. Currently is utilized in:
Self-help groups
Peer-counseling programs
Humanistic theories focus on helping individuals to achieve their greatest potential rather than focusing on pathology.
Criticisms:
- Vague
- Difficult to test empircally
FAMILY SYSTEMS APPROACHES:
• The family is viewed as a complex interpersonal system
• Hierarchy and rules: shape and sculpt family member behavior
Can be functional (dynamic support growth of family members and accept change) or dysfunctional (nurture psychopathology and maintain it)
FAMILY SYSTEMS APPROACHES:
• How psychopathology manifests in an individual is contingent upon:
Family cohesiveness
Communication style
Adaptability to change
Common issues in family systems: inflexible family(resistant to forces outside family and do not adapt well to changes in family), enmeshed family (family members overly
involved, individual family members may feel controlled), disengaged family (family doesn’t pay attention to each and act as isolated units)
FAMILY SYSTEMS THERAPY: family system theorists believe that a person’s problems stem from interpersonal problems, you cannot help the individual without treating the
entire family
• Behavioral Family Systems Therapy (BFST): focuses on family communication and problems solving
Behavioral and cognitive methods are harnessed to teach effective communication and problem solving skills
ASSESSING FAMILY SYSTEMS APPROACHES: research in this domain can be hard since relational dynamic are hard to capture, they will often behave differently in a lab
• Particularly useful in the treatment of children
• Families play a strong role in impacting psychological symptoms of its members
THIRD-WAVE APPROACHES:
DIALECTICAL BEHAVIOUR THERAPY (DBT): most established third way approach and developed by marsha lineham to treat those with borderline personality disorder, more with
borderline personality disorder who are suicidal
• Dialectical: there is continual tension between conflicting thoughts, images, or emotions among individuals who are at risk of psychopathology (ex. Individuals with borderline
personality disorder will feel like they want to connect with and push away an individual, conflicting emotions)
Three main goals: 1. To improve problem solving skills, 2. To improve interpersonal skills 3. To improve the management of negative emotions
DBT focuses on the effective management of negative emotion and effortful control over impulsive behaviors
• DBT has significant transdiagnostic relevance, it has been adapted to treat mood and eating disorders, issues with emotional regulation and impulse control issues
ACCEPTANCE AND COMMITMENT THERAPY (ACT)
• Developed by Steven Hayes
Fundamental assumption that experiential avoidance (avoidance of painful thoughts, emotions or memories)underlies many mental health problems
Intervention models combine:
-Mindfulness (state of consciousness where attention is focused on the present) and acceptance (willingness of a person to experience their thoughts, emotions and
sensations without trying to change or avoid them) in order for positive thoughts
- Behavioral principles
- Understanding of personal values
ASSESSING THIRD-WAVE APPROACHES: further research is needed on how these approaches work and why they work so affectively
• Effectiveness of therapies with a focus on emotion regulation suggest that these approaches can be useful in treating many mental health challenges
USING NEW TECHNOLOGY TO DELIVER TREATMENT: there are many disparities for mental health access associated with ethnicity, race, low SES, rural locations, immigration
status
• The rate of mental health challenges is higher among disadvantaged ethnic minority groups
These are the groups that also have less access to mental health services
• Telepsychology: can reduce disparities in mental heath service access (used during covid 19)
 ▫

SOCIOCULTURAL APPROACHES
SOCIOCULTURAL FACTORS:
• Socioeconomic disadvantage:
-
Transdiagnostic risk factor for many mental health concerns
psychology
• Upheaval and disintegration of societies are risk factors for mental health concerns
• Social norms and policies stigmatize and marginalize certain groups of individuals:
These individuals are at an increased risk for mental health challenges
- E.g. LGBTQ individuals experience higher rates of substance use, anxiety, depression, and suicidality in comparison to heterosexuals, there is a 7% reduction of suicide
attempts for sexual minority youths in states who passed marriage
• Culture: knowledge and meaning within a group of individuals which is passed on through generations. Strong focus on shared:
Beliefs
Values
Behaviors
Ways of life
Shared cultural belief systems play a strong role in determining how psychological disorders are understood and how they are identified, rates vary across sexes and cultures
• Impact of social media:
We are more likely to accept information which supports our beliefs and we are more likely to seek out friends with similar beliefs
• opinion based confirmation bias can end up strengthening rumours and tends to segregate groups and end up with echo chambers
Echo chambers:
- Like-minded clusters of opinion
- Selective exposure to others and opinion-based confirmation bias ends up reducing the likelihood of exchanging different perspectives
• The new age of misinformation has significant consequences for culture and our understanding of mental illness
CROSS-CULTURAL ISSUES IN TREATMENT: people with diverse backgrounds are typically treated with the same psychotherapy
• Multiculturalism in therapy: a clinician’s investment into embracing cultural differences which exist in their clients.
They must simultaneously acknowledge the impact of their own culture in shaping their perceptions of and responses towards clients.
• Psychotherapy: emphasizes the expression of emotions and vulnerability in sharing personal concerns
Some cultures tend to value restraint in emotional expression, others place a high premium upon emotional expression
• Italian and Jewish families tend to show tendency to use emotional expression to show vulnerabilities, conversely Scandinavian asian and native Americans tend to
withdrawal and don’t discuss feelings and openly
• Family based therapy tends to be more appropriate than individual therapy with cultures that are highly family oriented (ex. Native american, hispanic, african american,
asian)
• Is ethnic matching between therapist and client important? Research tends to show that it doesn’t tend to be important to predict, matching can have an impact on client
preferences and treatment attendance
• Is gender matching between therapist and client important? In terms of gender matching, there isn’t much evidence, both male and females report a therapist of the same
gender, gender matching may be beneficial for comfort (important for searching and continuation
ASSESSING SOCIOCULTURAL APPROACHES:
• The sociocultural approach highlights the importance of focusing on larger social and cultural forces that impact behavior
• Strength: this approach does not place the responsibility of psychopathology on the individual
• Drawback: vague about how social and cultural factors cause psychological disturbances among individuals
Professions that focus on empowering the individual to alter social circumstances to improve quality of life are community psychologists and social workers
PREVENTION PROGRAMS: all three work to reduce psychopathology on individuals and community
• Primary prevention: ex. Drug abuse (changing neighbourhood characteristics)
Stopping a disorder from developing (before they even start)
• Secondary Prevention: could do questionnaire
Detecting a disorder at its earliest stages
Early identification through screening
Interventions designed to prevent the illness from becoming worse
• Tertiary prevention: ex medical treatments
Assisting individuals who already have a disorder
Goals: prevent relapse, reduce the impact of the disorder on the individual’s quality of life
COMMON ELEMENTS IN EFFECTIVE TREATMENTS
• Positive therapeutic relationship between client and therapist: can be a good indicator of outcomes (positive may account for more successful treatment)
• since therapy in interpersonal, it is an emotion experience and they need to trust them and believe they understand them
• clients with a positive relationship with therapist are more likely to be vulnerable, try new skills and new coping technique
• authenticity, empathy, unconditional positive regard
• Having an explanation for symptoms
• having a label for their symptoms and explanations helps them to feel better
• Client buy-in to the treatment approach
• when the rationale behind the approach, they are more likely to engage actively and apply the principles they learned in their daily lives and complete homework
• Confrontation of painful emotions
• assist individuals to become less sensitive to those emotions
• behavioural, systematic desensitization, psychodynamic might be used
• goal is to help client accept emotions and express them instead of avoiding
Purpose of all; to promote positive change and increase psychological functioning and well-being in the everyday life
 psychology
In this figure you can see the connection between institutionalization and incarceration
• data from US
• individuals released from psychiatric institutions, they start to live in group homes where there
wasn’t enough mental health support
• Some individuals didn’t have the support to watch and take care of mental health individuals so
there was a significant increase in homelessness (around 20-50% homeless suffer from
mental illness most commonly drug or alcohol dependence
• Bidirectional relationship between homelessnes and mental health patients

Same trend of incarceration from US occurs in Canada

• looks at psychiatric deinstitutionalization in BC and the neg consequences

Integrationist approach:
Biological what are your biological vulnerabilities?
Psychological: what coping mechanisms do you use? Do you feel in control of your life and problem solving
strategies
Social: do you have a support network?
All the factors collectively predict an individual’s mental health

Natural response IVAN PAVLOV:

They would salivate with food in mouth or if they heard footsteps
Ex. After a car accident a person may have stress response after seeing their vehicle

Behaviour change techniques:

 psychology
These three are biocycle social approach to understanding mental health
Risk factors all intertwine
Sociocultural: result of culture norms and environmental, deviance
behaviours are understandable from social stress
Biological: disorders as abnormal genes or neurobiological disfunction
Psychological: disorders result of thinking processes, personality styles

Cerebral cortex: outer layer of cerebrum, involves in complex thinking, two

hemispheres connected by corpus callosum
Each lobe separated into 4: frontal, parietal, occipital and temporal

Neurotranmitter

LIMBIC SYSTEM

ENDOCRINE SYSTEM:
Pituitary gland: Master gland- produces large
number of hormones and controls secretion
processes of other endocrine glands
• relationship with hypothalamus: illustrates GENETIC
complex interactions between central ABNORMALITIES
nervous system and endocrine
• When experiencing stress, neurons in
hypothalamus secrete CRF, carried from
hypothalamus to pituitary and stimulates the
pituitary to release ACTH, ACTH is carried by
the blood stream to adrenal glands and
triggers the release of approx 30 hormones
to help the body to adapt to emergency
situations At conception, zygote contains 46 chromosomes
• Individuals who have dis regulated HPA axis • one pair determines sex XX = female XY= male
have abnormal physiological responses to • Mother will always give x, male can give xy
stress that can make it more challenging to
• Alterations to chromosomes can cause:
cope with stress and can cause anxiety and
• down syndrome: one extra chromosome on
depression
21 pair, intellectual disabilities, heart malformations,
• HPA axis often implicated in stress but also in
facial features (flat face, small nose, slanted eyes)
anxiety and depressive disorders
• chromosomes contain genes and DNA
• Genes provides coded instructions, come in pairs
• Abnormalities in genes are more common than
abnormalities in the structure or number of
chromosomes
 ▫

ASSESSING AND DIAGNOSING ABNORMALITY

psychology
HOW ARE PSYCHOLOGiCAL DISORDERS EVALUATED?
• Purposes of psychological assessment: involves interviews, observations, psychological and neurological tests to get a better understanding and refine
Collect information
Draw conclusions
Develop treatment plan *most important
• Assessment: process of using clinical methods in order to evaluate psychological, social and emotional functioning
• information gathered includes symptoms, methods of coping with stress, physical conditions, drug and alcohol use, family history, cognitive functioning
• Utility of a standardized diagnostic system: Ex. DSM 5 and ICD 10
Supports effective communication among mental health professionals:
Facilitates research:
Informs community regarding best practices for treating psychological disorders
ASSESSMENT TOOLS:
Validity:
• Validity: the accuracy of a test in assessing what it is meant to measure
Concurrent (or convergent) validity: the degree to which a test shows the same results as other established measures of the same thoughts, behaviors, or feelings
*there are no definitive tests for the psychological disorders that we will discuss throughout this course
Reliability:
• Reliability: consistency of a test in measuring what it is supposed to measure
• Issue: when individual complete a test the second time they might try to complete the same responses, avoid this using alternative form
Standardization:
• Standard method of administering a test:
Can improve validity and reliability and reduce impact of extraneous factors
• Standard method of interpreting a test:
Increases the validity and reliability of test interpretation (ex. Have scores above a certain number considered to be clinically extreme)
Clinical Interview: subjective
• Typically a face-to-face conversation between a client and mental health professional
Information is gathered regarding:
Behavior
Emotions
Attitudes
Life history
Personality
Mental status exam is often used: evaluate 5 main categories
1. Client appearance and behaviour: look at overt physical behaviours, appearance, cooperation, facial expressions
2. thought process: how fast does client think? Are thoughts disorganized or in an organized manner?
3. Mood and affect: does client seem to be depressed? What mood do they say and does that match appearance?
4. Intellectual functioning: attentive to how well client speaks, any attention or memory deficits
5. Sensorium: clients general awareness of surroundings, and orientation to things like time place and people. If a client understands when and where and who they are,
they tend to be appropriately oriented
• Multiple formats can be used:
Structured: ask a series of standardized questions about their symptoms and concrete criteria is used (benefit: enhanced reliability and validity, drawback: you don’t
have a whole lot of flexibility)
Unstructured: open-ended questions are asked
Semi-structured: combined both, able to follow up on specific questions in an attempt to gather more personal information
Computerized methods are currently under development
Symptom Questionnaires
• Symptom questionnaire: used as assessment tool
May be generalized or focused on a particular disorder (ex. BDI 2 useful for predicting and detecting major depressive disorder, but can
T be used as single assessment
Not used for the purpose of diagnosing a psychological disorder
Personality Inventories
• Questionnaires that are used as one component of the assessment procedure in order to assess:
Well-being
Self-concept
Attitudes and beliefs
Methods of coping
Social resources
Vulnerabilities
Perceptions of environment
• Minnesota Multiphasic Personality Inventory (MMPI): most widely used personality inventory
• translated into more than 150 languages
• includes 10 clinical skills, assess 10 major categories like: substance abuse, anxiety, etc.
•
 ▫

psychology
ASSESSMENT TOOLS CONT’D:
Personality Inventories
• MMPI was developed empirically and contains 4 validity scales (assess clients test taking skills, attitude, whether they answered honesty)
• Criticisms of the use of MMPI:
Questionable generalizability to culturally diverse samples
Linguistic accuracy of translated versions is in question
Behavioral Observation and Self- Monitoring : helps clinicians understand certain behaviours
• Behavioral observation: drawback: individuals may alter behaviour as they know they are being observed, and sometimes direction observation is impossible and would then
use role-play
Clinicians identify particular behaviors and will make note of what precedes and what follows those behaviors
This information can guide therapy
Behavioral Observation and Self- Monitoring
• Self-monitoring:
Traditionally, clients would provide a retrospective report to an interviewer about their feelings, emotions or behaviours
Smartphones currently offer innovative ways for client’s to self-monitor
• advantages: social interaction and physical emotions can be reported in real time, disadvantages: self-monitoring is vulnerable to self biases
Intelligence Tests
• Intelligence tests: usually reliable and valid, common for kids
Assess client’s level of cognitive functioning
Assess verbal and nonverbal skills
• Assessments of client intelligence can provide useful information to mental health professions in the diagnostic process
• Intelligence tests are controversial, don’t capture interpersonal or intrapersonal skills, artistic, musical skills etc
Neuropsychological Tests
• Neuropsychological tests:
Can provide useful information to assist with the detection of specific cognitive deficits
Often used if a clinician suspects neurological impairment
• Bender-Gestalt Test: paper and pencil test that tests sensory motor skills, individuals with brain damage may alter drawings or not produce them
• Doesn’t identify different types of brain damage
Brain-Imaging Techniques can reveal whether they have a brain injury or tumour and can reveal important differences such as neural activity
• Neuropsychological tests are often used alongside brain-imaging techniques in order to:
Identify specific neurological deficits
Identify possible brain abnormalities
BRAIN-IMAGING TECHNIQUES
• Computerized tomography (CT): show brain injury, tumours, structural abnormality, doesn’t show neural activity
X-ray beams are passed through an individual’s head
Radiation absorbed by each X-ray beam is measured
Uses a single plane but many different angles
Allows for an image to be constructed of a slice of the brain
Positron-emission tomography (PET):
Reveals activity in the brain
• Single photon emission computed tomography (SPECT):
Procedures very similar to those used in PET with the exception that a different tracer substance is injected, less accurate and less expensive
• Magnetic resonance imaging (MRI):magnetic field is created and causes realignment of hydrogen atoms in the brain, so when magnetic field is on hydrogen atoms emit
magnetic signals
Provides more finely detailed pictures of the brain
than other imaging techniques
Doesn’t require the use of radiation or radioisotopes
Two types:
Structural MRI : provides high resolution static imaging
Functional MRI: provides images of neural activity, images are taken just seconds apart so they will reveal brain changes in response to different stimulus
 ▫

psychology
Psychophysiological Tests
• Used to detect changes in the brain and nervous system:
Correlate with emotional and psychological changes
E.g. Electroencephalogram (EEG): measures electrical activity on the scalp induced by fire of certain neurons, used to detect seizures, tumours and strokes,
heart rate, respiration: responsive to stress, electrodermal response: galvanic skin response, electrical conductivity on the skin and emotional arousal (ex. Veteran with ptsd
might have strong electrodermal response to the images of war
Projective Tests
• Projective tests: controversial
Fundamental assumption: When individuals are presented with ambiguous stimuli, they tend to interpret this stimuli according to their current feelings, relationships,
conflicts, etc.
Two most frequently used tests:
- Rorschach Inkblot Test: developed in 1921, test is a good measure of disordered thinking, ex. In identifying schizophrenia
• has 10 cards and each card has a symmetrical in black grey and white, ask client what they see and what they think of
- Thematic Apperception Test (TAT)
• individuals are asked to make up a story in response to pictures and their stories might reflect their personality and motives
CHALLENGES IN ASSESSMENT:
Resistance to Providing Information
• Reasons for resistance:
Individual does not want to be assessed
Individual does not want to be treated
• ex. Child may be resistant if a parent told them to go to therapist as it wasn’t their idea in the first place, might purposely give biased info
• Sometimes individuals purposefully present biased and inaccurate information to the assessor
EVALUATING CHILDREN:
• Children have a difficult time self-reporting emotional and behavioral concerns: ex they will say they feel bad, mad, jealous
Parent reports can be important in understanding children’s functioning.(clinicians will interview parent) (parental perception of their children isnt important and have
different expectations for their kids behaviours)
• Children may focus on physical symptoms they are experiencing
• It is important for a clinician to be especially mindful of the nonverbal behavior that children display
• Parent psychological well-being: has a tremendous impact upon the mental health of children
• Reduced help-seeking behaviors among caregivers are associated with:
Beliefs that mental health issues are caused by a child’s personality
Negative perceptions of mental health services
Perception of stigma associated with mental health problems
• parents with a psychological disorder can have a significant impact on the behaviours of their kids, and may not seek help
• kids with anxious parents may show more psychological disfunction in heighten fears, low control, behavioural issues and insecure attachments
• Culture is an important factor in determining whether caregivers will seek help for their children:
• eastern cultures: tend to value interdependence and reliability on family (enmeshment between mother and child is supported in Japan)
• socially anxious: shy anxious or reserved are valued in Asian country, whereas in western these are frowned upon
• individuals tend to be much more likely to access treatment if they are caucasian, have insurance, live in urban area, and kid with severe mental health challenges
Cultures impact how abnormal emotions and behaviors are defined
Cultural background can impact whether caregivers seek out mental health services
• Teachers are often asked to provide information concerning a child’s functioning (sometimes first one to recognize children need mental health support)
Evaluating Individuals Across Cultures
• Mental health treatments tend to be more effective when:
Therapists display multicultural competence
• low cultural competence among mental health professionals is associated with disparities and treatment outcomes
• Ex. Minority clients are much less likely to state concerns. To seek out info or to feel trust
Treatment aligns with the client’s culture
DIAGNOSIS;
• Diagnosis: a label that we attach to a group of symptoms that occur together
• Syndrome: a set of symptoms (not a list of symptoms that every individual will display all the time, can be substantial overlap with symptoms of two syndromes
• often overlap with depression and anxiety
People differ in terms of which symptoms are most prominent
• Classification system: the set of syndromes and the rules used to determine whether an individual’s symptoms are part of one or more of those syndromes
• History of classification systems:
Hippocrates: first classification system for psychological symptoms, divided mental disorders into mania, melancholia, paranoia and epilepsy
Emil Kraepelin: published first modern classification system, forms foundation for systems we use today
• Classification systems commonly used today:
DiagnosticandStatisticalManualofMentalDisorders
(DSM)
International Classification of Disease(ICD)
 ▫

-
Diagnostic and Statistical Manual of Mental Disorders (DSM)
psychology
• First edition as published in 1952 in an effort to improve communication about the types of patients cared for in hospitals (early edition of this system relied on influence
of psycho analytical theor
Contained 60 psychological disorders
Has gone through 4 major revisions
• Most updated version is the DSM-5-TR
• Latter editions of the DSM (DSM-III and later): DMS - 5 uses a continuum in the diagnosis including autism and personality disorders
Include specific criteria that must be present to receive a diagnosis
Include a specified time duration that individuals must show symptoms in order to be given a diagnosis
The symptoms must be interfering with an individual’s:
• Ability to function
• Sense of well-being
Controversial Elements of the DSM
• The following are some of the most controversial topics regarding the current classification and diagnosis of mental health disorders:
1) Reifying diagnoses: term meaning trying to put in concrete form that is an abstract form, judgements are biased
2) Category or continuum: debate whether it should be one of these, dimensional have been added and reflect increasing support that all behaviours fall on continuum
3) Differentiating mental disorders from one another: comer morbidity, one who has one disorder may have another as their symptoms overlap ex. Irritability and
aggitation (schizophrenia, anxiety, depression) tried to fix this by reducing the overlap, specifically for personality disorders
• questions: “which diagnoses should be the primary? Which one should be treated?”
4) Addressing cultural issues: culture bound syndrome: cultural differences in delusions in schizophrenia
THE SOCIAL-PSYCHOLOGICAL DANGERS OF DIAGNOSIS;
The impact of a diagnostic label
• Once a diagnosis is given: people have a tendency to view it as real instead of as a judgment.
Thomas Szasz criticized the use of diagnostic symptoms (too many biases in determining, mental disorders don’t exist but instead are repressed by society and refuse to
accept their uniqueness)
Research by David Rosenhan (1973) highlights the unintended consequences of diagnostic labels (had him and 7 others admitted to hospitals and state that they heard
voices about empty hollow and thud, all but one got schizophrenia, the other patients noticed the normality
• Once a diagnosis is given: people have a tendency to view it as real instead of as a judgment.
Thomas Szasz criticized the use of diagnostic symptoms
Research by David Rosenhan (1973) highlights the unintended consequences of diagnostic labels
• “Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the
diagnosis acts on all of them as a self-fulfilling prophecy. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves
accordingly”
- David Rosenhan (1973)
FUNCTIONS OF DIAGNOSTIC SYSTEMS
• Despite the issues associated with diagnostic systems, they serve the following functions:
Organize psychological symptoms which facilitates communication across clinicians (mainly)
Standard diagnostic system facilitates research on psychological disorders
WHAT HAPPENS AFTER A DIAGNOSIS IS MADE?
• A client works with their therapist to develop a treatment plan
• The plan should be comprehensive, should meet the clients needs, should be designed to improve psychological functioning, establish clear goals and should allow for
patient tracking
• therapist is responsible for tracking and keeping records, and focused to put treatment on suicidal idealization, and self care
• Diagnostic labels can:
Deter individuals from seeking treatment
Support self-fulfilling prophecies by those who have received a diagnostic label

In order to get a full part of person, you need to look at these collectively
 psychology
Types of validity: Example of structured interview

If the test is measuring a general characteristic,

Test scores should be similar at two points of time

Types of reliability

Often interviews or observational members and require that they make

judgements in similar ways
• high interrater they have come to the same conclusions

MMPI

Example of Rorschach Inkblot

Test

Even if they are willing to

discuss, their
understanding of their
behaviours and emotions
may be unclear
• ex. Kindergartens
• Behaviours can
provide how they
are feeling and show
DSM - 5 PANIC DISORDER critical information
criteria
 psychology
PRACTICE QUESTIONS:
Thomas Szasz was a ______ who argued that individuals have historically labeled individuals and groups abnormal in order
to justify control of that group. Szasz is a proponent of the _______ perspective.
• Psychiatrist; cultural relativism
In their theories, _______ focused on self-efficacy whereas, _____ focused on irrational negative assumptions (about
themselves and the world) in determining psychological well-being.
• Bandura; Ellis
Albert has lived by railroad tracks throughout his entire life. He is able to disregard the noise of trains at night while he’s
sleeping because of this part of his brain:
• reticular formation
 ▫

psychology
THE STUDY OF PSYCHOPATHOLOGY:
There are many challenges in studying psychopathology:
1) It is difficult to accurately measure abnormal behaviors and feelings (have to rely on self-reports of internal states, and can be distorted both intentionally and
unintentionally, Observer assessments can be bias by stereotypes (gender, culture, etc), can have idiosyncratic biases as well as a lack of information
2) Difficulty with recruitment, hard to obtain participation (ex. To recruit individuals who experience paranoia)
3) There are likely multiple causes for abnormal behaviors and feelings (typically biological, psychological and social causes for psychopathology so hard to incorporate all)
• have to rely on numerous studies, multi method approach helps in terms of advancing the field of psychopathology
• Every research method has its own limitations
THE SCIENTIFIC METHOD
Operationalization: the specific ways to define the variables of interest and impacts how we measure and manipulate them
• the way you operationalize a term will have an impact upon the method you use to access that variable
• The scientific method: a series of steps that are used to obtain and evaluate information regarding a particular issue
This is done in a systematic manner in order to enhance accuracy and validity
1) Defining the issue to be studied
For this lecture, we will focus on understanding the relationship between depression and stress
2) Generating a hypothesis
Hypothesis: testable statement of our expectations regarding the issue of interest
• ex. Individuals who have recently been under stress are more likely to be depressed in comparison to those who have not
• Null hypothesis: people who have recently been under stress are not more likely to be depressed in comparison to those who have not
3) Choosing a method for implementation, part of your method is to define the phenomena of interest and use an operational definition
• this is how are you going to concretely define your variables within your study (variable: factor or characteristic which can vary within an individual like mood or attitude
or between individuals like sex and ethnicity)
• Independent variable: factor that is manipulated within the research study (ex. You can manipulate the amount of stress someone is experiencing)
• Dependent variable: factor that is being measured as an outcome (ex. You might want to access depressive symptoms)
4) Data collection
5) Drawing appropriate conclusions from data
6) Disseminating results
ETHNICAL ISSUES IN RESEARCH- important in abnormal psychology
Human participants committees (a.k.a. human subjects committees, institutional review boards, ethics committees): established at all universities, ensure benefits will
outweighthe risks
Ensure the protection of basic rights for every participant:
1) Understanding the study (participants need to understand the nature of the study and the factors that might affect their willingness to participate (ex. They need to
know if they feel distressed through the study, those unable to understand the risks (children, adults with cognitive impairments) they must have guardian to help make
them make a judgement
2) Confidentiality (identity and information gathered from participants must be withheld) permission is required and not aggregate data (which is typically used)
3) Right to refuse or withdraw participation (individuals must have this without suffering adverse consequences (ex. If they are earning credits at school they have have
an alternative activity) payment for being in a study can’t be so high where they feel they can’t refuse (ex. Don’t offer 1000 to homeless)
4) Informed consent(should be documented in writing, some exceptions: anonymous survey, verbal consent
5) Deception: used only when absolutely necessary (shouldn’t be deceived about any elements that would affect willingness) if used, researchers have to explain
6) Debriefing have to explain purpose of research and answer any questions regarding the research
CASE STUDIES:
Case studies:
Detailed histories of individuals who have a psychological disorder
Useful in understanding the experiences of individuals without relying on aggregate data
• if you wanted to use a case study, addressing stress or depression an individual may be interviewed in an attempt to understand whether there are links between
stressful experiences in their life and depressive symptoms friends and family may also be interviewed in order to obtain more detailed and rich info
EVALUATING CASE STUDIES:
Benefits of case studies:
They capture the uniqueness of the individual
Can be the only way to investigate rare issues (ex. Research among individuals with dissociate identity disorder , it might be difficult to gather a group of participants for
aggregate data, so instead you might focus on on individual with this disorder, neurological testing of an individual can give important info about the region of the brain that
are associated with identity switching and may help with neurological biomarkers for individuals with identity disorders
Help in generating new ideas which can be tested using different methodology
• Drawbacks of case studies:
Issues with generalizability because you focus on one individual it can be difficult to generalize
Can lack objectivity
• this can be part of individuals telling story or their mental health provider, and because of this two case studies conducted by two different researchers can lead to
different conclusions regarding motivations and vents within a persons life
 ▫

psychology
CORRELATIONAL STUDIES:
Correlational studies: most common form of research study that is conducted in the field of psychology and medicine
Investigate the relationship between an independent variable and a dependent variable
Neither variable is manipulated (ex. Association within gaming and violence or social media and depression)
Most common type of research study conducted in the fields of psychology and medicine
Types of correlational studies:
Assessment of the relationship between continuous variables (ex. Depression on a scale from 0-100 or stressors people experience and the severity of their depressive
symptoms)
Group comparison study (at least one variable is not a continuous and rather categorical)
*Either approach can be cross-sectional (observing individuals at one time) or longitudinal ( observing individuals for two or more time points - advantage= can reveal independent
variable may pre-see the dependent ex. Individuals who are not depressed may be more likely to become depressed if they experienced a stressful event
Measuring the Relationship Between Variables
• Correlation coefficient:
Statistic that represents the relationship between variables (denoted by r)
Can range from -1 to +1
• positive correlation = as values of the independent variable increase, values of dependent increase or as vice versa
• Negative correlation = as values of the independent variable increase, values of dependent decrease or vice versa
• Magnitude of correlation = extend to which variables move in tandem, the closer the correlational coefficient is to -1 or +1, the greater the magnitude (correlations in
psychological research are in low to moderate range, 0.2-0.5
STATISTICAL SIGNIFICANCE
Statistical significance: an indicator of how probable it is that a result occurred by chance
Often in psychological research the p-value to reject the null hypothesis is set at 0.05, can have variability (this means the probability is less than 5 in 100
Statistical significance(impacted by magnitude of coefficient and the sample, larger correlation and sample increases the probability of achieving statistical significance) is
different from clinical significance (research is done to assess both)
CORRELATION IS NOT CAUSATION
• A statistically significant correlation only tells us that a relationship between the variables is present (ex. Assessment of stress and depression, it may be that stress causes
depression, vice versa, or both or there might be a third variable not shown in study that could be the reason, ex. Poverty
SELECTING A SAMPLE
• Sample: a group of individuals assessed from the broader population that we want to study, we want to use info from sample to apply to pop.
• Important considerations:
Representative sample: very similar to population of interest (in terms of sex, ethnicity, age), if it is not representative it is bias and limits generalizability
• a way to do this: generate a random sample of pop. (Chances are high that it will be representative of population)
Selection of a comparison group: should match other group on every variable that affects the outcome (ex. Two groups are not as similar as possible differences. Ex women
tend to be more depressed than men, if you look at groups, group with more women will show higher bc due to sex composition
EVALUATING CORRELATIONAL STUDIES:
• Advantages:
Focus on situations that occur in the real world instead of being manipulated within labs (have external validity)
Longitudinal designs are useful in evaluating potential directionality of a relationship (if there are no differences before but then after, you have strong confidence
• Disadvantages
Longitudinal designs are time consuming and costly
Cannot reveal causality
Third variable problem
EPIDEMIOLOGICAL STUDIES:
• Epidemiology: study of the frequency and distribution of a disorder within a population
• Focuses on 3 types of data:
1) Prevalence= proportion of population diagnosed with a particular disorder at a certain point in time, or certain range of time
2) Incidence= the number of new cases that develop in a particular span of time
3) Risk factors = associating with a higher risk
How do researchers go about evaluating all three? 1. Population of interest identified 2. Random sample 3. Structured interviews all useful in who is at greatest risk but don’t
know what caused it (third variable still a concern)
EXPERIMENTAL STUDIES: HUMAN LABORATORY STUDIES
Human Laboratory Studies
• In a lab setting you can manipulate the independent variable to determine the impact upon the dependent variable (ex. Expose participants to a stressor in a lab and determine
it resulted in more depression (unethical, so instead analogs are created)
• Internalvalidity:
An experiment has strong internal validity if we are confident that our manipulation of the independent variable resulted in the dependent variable
In order to control third variables, a control group or control condition is used
Random assignment is critical
Attempts to reduce demand characteristics are often used
 ▫

psychology
HUMAN LABORATORY STUDIES CONT’D:
• Internal validity:
Attempts to reduce demand characteristics (situations that cause participants to guess the cause of study and change their behaviours, to prevent guessing they may
use filler measures = include items thats access depression that is embedded within other tests or cover stories= tell them a false purpose of the study, and debriefed after)
are often used
• Internal validity:
The importance of double-blind experiments
Participant behavior can be affected when they know which group (level of the independent variable) they are in (level of independent variable)
Experimenter behavior can be affected when they know which group (level of the independent variable) the participant is in
• in . order to reduce demand characteristics experimenters and participants should be unaware of which participants are in the ,control and which are in experimental,
with this we can be confident that the stressor is what is leading to changes in terms of depressive symtoms
EVALUATING HUMAN LABORATORY STUDIES;
• Primary advantage:
Control
• over third variables, independent, variable, and also dependent
• Primary disadvantages:
External validity can be unsatisfactory
• generalizability is often in question (are stressors equal to analogs)
There are some variables we cannot ethically manipulate
• can’t induce severe stress ethically
EXPERIMENTAL STUDIES: THERAPY OUTCOME STUDIES
THERAPY OUTCOME STUDIES:
• These are experimental studies that assess whether a particular type of therapy can reduce the presence of psychopathological symptoms
• Control groups are critical. There are 3 main types:
Simple control group= consists of participants don’t receive experimental therapy, tracked the same time, assessed at beginning and end
Wait list control group= don’t receive experimental but waitlisted to receive it later when the study is complete, assessed at beginning and end
Placebo control group= used to test utility of drugs, treated same as treatment group but given inactive substances
EVALUATING THERAPY OUTCOME STUDIES
• Lack of clarity regarding which element of therapy led to positive outcomes (vast majority use group of treatments, hard to know which part gave change)
• Is it unethical to withhold treatment? Alot of therapy compared two or more utilities that are already expected to have a positive impact
• How much should the therapist respond to the needs of the patient? How much can the therapist alter it without compromising the experimental integrity of the study
• Potential issues with generalizability: mental health services are not always delivered in controlled atmosphere
Efficacy (how well does a therapy work in highly controlled settings) vs effectiveness (how well does a therapy work in real world settings)
EXPERIMENTAL STUDIES: SINGLE-CASE EXPERIMENTAL DESIGNS
SINGLE-CASE EXPERIMENTAL DESIGNS
• A single person or a small number of people are studied intensively (different from case study in that the group are exposed to manipulation)
Different from case studies in that the individual(s) is exposed to a manipulation or intervention
Behavior is assessed before and after in order to determine the impacts of that exposure
ABAB DESIGN: fairly common
• ABAB Design (aka reversal design):
Intervention is introduced, withdrawn, reinstated
- Participant behavior is assessed when treatment is present and absent
• ex. When you study the impact of a drug with depression, a depressed participants might be assessed everyday for 2 weeks, then given drugs for 4 weeks and
depression would be tracked everyday for 4 weeks then drugs is withdrawn for 4 weeks then reinstated for 4 weeks
• Results suggest depression levels are lower when taking the drug
MULTIPLE BASELINE DESIGNS:
• Intervention could be:
Given to the same person but in different contexts
Given to different people at different points in time
• ex. To assess whether a medication could reduce depressive symptom, a researcher may teach an individual how to use meditation at work, at if they decrease at work
but not at home, there is some evidence that the meditation was the underlying cause for the decrease in symptoms
• Evidence of this approach could be garnered if the individual was asked to practice meditation at home and also decreased symptoms
• Researcher could also teach meditation to multiple people at different points of time and experiences are likely to be different, and if they are all he same then if shows
effective
EVALUATING SINGLE-CASE EXPERIMENTAL DESIGNS:
• Advantage:
Allow for intensive assessment of participants (intensity can let researchers pinpoint behaviours impacted by treatment)
• Disadvantage:
Results may not be generalizable
 ▫

psychology
EXPERIMENTAL STUDIES: ANIMAL STUDIES
ANIMAL STUDIES:
• Many researchers view it as acceptable to expose nonhuman animals to situations in a lab setting that would be unethical to impose on humans
There is controversy surrounding this viewpoint
• Animal studies provide researchers with significantly more control over lab conditions and third variable problems
• Seligman states that learned helplessness is similar to depression in humans, both experienced apathy, inability to see opportunities and see low level of initiation
behaviour; depression comes from people learning that they have no control over parts of their lives, good for battered spouses, poverty
• One example of an animal study: seligman and colleagues (subjected dogs to uncontrollable stressor in the form of an electric shock
• Group 1: shocks but could control them by jumping over a barrier, group 2: shocks but couldn’t move anywhere, group 3: no shocks
• The group that couldn’t control the shocks, initially responded by jumping around the cage and slowly became passive, they learned that they couldn’t
control it when they were present: learned helplessness and the other groups didn’t experience this
• Some animal studies are conducted in order to evaluate the effectiveness of drugs (some animals are killed after to understand the physiological aspect of the drugs)
• Useful in early research when the side effects of drugs aren’t known
• Evaluating animal studies:
Ethical issues: is it ethical to conduct painful, dangerous and sometimes fatal?
Generalizability: is the research conducted on other species generalizable to humans?
GENETIC STUDIES:
FAMILY HISTORY STUDIES: provide info about potential genetic transmission of disorders, issues that families share both genes and environment so individuals might have the
disorder as they share the same environment ex. Share household so share the same poverty
• Can’t disentangle the impacts of genetic and environment contribution to disorders
Disorders that are transmitted genetically
Should show up more frequently in families of individuals who have the disorder
In order to conduct a family history study:
Individuals who have the disorder must be identified. This group is referred to as the probands
A control group of individuals who don’t have the disorder must be identified
An assessment of relatives with the disorder is conducted (researchers are most interested in first degree relatives; i.e. full siblings, parents and children as they are
most genetically similar
• percentage of genes that a person has in common with relative decreases substantially with distance
TWIN STUDIES:
• Monozygotic twins:
Share 100% of their genes
Come from a single fertilized egg which splits in 2
• Dizygotic twins:
Share 50% of their genes
Come from 2 separate eggs fertilized by separate sperm
• Concordance rate:
The likelihood that both twins will have a particular disorder if one twin has it
• if a disorder is determined entirely by genes, the concordance rate should be around 100% for monozygotic twins and much less for dizygotic
• If a disorder is determined partially by genes, the concordance rate should be higher among monozygotic twins than dizygotic
• Ex. If you have a concordance rate for a disorder for monozygotic is 50% and for dizygotic is 20% since the monozygotic twin rate is higher, evidence the
disorder is genetically transmitted, and since its under 100% for monozygotic both genes and environmental factors affected the disorder
• issues of twin studies: can’t fully untangle genetic and environmental impact since monozygotic have more similar environmental impacts than dizygotic (treated similarly,
similar talents, look the same)
ADOPTION STUDIES: environmental is connected to adopted parents, genetics to biological
• Can be carried out in a variety of ways
• Harness the fact that individuals who are adopted:
Share genes with biological parents who didn’t raise them
Do not share genes with adoptive parents who did raise them
*This helps researchers to disentangle environmental and genetic contributions to a disorder
MOLECULAR GENETIC STUDIES AND LINKAGE ANALYSIS:
• Molecular genetic studies (association studies):
Research assessing associations between genetic abnormalities (genetic markers) and psychopathology
• ex. You might compare group of individuals who have been diagnosed with OCD with individuals with no known psychopathology (DNA from both groups is
attained and genotyped in order to assess who has the genetic marker)
Linkage analysis: researchers will attempt to narrow down gene marker location by looking for characteristics that have known genetic markers and tend to co-occur
with the disorder (ex. Mood disorders, researchers might find two markers on chromosome 11, linked to mood disorder in family, genes are important in terms of
vulnerability in mood disorders
 ▫

psychology
CROSS-CULTURAL RESEARCH:
• In the past few decades there has been a stronger reliance upon cross-cultural research in abnormal psychology
• looks at similarities and differences across cultures in terms of manifestations in certain psychological disorders as well as causes and treatments
• The manifestations of psychological disorders differ across cultures and theoretical variables can have different manifestations across culture
• with emotions, families who score high with expressed emotions tend to be critical and hostile towards other families members and over evolves, individuals with
schizophrenia whose family scores high tend to relapse at a higher rate than those with families with low expressed emotions
• culture plays a large role in terms of targets of criticism (anglo-americans criticism is targeted at faulty personality traits or psychotic behaviours, whereas
individuals of Mexican decent criticism focuses of disrespectful and disruptive behaviour
• Challenges: important when cross cultural questionaries that they are valid and in clients preferred languages
Caution must be exercised when attempting to apply theories that were developed for one culture onto another
Language barriers
META-ANALYSIS:
• Meta-Analysis:
Statistical technique which provides a summary of results across numerous studies
Can overcome issues arising from small sample sizes
Step 1: conduct a literature search
Step 2: transform the results of each study into statistics that can be compared across studies, affect studies are used
Ex. Research looking at children’s depressive levels have found that research thats been done more recently have resulted in lower levels of depression, meta-analysis
suggested that depression levels might be increasing among kids
Issues with using meta-analysis:
• studies have methodological flaws
• File drawer effect problem where studies that don’t support the hypothesis are less likely to be published; inherent biases
ABAB DESIGN

Family history studies, percent of genes in common

 psychology
Functional to dysfunctional:

Anxiety has an immediate

response: chest tightens, hands
become sweating, fast heart
rate, anxiety is normal and
adaptive, prepare for new
experiences,

ANXIETY VS FEAR

• Anxiety: future-oriented tension, sense of dread, or apprehension.

• Fear: immediate emotional response to a threat (perceived or real) in the environment
Both have been selected for in terms of evolution and impacted by our perception of experiences as being threatening or non
• throughout evolutionary history, people have developed a fight or flight response, comprised of physical and psychological response that assist us in terms of
dealing with threat
• The physiological changes result from activation of two main systems controlled by hypothalamus, autonomic nervous system (sympathetic division) and adrenal
cortical system

When you experience a threat, the hypothalamus will activate your

sympathetic division of your autonomic system, sympathetic will act on internal
organs and smooth muscles to result in changes: liver will release more sugar
in order to fuel your muscles (glucose), metabolism will increase in order to
prepare for energy, increase in heart rate, blood pressure, and breathing
rate
• muscles will become tense, and less essential functions like digestion tend
to be minimized, so saliva and mucus will dry up
 ▫ ▫

THREAT PERCEPTION:
- psychology
When we perceive a threat, the hypothalamus will activate the sympathetic division of the autonomic nervous system, your body will secrete endorphins (natural pain killers
and will help fight or flight response, surface blood vessels will constrict which helps with bleeding
• The following physical changes occur:
Liver releases more sugar
Metabolism increases
Increase in:
• Heart rate
• Blood pressure
• Respiration rate
• Muscles tense
• Digestion is minimized
• Body secretes endorphins
• Surface blood vessels constrict
• Spleen releases more red blood cells: helps to carry more oxygen
• When a threat is perceived, the hypothalamus will activate the adrenal-cortical system:
This is done by releasing corticotropin-release factor (CRF)
CRF signals to the pituitary gland to release adrenocorticotropic hormone (ACTH)
ACTH stimulates the adrenal cortex to release a group of hormones (including cortisol) includes about 30 hormones that play a critical role in how the body is going to
adjust to emergency situations
• ACTH: the body’s major stress hormone and the amount of cortisol in blood or urine often used to measure stress
PANIC DISORDER: symptoms of a panic attack tend to look like a medical emergency, these perceptions are incredibly common
“I think I’m having a heart attack, please help me.. . I can’t breathe, I’m dizzy.. .I might be dying”
Panic attacks: individuals with panic attack disorder think they are facing a life long issue, more likely to have family history of chronic illness, most people will feel shame
Short, intense periods during which individuals experience symptoms including:
• Heart palpitations
• Trembling
• Shortness of breath
• Dizziness
• Intense dread
• Fear of dying
• some panic attacks happen without any environmental triggers, wheras others are trigger by certain events
• Around 28% of adults have occasional panic attacks when experiencing a lot of stress
• For most people, they are isolated events
• Diagnosis: made when attacks are common occurrence, not trigger by particular event, and when people worry about having them that they change their behaviour
• Around 3-5% suffer from diagnosable panic attack disorder, emergence is from adolescence to mid 30s and tend to be more common in women and tend to be chronic
THEORIES OF PANIC DISORDER:
• Biological Factors:
Panic disorder runs in families
• Heritability of 43-48%, but no specific genes have been identified
Fight-or-flight response is poorly regulated (might be because of poor regulation of neurotransmitters like norepinephrine, serotonin, GABA, or CCK
Can be easily triggered if:
• They hyperventilate
• Inhale a small amount of carbon dioxide
• Ingest caffeine
• Breathe into a paper bag
• Take infusions of sodium lactate (resembles lactate during exercise and tend to initiate physiological changes within the fight or flight
• Individuals that do not have a history of panic attacks might experience discomfort during these activities or triggers but will rarely experience a panic attack
Differences between individuals with and without panic disorder in areas of the limbic system, which is critical for determining how people interpret internal sensations
Abnormalities in thalamus and somatosensory cortex
Dysregulation of norepinephrine systems in the locus ceruleus(strong pathways within limbic system
And poor regulation is said to lead to panic attacks and might stimulate limbus and lower activation for anxiety
• Cognitive Factors:
Individuals who are at risk for panic attacks typically: Typically
• Pay close attention to their body sensations, b/c they are hyper-vigilant for body sensations, this arousal can make Involved in stress response for behaviour see
Future attacks more likely differenc
• Misinterpret body sensations in a negative way es in
• Engage in catastrophic thinking(increases a sense of anxiety and physiological changes, ex. Often increase of heart these
Rate and respiration rate with catastrophic thinking, and then may interpret these sensations catastrophically regions
• anxiety sensitivity: common, belief that body symptoms have. Harmful consequences and it associated with panic among
• Have increased interoceptive awareness individuals
• interoceptive conditioning: occurs when body cues have happened at the beginning of previous attacks and now with and
Serve as conditioned stimuli which now signal new attacks without
panic
 ▫ ▫

psychology
THEORIES OF PANIC DISORDER CON’T:
• Cognitive Factors:
Feelings of control can play a role
• In one study, two groups of panic disorder were asked to wear breathing masks to deliver co2, one group told they couldn’t control the amount of Co2, the other
group told them they could control, in reality, neither could control and both inhaled the same
• 80% of the people who believed they had no control experienced a panic attack, whereas 20% of people who believed they had control had panic attack

• An Integrated Model
TREATMENTS FOR PANIC DISORDER:
• Biological treatments:
Medications which affect serotonin and norepinephrine systems are the most common biological treatment
• SSRIs (Paxil, Prozac, Zoloft)
• SNRIs (Effexor)
• Tricyclic antidepressants
• Benzodiazepines (tend to suppress activity in the central nervous system and the functioning of GABA, norepinephrine and serotonin and are physically and
psychologically addictive and often have high withdrawal symptoms, aren’t prescribed at the same rate as the ones above
• Most individuals with panic disorder have a relapse of symptoms if they discontinue their drug use and haven’t received CPT in conjunction with their medicine
• Cognitive-Behavioral Therapy: often taught relaxation and breathing exercises which allows clients have control over their symptoms, they are often taught to identify the
catasrophising conditions that they have got about changes and physiological changes and might be asked to keep a diary of thought, therapists often challenge them
theirselves, it is common for therapists to use systematic desensitization therapy in order to gradually expose clients to fears while assisting them to maintain control
With the guidance of a therapist, clients confront the thoughts and situations that cause them anxiety. This is useful since:
• It helps clients to challenge and modify their irrational thoughts
• It helps clients to extinguish behaviors that have developed in response to their anxiety
SEPARATION ANXIETY DISORDER: common for these individuals to be shy, sensitive and demanding of adults, refuse to go to school, forced to go to school they may
experience headaches, nausea, stomach aches and common to follow parents around house, nightmares with themes of separation, hard time sleeping alone, and belief that
something bad is going to happen to their caregivers if they aren’t with them, tend to have exaggerated fears of natural disasters, kidnapping, accidents
• In all cases, emotional distress is caused by being separated from parents
• Only diagnosed if symptoms have lasted for at least 4 weeks AND impair the child’s functioning
• Separation anxiety occurs in 4-10% of children and tends to be equally common in boys and girls
• If left untreated, it can continue through childhood and into adolescence and can impede social and academic development
• According to the DSM-5, separation anxiety disorder can:
Occur at any point in the lifespan
Can begin at any age
• Prevalence:
7.7% of adolescence (13-17 years) 6.6% of adults (18-64 years) more cognitive and emotional symptoms, fewer somatic, difficulty with change (marriage,
partnership, moving, focus on kids or parents, rigid routines, talk alot, peek onset tends to be around early 20s)
• over half of the people who report having separation anxiety disorder report the onset of having symptoms in adulthood,worldwide 5%
• Previous editions of the DSM limited separation anxiety disorder to kids and to adolescence
• Separation anxiety disorder is highly comorbid with both internalizing(depression, bipolar, specific and social phobias, panic, generalized anxiety and PTSD) and externalizing
disorders(ADHD, operational defiant disorder and conduct disorder) represents a vulnerability factor for multiple psychiatric conditions
THEORIES OF SEPARATION ANXIETY DISORDER:
• Biological Factors:
Children who have separation anxiety disorder commonly have family histories of depressive and anxiety disorders
Heritability estimate of 70% (high) more so females
Tendency towards behavioral inhibition tends to be heritable
• kids who score high on behavioural inhibition tend to be shy, fearful and irritable as toddlers, as school kids: cautious, quiet and introverted, tend to withdrawl from new
and clingy to caregivers and display excessive arousal (behavioural inhibition tends to be a strong risk factor for all types of anxiety disorders through childhood)
• Psychological and Sociocultural Factors:
Caregivers of children who have separation anxiety disorder tend to be:
• More controlling (behaviorally and emotionally) more anxious
• More critical and negative
• Also mothers with high trait anxiety tend to more likely to use overprotection or less assertive parenting, and associated with higher rates of separation anxiety
TREATMENTS FOR SEPARATION ANXIETY DISORDER: children in both CBT groups tended to show significant decline in anxiety, those who just had education showed less
improvement and in all 3 there was declines in anxiety that persisted over a 1 year period
• CBT: common, kids tend to benefit most from this b/c they are taught skills on how to cope, and help challenge their thoughts of anxiety
Helps to create changes in thinking and behavioural patterns
Helps reduce anxiety
• kids will learn relaxation exercises to implement during separation and fears are challenges, self-talk as a way to calm down, as sessions go on, time separated
from parents is slowly increased, parents are taught to model non anxious responses in terms of separation
• Variations of CBT: Mindfulness-based therapy and acceptance and commitment therapy have been found to be effective
• Drugs commonly used: biologically
Antidepressants
Antianxiety drugs
Pharmacological treatments are typically combined with psychological treatments
 ▫

psychology
SELECTIVE MUTISM:
• Selective Mutism (SM): prevalence is around 0.03 - 0.8% so fairly rare
Failure to speak in certain social situations
There is a strong association between SM and anxiety (social phobia in particular)
Classified as an anxiety disorder in DSM-5
• Kids with SM are capable of age appropriate language but remain quiet in situations that elicit anxiety (at school, playground) this lack of speech can interfere with
social, occupational and academic activities (seems in involve the interaction between genetic, temperamental, developmental and environmental factors
• Average age of onset tends to be 2 1/2 to 4 1/2 and is more common in girls but condition can go unnoticed until child goes into education
GENERALIZED ANXIETY DISORDER: associated with physical symptoms: sleep disturbances, chronic restlessness, muscle tension, gastrointestinal symptoms and chronic
headaches, anxiety bring distress
Generalized Anxiety Disorder (GAD): tend to worry about multiple things, common, affects 3% of individuals between 18-64, lifetime presence: 7.7% (female) 4.6 (male),
Anxiety is a constant feature and focus of anxiety shifts quickly, kids can also experience it
Individuals with GAD tend to experience excessive anxiety about typical, everyday situations
• GAD is less understood in comparison to other anxiety disorders: comorbidity tends to be the norm with more than 80% with lifetime anxiety disorder experiencing another
lifetime anxiety disorder which is typically major depressive disorder
• individuals with GAD from high income countries tend to show higher levels of impairment compared to middle or low income countries
Research involving adults from 26 countries (Ruscio et al., 2017) suggests that GAD is a common psychological disorder that involves comorbidity and functional impairment
THEORIES OF GENERALIZED ANXIETY DISORDER:
• Emotional and Cognitive Factors:
Emotionally, individuals with GAD report:
• More intense negative emotions
• High reactivity to negative events
• A lack of control and manageability of emotions
Cognitively, individuals with GAD tend to make maladaptive/negative assumptions (ex. It is better to expect the worst or I have to prepare myself for danger) which lead
them to respond to situations with automatic thoughts that:
• Trigger anxiety
• Cause hyper-vigilance
• Lead to overreactions
• Many cognitive concerns among individuals with GAD tend to reveal concerns about losing control or about their inability to tolerate certainty
• Why do some individuals become hypervigilant for potential threats? Hypervigilant appears when someone experiences stressors or trauma that is uncontrollable (significant
rejection or loss) in terms of the cognitive avoidance model, this looks at the functional significance of worrying
• research suggests that worrying leaves individuals with GAD to avoid both internal and external threats and helps them reduce reactivity to unavoidable
negative events
• Constant level of anxiety might be more tolerable then sudden increases in negative emotion, some individuals tend to have preference for chronic distress
rather than sudden stress
• Individuals with GAD tend to display maladaptive interpersonal behaviour (appear hostile, cold and intrusive)
• Does worrying serve an important function?
• Biological Factors:
Heightened activity in sympathetic nervous system
Greater reactivity to emotional stimuli in amygdala
Abnormalities in the GABA neurotransmitter system may be an underlying factor
• when GABA bonds to a neuro receptor it prevents that neuron from firing, individuals with GAD might have a deficiency of GABA or GABA receptors and might
result in an excess of firing of neurons through multiple brain regions, but the limbic system in particular
• excessive and chronic neural activity might leave people with chronic anxiety with diffuse symptoms
TREATMENTS FOR GENERALIZED ANXIETY DISORDER
• Cognitive-Behavioral Treatments: also helps with depressive symptoms (high degree of comorbity between GAD and depression)
Focus on:
• Challenging negative and catastrophizing thoughts
• Developing coping strategies
• tends to be superior to placebo and non directive supportive therapy
• Positive effects: tend to remain around 2 years or more
• Anxiety pre-seeds the onset of depressive episodes
• ERT: newer type of therapy that focuses on emotional awareness and regulation, research shows it is useful in treating GAD well
CBT therapy tends to be equally effective as benzodiazepine treatment
• Biological Treatments:
Benzodiazepine drugs: provide short-term relief from symptoms of anxiety but have lots of side effects and addictive, long-term use is risky
• Xantax, and Valium
Antidepressant medications: such as SSRIs and SNRIs can be effective
• when people discontinue their drug use, their anxiety symptoms will reoccur
• Meta-analysis support a combination of drug treatment and CBT
▫ ▫

SOCIAL ANXIETY DISORDER:

psychology
• Individuals with Social Anxiety Disorder:
Become very anxious in social situations and experience fear of:
• Rejection
• Judgment
• Humiliation
• tend to be so anxious in social situations that their lives become focused on avoiding social encounters
• associated with the development of other disorders, mainly depression
• The development of close relationships and social support can significantly lower the risk of developing symptoms in adolescence and early adulthood
• for individuals in treatment, higher levels of perceived support tend to be associated with much better prognoses
• Social Anxiety Disorder: is one of the most prevalent mental illnesses
Contributes to the development of other mental health concerns
• Individuals with social anxiety disorder may do the following in social situations:
Tremble
Perspire
Feel confused
Feel dizzy
Have heart palpitations
Have a full panic attack
• they believe that other people notice their nervousness and judge them as being weak, crazy or unintelligent
• most common anxiety disorder, 3rd most prevalent mental health disorder with a lifetime prevalence of 12% in the US and internationally between 1 and 7%
• women are slightly more likely than men to develop social anxiety disorder (particularly in performance like speaking in public
• Onset: preschool years or adolescence, a time when they become self conscious and preoccupied about what others think about them
• Over 90% report having had embarrassing experiences in their lives like extreme teasing/bullying
THEORIES OF SOCIAL ANXIETY DISORDER:
• Genetic basis: research supports, but not specifically directed at social situations but instead towards a tendency more broadly to develop anxiety disorders
Social anxiety tends to run in families
Twin studies support genetic basis
Not specifically directed towards social situations, but rather a tendency to develop anxiety disorders
• Cognitive perspectives:
Have dominated psychological theories
• Individuals who are vulnerable to social anxiety disorders:
• have excessively high standards for their own social (ex. Believe that everyone should like them)
• focus on negative elements of social interactions (notice a frown on people they are talking to and might misinterpret
• evaluate their own behaviours in a harsh manner (might assume if they are feeling strong anxiety that it is because their social interaction isn’t going smoothly)
• safety behaviours are a common method to help reduce feelings of anxiety (avoid eye contact, avoid social interactions, rehearse what they say, avoid disclosing
personal info) when a social interaction is over, they ruminate about other peoples reaction to them as well as their own social performance
• What creates the behavioral habits and cognitive biases that are often seen among individuals with Social Anxiety Disorder?
• one theory is that it involves interactions and relationships with caregivers (Ex. Adults w/ this disorder describe their caregivers as controlling, protective, critical
• experimental research suggests that family environments and parenting modelling of socially anxious behaviour describes the development, especially true among
people who are temperamentally predisposed to shyness
TREATMENTS OF SOCIAL ANXIETY DISORDER:
• Drug therapies:
SSRIs and SNRIs (both are effective in reducing symptoms, but when they stop taking them their symptoms return)
• Cognitive-behavioral therapy (CBT):
Useful treatment for social anxiety
• behavioural component: tends to involve exposing clients to social situations that trigger anxiety while helping them to maintain a state of relaxation
• cognitive component: focuses on identifying negative cognitions and teaching clients to challenge them
• CBT tends to be equally effective as antidepressants in reducing symptoms
It is significantly more effective in preventing relapse after therapy
• Mindfulness-based interventions (teach people to be less judgemental about their own thoughts and responses and become more focused on the present) and acceptance
and commitment therapy (ACT) can be useful (tends to build on CBT to highlight mindfulness, acceptance, values, and effectiveness)
• Internet-based Cognitive-Behavioural treatments (ICBT) are showing some promise (becoming more common, COVID-19 introduced a lot more and are found to be quite
effective)
 ▫

psychology
SPECIFIC PHOBIAS AND AGORAPHOBIA
Specific phobias: unreasonable or rational fears
• Specific phobias are grouped into 5 categories in DSM-5:
Animal type
Natural environment type
Situational type
Blood-injection-injury type
Other
• diagnostic criteria includes an individual actively avoiding the object, situation or enduring it with intense anxiety or fears, symptoms have caused the individual distress or
impairment and the symptoms shouldn’t be better explained by a different mental disorder or physical disorder)
• Duration for diagnostic criteria: symptoms need to persist for at least 6 months
• When individual faces fear, they will have intense anxiety which may manifest as a panic attack, also tend to fear the possibility of facing the fear and avoid it)
• Symptoms
• Fear or anxiety about a particular object/animal/situation that is not proportional to
Most specific phobias develop in childhood
These phobias will typically persist into adulthood if they are not treated (adults with specific phobias are aware that their stimulus related anxiety is unreasonable, kids not
• heights and animals are the most common
• instead of treatment, the vast majority tend to adapt their lives to avoiding the feared stimulus, just severe cases get treatment
• Epidemiological studies reveal that the lifetime prevalence worldwide is around 7.2%
• Animal type:
Snakes and spiders are the most common (bc it has been adapted for humans to fear them)
• most people who face their feared animal will startle, move away but won’t live in terror or avoid them
• Natural environment type: mild or moderate fears are common and adaptive, diagnosis only applied if people reorganize to avoid or significant anxiety when face
Focus is on situations that occur in a natural environment (e.g. storms, heights)
• Situational type:
Often involve fear of public transportation, elevators, driving, or flying (e.g. claustrophobia)
• blood-injection-injury type: individuals with other forms above usually show significant increases in blood pressure, rate, fight or flight
• show significant drop in blood pressure, rate, and at high risk of fainting, runs stronger in families compared to the others
AGORAPHOBIA: manifests in early 20s, more common in women than men, often reach a point where they can’t leave home without someone else
• Individuals with agoraphobia tend to have a strong fear of places where they may have a hard time escaping or getting assistance if they become anxious (ex. Public
transportation, boat, plane, parking lot, shops, or being alone in public) tend to fear they will embarrass themselves if others notice symptoms or notice them escape (in reality
people can’t tell) substance use is common way to reduce anxiety when pressured into a situation
• Approximately 50% of individuals with agoraphobia have experienced panic attacks
The other 50% have typically experienced:
• Another anxiety disorder
• Depression
• Somatic symptoms disorder
THEORIES OF PHOBIAS:
• Behavioral Theories:
Mowrer’s (1939) two-factor theory:
• Classical conditioning leads to the fear of a particular object (previously neutral object, the conditioned stimulus, is paired with an object that naturally elicits a reaction)
• Operant conditioning maintains that fear
• Some researchers argue that phobias can develop through observational learning
• Theory of prepared classical conditioning: many phobic objects tend to be objects that proposed a threat to humans through evolutionary history, avoiding helps in terms or
survival and generating offspring
Developed by Martin Seligman (1970)
Evolution has selected for quick conditioning of fear to specific stimuli
• small kids learn fears in response to what they see in their caregivers
• gun, knifes likely to cause harm but haven’t been around enough to develop a fear and very rare
• experimental research has found that anxiety reactions develop faster to pictures like snakes and spiders when paired with electric shocks, typically taking 1 or 2
pairings, compared to pictures like houses or flowers which would take 4-5 pairings to elicit fear response, extinguishing fears of houses/flowers is easier than snakes
• Biological Theories:
First degree relatives of individuals with phobias are 3-4 times more likely to have a phobia in comparison to first degree relatives of individuals without phobias
Twin studies support a genetic component
• some research found that situational and animal phobias are associated with similar genes, but other research has just found general genetic propensity towards phobias
which isn’t specific to a type of phobia
 ▫

TREATMENT FOR PHOBIAS CON’T:

- psychology
• Behavioral Treatments: tend to be the most common and often one intensive therapy session can do significant reductions in terms of anxiety and phobic behaviours
Rely on exposure in order to extinguish fear response
• This exposure tends to be very effective and successfully treats most phobias
3 fundamental components of behavioral therapy for phobias:
• Systematic desensitization (clients will formulate a list of feared situations and rank them, learn relaxation techniques and exposing themselves to the ranking
starting from least fear and until they react the peak without experiencing anxiety)
• in terms of the behavioural approach for treating blood injection injury phobias, requires diff type - need to learn to tense muscles until they feel warmth (applied
tension technique which increases heart and blood rate which will minimize fainting, after systematic desensitization can be used)
• Modeling
• Flooding
• Modeling techniques:
Often used in conjunction with systematic desensitization (ex. Therapist treating spider phobia could model each fear in the ranking before asking client to perform
them, client can learn to associate their ranked fears with a calm response they see in therapist, this reduces anxiety associated with those behaviours
Seem to be equally effective as systematic desensitization in reducing phobias
• Flooding:
Intense exposure to a feared stimulus until anxiety is extinguished (ex. Person with claustrophobia might lock themselves in a closet for many hours, before flooding the
therapist will usually prepare the client with relaxation techniques that they can use to reduce fear
• tends to be as effective as modelling or systematic desensitization but tends to work faster
• downside: hard to get people to agree to their approach as it elicits tremendous amount of anxiety
TREATMENTS FOR PHOBIAS:
• Biological treatments: tend to cute vast majority of phobias in just a few hours but relapse can occur, confronting fears is incredibly important for the relief of phobias
and a behavioural therapeutic results in the best outcomes
Benzodiazepines are sometimes used
Produce temporary relief but the phobia remains
Risk of addiction
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS (OCRDs) OCD removed from the anxiety disorder category on the DSM-5 and OCRD was created and is controversial
• Obsessive-compulsive and related disorders (OCRDs):
Have an obsessive-compulsive component
Include: all share impaired behavioural inhibition, age of onset, comorbidities, neuro circuitry, neurotransmitter abnormalities, and responses to treatment
• Obsessive-compulsive disorder (OCD)
• Hoarding disorder
• Body dysmorphic disorder (BDD)
• Trichotillomania (hair-pulling disorder)
• Excoriation disorder (skin picking)
OBSESSIVE-COMPULSIVE DISORDER: vast majority tends to show more than one obsession and that will evoke distress and the development of compulsions in order to try to
neutralize those feelings
• Diagnosed when client experiences overwhelming obsessions(thoughts, images, ideas, urges that are unwanted, intrusive and repetitive that usually causes alot of anxiety,
tend to create ritualistic behaviours) or stress compulsions, or both
• obsessive thoughts occasionally happen to all people but individuals with OCD cannot ignore these thoughts easilu
• The most common obsessions:
Germs, cleaning, contamination, illness
Responsibility for causing or failing to prevent harm
Forbidden thoughts: aggressive, sexual, and religious
Symmetry and order
• Compulsions: individuals with OCD will usually create rituals that are purposeful and goal directed, but tend to be disproportionate to the obsession they are trying to
neutralize
Repetitive behaviors or mental acts
Individual feels they must perform these in order to reduce distress/anxiety
Can be covert (mental, internal, repeating numbers, or phrases) and/or overt (behavioural, counting, repeating routine actions)
• often spend large portion of their day completing these rituals that often dominates daily life and interferes with work or relationships
 ▫

psychology
OBSESSIVE-COMPULSIVE DISORDER CON’T:
• Characterized by irrational beliefs, some individuals with OCD acknowledge their compulsions, others thing they are rational
• Individuals with OCD have varying degrees of insight into their obsessions and compulsions
• associations between obsessions and compulsions often results from magical thinking (ex. Repeating a behaviour can protect someone from danger, checking the stove 10
times, that individual may feel security that the stove is off)
• Symptoms of OCD cause people to suffer from significant stress and try hard to reduce anxiety and this energy is in the form of compulsions, but these compulsions just
further reinforce the behavior
Individuals with OCD typically acknowledge that their thoughts and behaviors are irrational.
• They have tremendous difficulty in controlling them
• Lifetime prevalence of 2.3% (worldwide about 1-3% and doesn’t diff across countries)
• Average age of onset for males = 6-15 years (more males are effected as children)
• Average age of onset for females = 20-29 years (females more effected in adults)
• by mid adolescence the ration for which gender is more effected it is quite equal (kids will try to hide symptoms and delay treatment)
• Chronic condition but symptoms can increase or decrease to diff points in a persons live depending on environmental factors like stressors
• The most common condition that co-occurs with OCD is major depressive disorder, around 66% of individuals with OCD are also diagnosed with depression
• High rates of comorbidity with:
Anxiety disorders
Mood disorders
Impulse-control disorders
Substance use disorders
HOARDING: different than OCD since people will often have thoughts about possessions apart of their stream of thought and no intrusive thoughts
• Uncontrollable urges to keep items (no utility or value, but show strong emotional attachment to possessions and give them identity, give them characteristics “hurting objects
feelings)
• Individuals tend to develop a sentimental attachment to items(forced to get rid of objects they will be angry, sad or anxious)
• Hoarding may have different biological underpinnings than OCD
• Individuals with hoarding disorder: hoarding disorder increases with age
Tend to feel comforted by the items they collect
• Do not typically report feelings of anxiety regarding their hoarding
Occurs in around 5% of the US population
High rates of psychiatric comorbidity (comorbid with major depression, social anxiety and generalized anxiety)
TRICHOTILLOMANIA: can pull hair from any part of body, most common is head, then eyebrows then pubic region
• Hair-pulling disorder
Individuals repetitively pull out their own hair
• This results in noticeable hair loss and functional impairment
• Automatic (when people are unaware of pulling behaviours) vs focused pulling (aware and actively trying to remove hair that is irregular or out of place)
• prevalence: .0 - 2% in adults and tends to effect females with 4-1 ratio, childhood the sex distribution is equal, average age for onset is 10-15 years
EXCORIATION (SKIN-PICKING DISORDER)
• Occurs when an individual picks at their own skin from any part of the body in a recurring manner
Typically results in scars, skin lesions, and sometimes infections
• often pick at multiple sights, but most commonly face, hands, fingers, arms and legs
• Sometimes pick healthy skin or irregular
• Associated with an inability to stop even if they try to stop, leads to shame, embarrassment, anxiety and depression
• prevalence: around 2-5% and usually begins in adolescence and focuses on acne lesions
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS (OCRDs)
• OCD, hoarding, trichotillomania and excoriation all share the following features:
Repetitiveness
Issues with behavioral inhibition
• similar comorbidities
• individuals will often feel tensions before their behaviour and relief after giving into the impulse
 ▫

- psychology
BODY DYSMORPHIC DISORDERS (BDD): very common how humans want to change how they physical look, dislike parts of the human body
• individuals with BDD are very preoccupied with a certain part of the body they think is defective that other people see as normal
• Most common preoccupations are with the skim, hair, nose, eyes, eyelids, lips, mouth, jaw, and chin (these obsessive concerns results in significant stress, impairments
in terms of interpersonal relationships and can cause significant amount of anxiety
• Excessive concern about physical appearance from feeling unattractive to feeling as though they look like a monster
Results in significant distress
Leads to impairment in interpersonal relationships
Obsession may be limited to 1 part of the body, but may include several (average of 4 bodily preoccupations)
• There are gender differences in areas of concern (women focus on face, weight, stomach and breasts, men focus on body built, genitals, excessive body hair or thin hair
• these gender differences reflect on society in terms of gender norms about perceived attractiveness
• Individuals with BDD often engage in the following compulsive behaviors:
Mirror gazing
Touching
Checking
Inspecting
Grooming
Seeking reassurance
Covering perceived flaw with makeup or clothing
• thought that appearance based compulsions might temporarily cause relief
• Average age of onset = 16 years
Typically becomes chronic if not treated
• Tends to affect men and women equally
• Comorbid with:
Anxiety disorders
Depressive disorders
Personality disorders
Substance use disorders
OCD
• social media may impact BDD ( the average time on social media has increased dramatically, platforms provides feedback about appearance so social media does not
CAUSE BDD but it could contribute to symptoms
• exposure to social media has been found to increase likelihood that people will participate in appearance comparisons and self objectification and can contribute
to BDD
• excessive selfie use is seen as a safety behaviour in order to manage the stress associated with BDD
• Individuals with BDD may:
Avoid social activities because of perceived conformity
Become housebound and
Obtain cosmetic surgery (not advised as it could make it worse and create new concerns)
• Muscle dysmorphia is a subtype of BDD that exclusively effects men who view themselves as weak or small, even though these men have average or above average
muscle mass (also known as reverse anorexia) tend to weight lift, diet and drug use to increase muscularity
• BDD is associated with suicidal ideation (about 80%) , suicide attempts (about 21%) , and completed suicide
THEORIES OF OCD AND RELATED DISORDERS:
• Biological Theories:
OCD research suggests strong genetic predispositions.
OCRDs are associated with a neural circuit involved in motor behavior, cognition, and emotion
Activity in the hypothalamic-pituitary-adrenal (HPA) axis may be associated with OCRDs
• stressful life events pre-seed the inset of OCRD and symptoms increase when a person is experiencing significant stress
Individuals with OCRDs tend to get relief from drugs that regulate serotonin (serotonin enhancing drugs show a significant reduction in the rate of activity in the neural
circuit thats implicated in OCRD’s
• individuals with OCRD’s who respond well to behavioural therapy tend to show significant decrease of activity in the caudate nucleus and thalamus
Family history studies show that OCRDs run in families
• Cognitive-Behavioral Theories: everyone has intrusive thoughts, like harming others, or goes against their value, when we are distressed we are more vulnerable to these
thoughts and more likely to engage in ritualistic, rigid behaviours, most people can turn off these thoughts, people with OCD cannot
• individuals with anxiety elicit obsessions tend to figure out that when they engage in certain behaviours to help reduce anxiety (Ex. Checking doors might reduce
thoughts of break ins, every-time the obsessions come back and they engage in the behaviours to reduce them, those behaviours end up being negatively reinforced
• those with hoarding disorders tend to have extremely strong senses of responsibilities and guilt for wasting things
• those with BDD tend to show strong biases towards appearance stimuli and overvalue and have negative interpretations of their perceived flaws
Individuals with OCD may experience anxiety or depression which triggers intrusive and negative thoughts when encountering a negative event
Compulsions seem to develop through operant conditioning
 ▫
▫

psychology
• Biological Treatments:
Antidepressants can help relieve symptoms of OCD
• Approximately 50-80% of patients with OCD show decreases in symptoms when taking antidepressants affecting serotonin (in comparison to 5% in a placebo
group) tells us that lots of people with OCD done respond to SSRI, some research showed that e typical anti psychotics can be used in conjunction with SSRI for patients
that don’t respond well to SSRI’s alone
• Many individuals with OCD do not respond to SSRIs
TREATMENT OF OCD AND RELATED DISORDERS:
• Cognitive-Behavioral Treatments:
Most clinicians recommend the use of drugs in conjunction with CBT to treat OCD
• CBT which uses exposure and response prevention is very effective (exposes client repeatedly to obsessions - unlocked door, after exposure they are prevented from
engaging in compulsive responses (locking the door), preventing individuals to engage tends to lead to extinction of anxiety regarding obsession
• clients learn that even in they don’t engage in that behaviour, they can cope with their anxiety (anxiety increases every time they resist engaging in behaviour)
• Sometimes clients are given homework which assists them in confronting their obsessions and compulsions (asked to resist checking door, drop fork on floor and eat
with it)
• The cognitive component of CBT: Requires the therapist to challenge the client’s moralistic thinking and string sense of responsibility (ex. Might be asked to notice
that everyone around the house is safe even if they didn’t check the door in the past hour)
• CBT approaches tend to lead to very significant reduction in both obsessions and compulsions in around 60 to 90% of clients and CBT is at least as effective as
SSRIs but the recommendation is to use CBT in combination with SSRIs for the most effective treatment. In the majority of patients who do get CBT treatment
improvements will persist for up to six years and disorder
Effective in treating:
• Hoarding disorder
• Body dysmorphic disorder (BDD)
• Trichotillomania (hair-pulling disorder)
• Excoriation disorder (skin picking)
POST-TRAUMATIC STRESS DISORDER AND ACUTE STRESS DISORDER
• Exposure to trauma can result in the following psychological disorders:
Posttraumatic stress disorder (PTSD)
Acute stress disorder (ASD)
• the DSM-5 constrains trauma to events that expose a person to deaht, threaten death, serious injury or sexual violations (these exposures tend to in-still fear and
helplessness
• DSM-5 diagnosis requires that the person either experience the traumatic event direct or to witness the event, learn that the event happened to an individual they
are close to or experience repeated or extreme exposure to detaisl concerning a traumatic event (ex. First responders are repeated exposed)
These disorders both manifest in psychological and physiological symptoms
• These symptoms emerge acutely in individuals following trauma exposure
• Approximately 7% of adults develop PTSD in their lifetimes (symptoms that are mild or moderate will let some function typically but for others symptoms can be
debilitating and can deteriorate work, home and social lives
Women are at a higher risk since they are more often the victims of sexual assault, abuse and rape, around 20% of women face sexual assault, men 10%
• this sexual assault is associated with social stigma which can decrease the support they receive, men report traumas associated with less stigma (physical assault,
accident or exposure to war)
• 4 types of symptoms must be present for a diagnosis of PTSD: with the DSM-5 criteria
1) Reexperiencing the traumatic event (often involve intrusive images, thoughts, flashbacks(tend to be disturbing as they are intense an relive the traumatic expoures,
also vivid sensory experiences they may experience sounds, tastes, smells and body sensations and environment can trigger flashbacks ex smell), reoccurring nightmares)
2) Avoidance (persistent avoidance and memories thoughts that remind trauma are incredibly common, people with PTSD often isolate from others which can lead to
issues with interpersonal relationships and social functioning
3) Negative changes in mood or thought (individual may not remember all elements and blame self for being damaged for it, survival guilt is common for those who
lived through events where others have been injured or died - chronic distress and emotional numbness or withdrawal are common (may detach from experience)
• dysfunctional methods to reduce negative feelings often end up manifesting in self medication with alcohol/drugs or other unhealthy approaches
4) Chronic arousal or hyper vigilance (people who experience trauma tend to have changes to their CNS, they end up being on guard and tend to focus attention on
potential threats and have a higher level of irritability and agitation
Individuals with PTSD are likely to experience:
Insomnia (issues with sleep, sounds,and images within dreams that remind traumatic experiences can cause panic, hyper vigilance can lead to exhaustion (associated
with the development of PTSD and the maintenance of PTSD)
Dissociation (happens when different elements of sense of self become disconnected, a person may feel they aren’t in their own body, world isn’t real, looking down
at themselves from a third person perspective, PTSD with prominent dissociation is diagnosed when dissociated symptoms are persist and problematic
• Acute Stress Disorder (ASD):
Caused by traumatic events
Symptoms occur within 1 month of exposure
Symptoms last no longer than 4 weeks
Characterized by symptoms experienced in PTSD (reexperiencing trauma, intrusive thoughts, constant arousal, etc.)
Dissociative symptoms are common: numbing and detachment, reduced awareness of surroundings, derealization (unreal or dream-like experience of the world), deep
personalization (detached from mental processes and body) and difficulty recalling critical elements of trauma
 ▫

- psychology
• Adjustment disorder: people diagnosed don’t meet the criteria for diagnosis PSTD or acute stress disorder, anxiety or mood disorder resulting from stressful experience
• stressors that catalysts adjustment disorder vary in terms of severity, whereas stressors for PTSD or acute stress disorder are extreme
Involves a cluster of symptoms that occur within 3 months following a stressor:
• Emotional and behavioral symptoms include:
• Depressive symptoms
• Anxiety symptoms
• Antisocial behaviors
• Reactive attachment disorder (RAD):
Caused by severe neglect, abuse, and maltreatment occurring during early childhood
Usually presents between 9 months and 5 years of age
Children tend to: show interpersonal dysfunction and don’t see comfort or respond well to comfort when stressed, struggle to control emotions and have emotional dis
regulation
• Have a hard time forming emotional attachments
• Be emotionally withdrawn
• Show minimal positive affect
• Disinhibited social engagement disorder: the opposite of RAD and symptoms (tends to occur where kids have experience a lot of neglect in their lives)
• when kids develop overly familiar behaviour with adult strangers and really vulnerable to abuse and don’t experience discomfort with stranger adults
TRAUMAS LEADING TO PTSD
• risk factors associated with adverse psychological outcomes: demographic characteristics, proximity to the event and having few psycho-social resources
• a well developed support network is critical in terms of supporting a personal resiliency
• exposure to one traumatic event can be enough for a person to develop PTSD,, but multiple tend to increase the risk to develop
• Most individuals will experience at least one traumatic experience in their lifetime
PTSD is more likely to occur following trauma involving interpersonal violence (particularly sexual violence) and a history of repeated experiences with violence
• Secondary trauma:
When individuals experience a traumatic event through a narrative or firsthand account
• exposure to media that covers dramatic experience can exacerbate stress and cause people to worry more about future events
Individuals in occupations associated with high- stress and trauma exposure are more vulnerable to developing PTSD ex social workers, prosecutors, judges, therapists and
health care professionals, first responders are at really high risk around 10% of firefighters, ambulance personal, police and others around the world experience, firefighters
experience the highest due to being the most exposed to extremely injured
THEORIES OF PTSD: its known psychological, biological and psycho-social vulnerabilities all contribute to the likelihood that someone will go on to develop PTSD and a variety of
factors play a role in regards to a person’s psychological traits, characteristics of trauma, perception of the trauma and socio-cultural factors
People are more vulnerable to develop PTSD when
• Environmental and Social Factors:
Severity of trauma
Duration of trauma
Individual’s proximity to the event (are directly affected by the event)
Social support (those with a stronger support network and emotional support from others tend to recover faster from trauma)
• Psychological Factors:
Comorbidity is a risk factor (people who are already experiencing anxiety or depression will be at higher risk to develop PTSD
Coping methods play a role in PTSD vulnerability (people who used self-destructive mechanisms, like drinking or avoidance like isolating themselves tend to be more vulnerable
• dissociation coping mechanisms so psychological detaching from trauma tends to increase likelihood of PTSD
Sense of purpose in life is a resilience factor (finding purpose in the trauma makes it easier to cope and can help reduce PTSD vulnerability (reframing technique)
• positive side: higher ability to recover from traumatic experiences can lead to a stronger purpose in life
• Cultural Assets:
Ethnic identity: sense of belonging/commitment to an ethnic group
• people with a strong sense of ethnic identity have positive feelings about ethic group and show behaviours that highlight membership to group(lower anxiety, depression
and stronger protection from psychological dysfunction after a traumatic event
• Achieving ethnic identify in adolescence is associated with self-esteem, positive coping mechanisms, optimism and a sense of mastery
• Loneliness and depression are negatively associated
• A sense of ethnic identity tends to serve as a protective factor against psychological distress
• Biological Factors:
Neuroimaging research:
• Amygdala tends to respond more actively to emotional stimuli among individuals with PTSD (amygdala activates when we are processing emotional material and threat material
• Medial prefrontal cortex tends to be less active among individuals with more severe symptoms of PTSD (medial prefrontal cortex plays a strong role in modulating reactivity
within the amygdala in terms of its response to emotional stimuli
• Shrinkage in hippocampus among individuals with PTSD (due to overexposure to neurotransmitters and hormones that are released during the stress response
• plays strong role in memory, damage can lead to memory issues
 ▫ ▫

psychology
Theories of PTSD
• Biochemical Findings:
Resting levels of cortisol among individuals with PTSD tend to be lower than among individuals without PTSD (cortisol is major hormone released during fight or flight
response, high levels usually show high stress response, cortisol functions to reduce sympathetic nervous system activity after exposure to stress, so thought that lower
levels might result in prolonged activity of the sympathetic nervous system after a stressful event
Elevated heart rate
Increased secretion of epinephrine and norepinephrine (over exposure might lead memories of trauma to become over consolidated, more robust in memory
• Genetics:
Vulnerability to PTSD may be heritable:
• Twin studies (1 research consisting of 4000 twins who served in War, found that if one twin developed PTSD the other was significantly more likely to later develop if
they were identical)
• Cortisol production (adult children of holocaust survivors with PTSD are at a higher risk for developing PTSD and show abnormal levels of cortisol whether they ahve
been exposed to trauma or developed PTSD, abnormal level may be a heritable factor of PTSD
TREATMENTS FOR PTSD:
• There are 3 primary goals of psychotherapy for PTSD:
Expose clients to fearful stimuli (helps extinguish fear)
Challenge distorted cognitions (since cognitions are continuing to the persistence of symptoms
Assist clients in stress reduction (this is done in as many different facets of a personal life as possible)

Antianxiety and antidepressant medications are sometimes used in conjunction with psychotherapy
• Cognitive-Behavioral Therapy and Stress Management:
Systematic desensitization (client will identify anxiety thoughts or situations and rank them from worst to least anxiety and then the therapist would expose them to
elements in the hierarchy and use relaxation techniques along with exposure to reduce anxiety, typically impossible to return to traumatic event so therapist will ask them
to imagine it vividly, through this the therapist will monitor negative thinking patterns and help clients challenge thoughts

Two specific types of CBT:

• Prolonged exposure therapy (focuses on repeating exposure to remind of trauma
• Cognitive processing therapy (focusing on reinterpreting trauma)
• research shows that exposure therapy can result in reduced PTSD symptoms and can help with relapse prevention, also addressing negative thoughts can lead to an
overall reduction of symptoms
• There are some individuals who cannot tolerate exposure to traumatic memories
Stress-inoculation therapy can be effective in these cases (therapists will help clients learn skills in order to overcome challenges that are stressful and help
with issues that can result from PTSD (like interpersonal issues)
• Internet-based treatments can be effective (since there can be barriers to PTSD treatments
• helpful complimentary approaches: mindfulness techniques, yoga and meditation
• more and more virtual reality is used in order to expose clients to traumatic triggers, and found to be fairly effective
• Biological Therapies: these drugs will treat symptoms particularly sleep issues, irritability and nightmares that are common in PTSD
• some benefit, but evidence is mixed
SSRIs (sometimes used)
Benzodiazepines (infrequently used) significant side effects and strong potential to become addictive
Anxiety Disorders in Older Adults
• Approximately 15% of individuals over the age of 65 experience an anxiety disorder
• Typically manifests as:
Worry about loved ones
Worry about their health
Worry about their safety
• some older individuals have been experiencing anxiety for the vast majority of their lives and others in older age, overall rates of anxiety tend to decrease in older
age
This anxiety often exists in conjunction with depression and medical illness

Vulnerabilities:
Biological, psychological, social
• when these interact with new stressors and new traumas in our lives they can really
increase our risk for anxiety disorders
 psychology
Responses to threats:
Summarizes common responses to threat, once you interpret
an event as non-threatening the stress with subside,
behaviourally we tend to confront or escape stress
• with many anxiety disorders, threat response will
persist even with no threat present

Integrated model: highlights the integration of biological and psychological factors

- many people with panic disorder have a vulnerability to a hyper sensitive fight
or flight response to stimuli
• individuals who are involved in catastrophic thinking about their
physiological responses tend to go on to have panic attacks/disorder
• Hyper-vigilance for future panic attacks: people experience constant
anxiety, increases likelihood they will experience panic attacks again
• In terms of the conditioned avoidance response, people tend to make
associations between their symptoms of panic and certain situations
• if they avoid it and their symptoms subside, it aids their behaviour
which is common, go on to develop agoraphobia which is often comorbid with
panic

Cognitive-behaviour therapy

Disease Chair
Unconscious cognitions of people with GAD focus on detecting
threats in their environments
• they have to say the colour the word in printed in,
typically, individuals tend to be slower in naming the
words that have strong significane for their (failure for
those with GAD)
• Individuals with GAD tend to struggle and be slower
words that are threatening
 psychology
Social fears: lifetime prevalence of social fears in a national survey
DSM 5 for social anxiety disorder

30%

39%

DSM-5 separation anxiety disorder

Use of CBT: provided individually or in group setting

• in group setting, clients can practice fear behaviours in front of other people
while therapist guides them in terms of relaxation techniques, can be useful
• Groups can help individuals to challenge their negative thoughts
• Groups are equally effective as individual, it provides environment to engage in
social situations and build social skills

DSM-5 for specific phobia

Treating claire with CBT

Unconditioned stimulus and response, the behaviour account of little albert’s phobia
Watson and Rainer put a white rat in front of 11 month old little albert and
when he reached for the rat they would bang a metal bar over his head, and
after pairing the crying would continue, and now little albert is fearful of white
animals
• showed that a phobia can be conditioned through classical conditioning and
this fear could be extinguished to be presented with the rat with no bang
• Many people avoid fears which means they could also avoid what could
extinguish their fears
 psychology
DSM-5 OCD

The orbital frontal cortex and basal ganglia tend to play a strong role in
DSM-5 Hoarding disorder
OCD
• the basal ganglia includes caudate nucleus and this filters impulses
that occur in the orbital frontal cortex and only let in the most
critical ones to reach the thalamus
• Theory: maybe the orbital frontal cortex and the caudate nucleus
are so active among individuals with OCD that too many impulses
reach thalamus and generate obsessive thoughts and actions

DSM-5 for posttraumtic stress disorder

 ▫ ▫

- psychology

SOMATIC SYMPTOM AND DISSOCIATIVE DISORDERS:

SOMATIC SYMPTOM AND RELATED DISORDERS:
• Biological and psychological factors are intricately intertwined (ex if your experience physical pain, this will have an impact on your ability to focus, sleep and well-being,
or the other way for psychological factors, if you get hurt and you focus on the pain it is going to enhance your perception of how the pain really is
• Individuals with somatic symptom disorders:
May experience physical symptoms that seem to be caused by psychological factors
Tend to be excessively concerned about their physical symptoms
Significant challenge: there is a possibility that the individual does have a real physical disorder just might be difficult to diagnose or detect (diagnosing somatic symptom
disorder is much easier if the psychological symptoms leading to physical symptoms can be identified and if physical exams prove that symptoms can’t attribute to
physiological issue
• In the DSM-5, somatic symptom disorders include:
Somatic symptom disorder
Illness anxiety disorder (formally referred to as hypochondriasis)
Conversion disorder
Factitious disorder
Psychological factors affecting other medical conditions (sometimes referred to as psychosomatic disorder, where people have physical illness (high blood pressure)
made worse by psychological factors: ex. Depression can exacerbate arthritis, diabetes, asthma)
SOMATIC SYMPTOMS DISORDER AND ILLNESS ANXIETY DISORDER:
• Individuals with somatic symptom disorder: complain about concerns that are obsessive when you actually look at their physical health, these concerns can end up
interfering with daily functioning and persist even when they are told they are okay
Have at least one distressing physical symptom
Spend a significant amount of time and energy focusing on these symptoms and seeking medical care for them
Common symptoms: with these symptoms they often assume the worst scenarios (stroke or cancer) and insist on medical procedures that aren’t needed
• Pain in body
• Fatigue
• Neurological symptoms (e.g. dizziness)
• Heart palpitations
• Gastrointestinal symptoms (e.g. nausea)
• might have health anxiety and have checking behaviour like check blood pressure numerous times daily, avoid certain actives as they may worry they make them
worse that can lead to isolation or interpersonal issues
• Prevalence of somatic symptom disorder: 5-7% of population, females are significantly more likely to get it at a ratio of 10-1
• Can begin in childhood, adolescence, or adulthood
• Illness anxiety disorder: formally hypochondriasis
Individuals with illness anxiety disorder worry that they have a serious illness or they will develop one. They don’t always experience physical symptoms
• Individuals with somatic symptoms disorder do experience physical symptoms and try to obtain treatment for them
• these individuals don’t have a physical disorder but are very preoccupied with the belief that they do, often misinterpret normal body sensations as a indicator of
significant physical affliction, this will cause distress or tendency to seek care (Ex. Headache, may assume they have brain cancer)
• core features: cycle of worry and reassurance seeking behaviour, in somatic symptom disorder focus is on the relief of stressed caused by the somatic symptoms
• Often engage in body checking behaviours, skin lesions, physical changes or hair loss (main concerns tend to impact social and occupational functioning)
• Individuals with illness anxiety disorder are not trying to seek attention but instead tend to get overly alarmed by health and tend to seek out unnecessary tests and
procedures to reduce fears and anxieties
• Individuals with somatic symptom disorder and illness anxiety disorder: symptoms end up becoming a significant part of person’s sense of identity and changes and
symptoms tend to parallel emotional well-being (Ex. When experiencing more depressive symptoms they tend to have more physical complaints)
• individuals with somatic symptom disorder significantly more likely than individuals with illness anxiety disorder to report more severe health anxiety, depression,
somatic symptoms and higher health service use
• Individuals with somatic symptom disorder significantly more likely than individuals with illness anxiety disorder to experience major depressive disorder, agoraphobia,
panic disorder
Vulnerable to anxiety and depression
May mask their distress with antisocial behavior
May mask their distress with alcohol/drug abuse
May express their distress in the form of physical symptoms
 ▫ ▫

psychology
SOMATIC SYMPTOM DISORDER AND ILLNESS ANXIETY DISORDER;
• During the COVID-19 pandemic: even in individuals without disorders, general health concerns associated with COVID have lead to more somatisation in the general pop,
individuals with no history of anxiety or somatic symptoms disorders tend to experience more somatic concerns in terms of COVID 19 (preoccupation with fatigue, aches)
• research has found that significant proportion of individuals complain about health concerns and somatic symptoms that aren’t well explained by medical condition,
always a possibility that these individuals are experiencing a physical disorder that hasn’t been appropriately identified through research
Somatic concerns associated with personal health have increased
Individuals with somatic symptoms disorders have experienced increased psychological distress
• Health concerns and multiple somatic symptoms (and no diagnosed medical illness) are associated with:
Disability
Low income
Impaired sleep
Psychological distress
High blood pressure
Obesity
High-cholesterol
Hospitalization
• important to keep in mind that these diagnoses are new to DSM-5 and are still poorly understood and many researchers are concerned that the criteria might risk
misidentifying physical illness as mental illness
• Multiple symptom concerns tend to more common in older adults in comparison to middle aged adults even when you control for medical illness
• Because of cultural norms that existed for adults when they were growing up, typically avoided admitting to depression or anxiety might have led to be more likely to
express negative emotions in the form of somatic complaints
• Somatic complaints are seen in young kids who lack the ability to use language to express challenging emotions
THEORIES OF SOMATIC SYMPTOM DISORDER AND ILLNESS ANXIETY DISORDER:
Individuals with these disorders often:
Assume that serious illnesses are common
Believe that physical changes are concerning (ex mild chest pain, they would interpret this as serious cardiac illness, interpretation as a serious illness may lead to
higher heart rate and that might exacerbate their pain - psychological factors exacerbating physical factors)
Believe they are vulnerable to many physical illnesses
• also tend to experience bodily sensations more intensely than others and pay stronger attention to physical symptoms and tendency to catastrophise symptoms
• There is a significant correlation between the severity of somatic symptoms and childhood/adolescent emotional/sexual abuse
• one study assessed older women from 7 european countries and found that women who had history of domestic or sexual abuse tended to report significantly
higher levels of somatic symptoms - suggests that painful events can have prolonged negative impacts on health, even if the event has subsided
TREATMENT OF SOMATIC SYMPTOM DISORDER AND ILLNESS ANXIETY DISORDER: usually difficult to convince patients that they need treatment because their concerns
are focused on physical ailments , they suffer from phsyical complaints but also anxiety and checking behaviours
• individuals with this disorder will insist they are ill even if physicians have ran numerous tests and said otherwise, frustrating for patient because symptoms aren’t
confirmed
It is typically difficult to convince individuals with these disorders that they need to seek psychological treatment
• Common therapies:
Psychodynamic therapies (help clients recall memories that may have triggered symptoms, also provides insight into the associations that exist between emotions
and physical symptoms
Behavioural therapies (clinicians try to understand reinforcements that individuals have received for health complaints and try to eliminate reinforcements and
reward healthy behaviour
Cognitive therapies (help clients learn to interpret their physical symptoms in an appropriate way and try not to catastrophise)
Cognitive-behavioral therapies (focus on identifying and challenging beliefs and misinterpretations about a clients physical sensations and exposing clients to anixety
triggers
• acceptance and commitment therapy has also been tried and this incorporates mindfulness and acceptance and can be useful, clinicians will sometimes use the belief
system and cultural traditions of clients to enhance motivate to engage in therapy
CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER:
• Conversion disorder: term comes from the assumption that psychological distress following trauma is converted intro physical symptoms, the term functional and
neurological symptoms is more neutral and doesn’t make the assumption of a psychological cause
Presentation of neurological symptoms not explained by a medical condition or neurological disease
Typically only involves one specific symptom
Examples: paralysis, blindness, mutism, non-epileptic seizures, difficulty swallowing and tremors
• around 20% of patients in neurological clients present with symptoms where medical causes have not yet been identified
• Number of individiuals who meet the criteria for persist conversion disorder is aprox. 20 in 100,000
 ▫ ▫

psychology
THEORIES OF CONVERSION DISORDER:
• Freud: physical symptoms signified very specific memories or concerns that are repressed
Believed that conversion symptoms result from the transfer of energy from repressed emotion into physical symptoms
• Primary (reduction in anxiety) vs secondary gain (attention and concern that the person receive from others
• Behavioral theories: view conversion disorder symptoms as a learned maladaptive behaviour that in reinforced by environment
Conversion symptoms alleviate distress by:
• Removing a person from challenging environments
• Allowing an individual to avoid unwanted situations/responsibilities
• symptoms were common in the first and second world war where soldiers were paralyzed or blind and unable to fight again, sometimes the physical symptoms
would represent the traumas they witnesses (shot a civilian in leg might develop strong leg pains)
• Children:
Often have symptoms that mirror the symptoms of an individual they are close to who has been diagnosed with a physical illness
• a child whose mother had stroke and lost right side, the child might lose ability to use right leg
• Tend to be significant associations within childhood trauma and the development of conversion disorder with more than 50% of individuals with conversion disorder
having a history of physical violence, and 25% having a history of childhood sexual assault
• Trauma isn’t always present which is why DSM-5 doesn’t include it as a stressor
• Individuals with conversion symptoms tend to be easily hypnotized and this tends to support that stressful life experiences and maltreatment might lead individuals to
spontaneously self hypnotize which the mind might dissociate sensory and motor functions from conscious awareness
Trauma can impact physical symptoms
THEORIES OF CONVERSION DISORDER:
• Neurological models:
Anxiety may impair sensory or motor areas of the brain
• It may be that conversion disorder involves changes in connectivity between the neural regions involved in loss of functioning and areas associated with the regulation/
experience of anxiety (one case with a women with conversion mutism, fMRI showed normal speech areas when the women did vocalization test. Impaired cognitively was
seen within speech areas and areas of the brain regulating anxiety within the anterior cingulate after receiving CBT, the woman overcame mutism and the cognitively was
restored
TREATMENT OF CONVERSION DISORDER:
• Very difficult to treat since individuals don’t think they have psychological symptoms that require treatment
Prognosis is often poor
• for some, symptoms will improve with time with no treatment, in terms of 3 year follow ups clients reveal that they had abnormal movements in around 90% of
cases
Types of treatment:
• Psychoanalytic (highlight expression of painful memories and emotions and identifying relationship that exists between these and the conversion symptoms)
• Cognitive-behavioural (reducing anxiety regarding trauma that may have caused symptoms as well as reducing the benefits that an individual may experience from
displaying the symptoms
FACTITIOUS DISORDER:
• When an individual fabricates an illness in order to receive medical attention (ex. Person may contaminant a urine sample with blood, inject fecal material into themselves
to create infection, might claim to have depressive symptoms when they don’t, suicidal when not, might inject hallucinogens before psychological evaluations
• different than other disorders as there is evidence that they are behaving in an intentionally deceptive way
• Individuals with this disorder fabricate symptoms of physical illness and sometimes psychological illness
• This disorder is commonly referred to as Munchhausen’s syndrome
FACTITIOUS DISORDER IMPOSED ON ANOTHER:
• When an individual deliberately claims that another has an illness (e.g. their pet, child, parent) this is munchhausen by-proxy
• act as devoted protector and draw praise from staff due to that, as a result of claims, pets or kids are subjected to dangerous or unnecessary procedures and
can end up dying
DISSOCIATIVE DISORDERS: characterized by a disruption of consciousness, or the typical integration that exists in terms of your identity, memories, perception, behaviour
and motor control and it tends to disrupts one or more facets of psychological function
• consciousness: awareness of self and environment
• We all experience some dissociation from consciousness: daydreaming, losing track of time, lost in book or movie
In typical experiences we can get into these states and get out of these states with ease (normal experiences)
• Dissociative disorders: occur when dissociation can’t be controlled and occurs unconsciously
Particularly common among individuals who have been exposed to trauma
 ▫

psychology
DISSOCIATIVE DISORDERS:
• 19th century strong interest in dissociation (Freud, Jung, James, etc.)
• After 1910, interest decreased because of the rise of behaviorism and biological theories in psychology
• Experiments on hidden observer phenomenon (Hilgard) revitalized interest:
Active mode to consciousness (conscious plans, voluntary actions)
Passive mode to consciousness (conscious registers information without any awareness of the info actually being processed)
• functional neuro imaging studies shown that hypnosis can increase or decrease neural activity and function connectivity between neural regions
• many activity can take unconsciously including problem-solving, motivation, decision mechanisms and working memory
• ex of hidden observer phenomenon: some anaesthetized surgical patients can later recall under hypnosis certain bits of music played during surgery
• for most people the active and passive modes of consciousness can weave our live experiences together seamlessly that we don’t notice the separation that
exists
• among people with dissociative disorders, can have chronic issues in terms of integration active and passive consciousness and seem split and operate
independently from one another
DISSOCIATIVE IDENTITY DISORDER:
• DID: identity disruption
Presence of 2 or more distinct identities or personality states (presence creates an obvious discontinuity in a persons sense of self, affect, memory, consiousness
and feelings of control, these different identities lead to clinically significant distress or functional impairment
• each identity has their own first person perspectives and reports their own subjective memories as well, often report of being unaware of their other identities
or amnesia for when the other identity was in control of their body (sometimes one-way amnesia occurs, when one of the alters is aware of the other, but the
other is unaware of the first
The identities that co-exist within the individual are referred to as alternate identities (alters)
Switch: the transition from one alter to another. One identity pushes the other one out of control
Individuals with DID typically experience recurring memory gaps (gaps in personal history, or job skills, driving skills, cooking skills)
• verifying reports of amnesia is difficult but some research suggests that information and memories can transfer even if the individual believes the identity
experiences amnesia
• Alternate identities can be very different in terms of: referred to alters
Facial expressions
Speech characteristics
Psychological responses
Interpersonal styles
Gestures
Ages
Sexual orientations
Allergic reactions
Visual acuity
• best characterized by a fragmentation of identity instead of separate identities (viewed as fragments of the host that the person creates as a coping mechanism
for traumatic experiences
• This dissociation provides a person an escape from emotional or physical pain that is associated with trauma
• Some common types of alters:
Child, persecutor(hostile to the hosts personality, associated with anger and shame thats is related to the trauma and perpetrator (often inflict pain like self
harming, burning or cutting), opposite gender, suicidal
• helper alters tend to display kind attitude towards host, advice to other personalities, or functions the host cant (hiding from abusive parents)
• alters tend to appear as a result of a child unsuccessfully processing trauma (overwhelming number of people with dissociative identity disorder report history
of abuse)
• chaotic or dysfunctional environments and severe physical and or sexual abuse tends to be common
• sexual, physical, and observed DV or abuse, tend to be triggers, individuals who are victims of early on-set child abuse and severe child abuse usually from
attachment figures tend to be more vulnerable to the disorder instead of PTSD
• one study found that 90-100% of individuals with identity dissociative disorder reported significant childhood abuse and/or neglect (keep in mind
childhood abuse and neglect are associated with loneliness, isolation and alienation, which supports the development and maintenance of this disorder
• Child alters are the most common (don’t age as person ages, childhood trauma is usually associated with dissociative identity disorder, can typically be created to take
on the role of the victim
• DID is a chronic and complex post-traumatic disorder
• Individuals with DID tend to experience depersonalization (detachment from yourself, tend to feel isolation, lonely and confusion for self) and derealization (detached
from environment and feelings of alienation are common, alone, different and disconnected)
• Feelings of alienation are common
• tend to be associated with psychological trauma, in the DSM-5 there is now a dissociative subtype of PTSD (ptsd is almost always comorbid with dissociative
identity disorder)
• Individuals with DID experiences significant behavioral and emotional challenges
• kids who have this disorder, have poor performance in school and prone to anti-social behaviour, vulnerable to participate in drug and alcohol abuse and
vulnerable to engage in early sexual relationships
• kids tend to show a lot of signs of PTSD: hyper-vigilance, flashbacks, nightmares and a strong startle response
• emotionally these individuals tend to be unstable and severe anxiety, explosive anger and sometimes anger
 ▫

psychology
DISSOCIATIVE IDENTITY DISORDER CON’T:
• Self-injurious behavior is common: burns, drug overdoses, cutting, and suicide attempts are commonn (significant association between dissociation and self-harming
behaviour)
• individuals with dissociative behaviours broadly, tend to report feeling numb after self-injury (thought that they might engage in self-harm as an escape or an
experience of internal conflict between their selves)
•
• Prevalence of DID: thought that this disorder in under-diagnosed, particularly by professionals who lack experience to identify it in the early process
Approximately 5% in psychiatric inpatients, 2-3% in outpatients, 1% in the general population
• percentage is highest in adolescence psychiatric outpatients and within psychiatric emergency units
• it might be the case that acute transient crisis situations can heighten this disorder’s symptoms
• the average patient of this disorder tend to experience years within the mental health symptom before receiving a diagnosis
• Majority are adult females
• Individuals with DID are at risk for the following:
ISSUES OF DIAGNOSIS OF DID: lot of factors that make diagnosis of DID challenging
• DID has been recognized in the DSM since 1980, though individuals with DID are often misdiagnosed and obtain inefficient treatment
• mental health professionals tend to have a lack of training in this area and skepticism regarding the existence of DID
• from the time the individual starts treatment for DID symptoms to the time of them receiving an accurate diagnosis and receive 4 other diagnosis and often
spoend 7-10 years within mental health services
• lots of elements of DID can be impacted by their cultural background, fragment of identity may take the form of demons, creatures, etc
• feelings of possession tend to be involuntary, distressing and uncontrollable (around 60% of people with DID in western settings tend to report feeling
possessed
• in the DSM-5, transition in terms of idenitity don’t need to be observed by other, can be self-reported (issues with recall can include everyday events
instead of just traumatic experiences
Many researchers and clinicians still question the validity of the existence of DID
THEORIES OF DISSOCIATIVE IDENTITY DISORDER:
• DID may be the manifestation of coping mechanisms that are used by individuals who have experienced intolerable trauma

• someone who experiences trauma and dissociation

• Its thought that alternative identities can provide a sense of security, safety that individuals are not receiving from their caregivers
• Alters can perform frightening functions and become a a-chronic approach to dealing with stressors or difficult situations in life
• Sociocognitive mode: plays a strong role in the development of DID
Alters may be created by individuals who harness the idea of DID as metaphors which fit their lives
Patients are role playing in order to deal with stress
• patients use of dissociative identities might be reinforced by attention and concern of others or media or cultural narratives
• Biological factors: : plays a strong role in the development of DID
Neurobiological responses in response to trauma
• ex. cingulate gyrus, the superior frontal lobe and the medial prefrontal cortex are all neural regions impacted by dissociation
• people with DID tend to have smaller hipocampul volumes, might be due to stress hormone exposure from early trauma
No genetic studies have been conducted to assess DID heritability, but dissociation more broadly
• the use of biomarkers in order to access DID, might lead to reduction in terms of misdiagnoses, treatment costs but also could increase a patients quality of life
TREATMENT OF DISSOCIATIVE IDENTITY DISORDER: goal of treatment is to integrate the alter identity or identities into a coherent sense of self and allow client to cope
with stress and build trusting and healthy relationships
• the process of integration is viewed as giving voice to every identity and helping them to be aware of one another, also to find out the function of each personality
and the trauma that led to each disorder
• ultimate goal: not to eliminate the alters, rather, have them coexist in a coordinated way
• 3-phase trauma-focused psychotherapy:
Stage 1:
• Focus on stabilizing DID symptoms and safety issues (create a therapeutic alliance)
• Creation of therapeutic alliance
Stage 2:
• Work on the ability to regulate affect and manage symptoms
• Processing, grieving, resolving trauma
Stage 3:
• Integration of dissociative self-states
• Increase in social engagement
 ▫

psychology
DISSOCIATIVE AMNESIA:
• In DID individuals often experience amnesia for the time when an alter is in control (can’t remmeber important facts about life and identities, often aware of these
significant gaps in memory
• For some individuals, periods of amnesia occur WITHOUT the presence of alters
• Dissociative amnesia:
Functional impairment resulting from an inability to remember autobiographical information. (Can be specific to a certain event or time period or can be more generalized to
a person’s identity
• individuals who are effected by dissociative amnesia are at an increased risk of suicide, onset is sudden and multiple episodes might be recorded (some episodes tend to
resolve quickly, others persist for years)
Prevalence: 1% for males; 2.6% for females
• Affects memory systems: might lose access of a traumatic event or elements, can result in memory gaps
Memory failures may result from severe psychological stress which prevents the integration of traumatic and normal experiences
• As a result, trauma-related memories may become inaccessible
• amnesia of traumatic events might be protective (ex. Survivors of childhood sexual abuse who have dissociative amnesia tend to have less depression and anxiety in
comparison to those who don’t
• Amnesia can be classified as:
Organic
• cause by brain injury from disease, surgery, accident, drugs
• Associated with the inability of remembering new information or anterograde(when a person have impairment fro new information, will rarely occur without retrograde
amnesia) amnesia
Psychogenic
• due to psychological causes
Generalized retrograde amnesia is very rare whereas amnesias for specific durations of time (particularly associated with trauma), are common
• involves impairments of memory of past events or personal history
• functional neuro imaging that has been done of individuals who have been diagnosed with retrograde impairments tend to show impairments in a neuro network that is
critical for auto biographical memory
• Successful recall of traumatic memories: makes treatment difficult
May increase risk of PTSD and suicidal ideation
On the other hand, it can be beneficial since these individuals may be better able to understand how trauma has impacted their lives and how to reduce trauma-related
symptoms
• Currently, there are no evidence-based treatments for dissociative amnesia which states that further research on the neuro biology of DID and dissociative amnesia is
critical in order to inform treatment approaches
• Dissociative fugue:
Individual travels to a new place and assumes a new identity with no recollection of their previous identity
They may behave normally in their new environment
Extremely rare diagnosis
• these individuals don’t find it odd that they don’t remember critical parts of past, may return home suddenly to previous identity and presume like nothing happened
• Often unable to recollect their life after the fugue
• Dissociative fugue:
May result from dissociation as a defense mechanism against stressors or memories that are intolerable to individual
A neurological model of repression has been proposed showing changes in activity levels in the prefrontal cortex in the hypo-campus
• individuals with dissociate amnesia can recover without treatment, if psychotherapy is used, it typically focuses on helping patients understand and remember the trauma
There may be automatic processes where these memories can be state-dependent
Ex. Lorena bobbit cutting off husbands penis after years of abuse. She claimed to have amnesia for the act of cutting it off
DEPERSONALIZATION/DEREALIZATION DISORDER:
• Individuals with depersonalization/derealization disorder:
Have many episodes of feeling detached from their body or mental processes
• often feel like outside observers of themselves
• Occasional experience of this is common if they are sleep deprived, taking drugs, or after significant stressor
• Lifetime prevalence: 0.8-2.8%
Equally common among males and females
CONTROVERSIES AROUND THE DISSOCIATIVE DISORDERS:
• Skeptics have argued that these disorders are fabricated in suggestible clients by therapists who reinforce this fabrication in clients via hypnotic suggestion
• Individuals who believe in repressed memories:
Argue that there is strong clinical evidence for dissociative amnesia
• Critics argue over the validity of these studies as well as the methodology used
• overall, there is no strong census in term of the legitimacy of our knowledge about dissociative disorders
psychology
Somatic symptoms and dissociative disorders
along the continuum
• ranges from function to dysfunction
• As individuals get closer to the
dysfunctional side it becomes more and
more important that they seek help in
terms of reducing the symptoms to
enhance their functioning and sense of
well-being

DSM-5 somatic symptoms disorder

DSM-5 for illness anxiety disorder

DSM-5 Dissociative identity disorder

psychology
DSM-5 for diagnostic criteria for dissociative amnesia

DSM-5 for differences between psychogenic and organic

amnesia

DSM-5 diagnostic criteria for depersonalization/derealization disorder

Scepticism has been further kindled by loftus, who developed

a method of distilling a childhood memory of being lost at the
age of 5 by asking a family member to engage in
conversation about that time that the individual felt lost
• this research has shown that false memories can be
instilled in others
• Other research studies have shown that if you
repeatedly asked adults about childhood events that
never happened, around 20-40% will eventually
remember these events and explain them in significant
detail
• All of these findings come together to show scepticism
concerning dissociative disorders

Social factors, psychological factors and physical symptoms are associated in

somatic symptom and dissociative disorders
• psychological factors can have a dramatic effect on how our bodies
physiologically function and how our physical symptoms can have a
significant impact on our psychological well-being
MOOD DISORDERS AND SUICIDE

SYMPTOMS OF DEPRESSION
• Individuals diagnosed with depression often report that they:
> Have no joy/pleasure in their lives
> Have no interest in activities that they previously enjoyed (anhedonia)
> Have depressive thoughts containing themes of guilt, hopelessness, worthlessness, and suicide
> Worthlessness and guilt is associated with unrealistic negative self evaluations or preoccupations with failures that have happened
> Have physical symptoms including changes in sleep, appetite, and activity levels, vary across individuals
> Tough time focusing and making decisions, lose touch with reality, delusions, false beliefs (psychotic symptoms)
> Shows depression is severe, hallucinations could be telling a person to commit suicide
> Decrease in energy and sustained fatigue
> Psychomotor retardation: walk slowly, talk slower, appear fatigued

DIAGNOSING DEPRESSIVE DISORDER

• DYSPHORIA: intense feelings of sadness, core feature of all types of depressive disorders
• Major depressive disorder (MDD):
> Acute (but time-limited) symptoms of depressed mood, symptoms will resolve even if left untreated
> Symptoms last at least two weeks
> Symptoms have a significant impact on an individual’s ability to function in their everyday life
> Individuals who experience one depressive episode are more likely to experience another, 15%
> Recurrent episodes will begin within 5 years of the first episode
> 5-9 depressive episodes throughout their life
> Predictors: Severity of symptoms, adult psychiatric comorbity, and multiple previous episodes

MAJOR DEPRESSIVE DISORDER (MDD)

• Comorbidity:
> More than 70% of individuals diagnosed with major depressive or persistent depressive disorder have another psychological disorder at some point in their lives
> Most common are substance abuse, anxiety disorder, and eating disorders
• Important consideration: typical depressive response to a negative event
> Depressive responses shouldn’t be responded to unless atypical responses such as suicidal ideation or severe impairment
> If individual experiences an extreme loss, they will likely experience many symptoms of a depressive episode, intense and prolonged grief coupled with functional impairment should be
considered depression
> Not an agreement on whether grief should be a pathological disorder
• The DSM-5 uses specifiers for disorders in order to assist in providing clarity or a better explanation of symptoms.
> Specifier Anxious distress: depressive symptoms occur in conjunction with anxiety symptoms

PERSISTENT DEPRESSIVE DISORDER

• Persistent depressive disorder:
> Chronic
> Previously termed ‘dysthymic disorder’ and ‘chronic MDD’ (in DSM-IV)
> Depressed mood for most of the day and for most days
> Has been occurring for at least 2 years (in children and adolescents, only 1 year)
> Should not have been without symptoms for more than a two month period
> Higher risk for comorbity disorders in comprise to MDD, specifically anxiety and substance abuse
> Also more susceptible to worse functional outcomes
> Presence of 2 or more of the following:
> Poor appetite
> Insomnia or hypersomnia
> Low energy or fatigue
> Low self-esteem
> Poor concentration
> Hopelessness

PREMENSTRUAL DYSPHORIC DISORDER

• Premenstrual dysphoric disorder (PMDD):
> Severe mood disorder
> Combination of cognitive-affective and physical symptoms
> Symptoms occur in the week before menses
> May experience an increase in anger or irritability which tends to be associated with more interpersonal conflict
> Common physical symptoms:
> Breast tenderness
> Bloating
> Weight gain
> Muscle pain
> Joint pain
> At least one symptoms of emotional sensitivity should be present
> Significant distress and/or impairment should be present in schools, work, relationships, and should minimize once menses are over
> 2-8% experience PMDD globally
> Comorbid with 70% of disorders

DISRUPTIVE MOOD DYSREGULATION DISORDER

• A disorder that was added in the DSM-5 Characterized by:
> Severe and chronic irritability
> Persistent negative mood
> Severe temper outbursts in children and adolescents
> Shouldn’t be used as a diagnoses for children under the age of 6 or adolescents over the age of 18
> Outbursts are usually in response to frustration, against property, against the self, or against others
> Children with disruptive mood are more likely to develop antisocial anxiety disorder and substance use issues
• Children and adolescents with DMDD typically have:
> Low frustration tolerance
> Challenges with emotional regulation
> Challenges with behavioral self-control
> Limited distress tolerance
MOOD DISORDERS AND SUICIDE

DISRUPTIVE MOOD DYSREGULATION DISORDER

• Common treatments for children with disruptive behavior disorders:
> Pharmacological interventions
> CBT: social skills training and parent training
• Environmental factors may contribute significantly to the irritability which is a hallmark of this disorder
> Parenting factors and peer victimization
> Identifying triggers is very important; exposure therapy can be very useful, increase frustration management
• Prevalence of 2-5%
• More common among males

PREVALENCE AND COURSE OF DEPRESSIVE DISORDERS

• MDD is one of the most common mental health disorders
> Prevalence of around 7%
> Individuals between 18-25 years are most impacted with a prevalence of 13%
> 64% of adults report having severe impairment
> Rates of impairment are lowest over individuals over 65, but increase over age of 85
• Half of patients who take medication for treatment will not respond to that treatment
• Major depression is more commonly reported among females (8.7%) than males (5.3%)
• Depression tends to be a long-lasting and recurrent issue
• Cultural Assets:
> Among individuals who are Black, indigenous, or people of color, (BIPOC individuals), lower rates of MDD are usually found
> Individuals who are exposed to adversity seem to be better able and manage stressful life experiences, lowers chances of developing MDD
> Research suggests they are exposed to moderate adversity which can produce resiliency
• Major Depressive Disorder in Children and Adolescents:
> 12.8% of adolescents experience a depressive episode
> 70% of episodes result in severe functional impairment
> Rates of MDD among preadolescents have increased drastically
> correlated with interpersonal difficulties, inschool performance
> Paediatric depression has been found in kids as young as 3, kids will experience somatic complaints, more irritable, show more symptoms of anxiety rather than talking about it
> Less hypersomnia, more variation in terms of weight and appetite, and fewer delusions in comparison to adults
> MDD is underdiagnosed and undertreated
> Males and females around equal, after puberty females is higher as they have more risk factors such as family conflict or abuse
• Major Depressive Disorder in Children and Adolescents:
> Common comorbidities:
> ADHD
> Anxiety disorders
> Disruptive disorders
> Substance use disorders
> Enuresis/encopresis (urinary/fecal incontinence)
> Separation anxiety disorder
> More impairment, more symptom severity, more chronic course in illness, decreased repose to treatment
• If left untreated, what are the consequences?
> Develop more significant issues, increased suicidal ideation, increased suicide attempts, social issues, academic issues
> 8% of adolescents with MDD will complete suicide by the time they are young adults
• Major Depressive disorder in Children and Adolescents:
> Early intervention is critical
> Treatment for MDD:
> Psychotherapy: individual, group, or interpersonal
> Antidepressants (SSRIs most commonly used)
> Prozac has best evidence for effective use
> 60% have success with psychotherapy, but medication and psychotherapy produce best results
> Kids are more likely to recover from an episode faster, have a higher rate of recurrence, and are more likely to be given a diagnoses of bipolar disorder

MANIA: THE OPPOSITE OF DEPRESSION

• Manic episodes:
> High energy, lots of confidence, destructive mood
> Period of persistently elevated or irritable mood
> Goal-directed activity or energy which lasts for a minimum of one week occurs
> People sometimes report feeling “high”
> Individuals often become boastful, overconfident and they can have poor judgement and decreased impulse control
> Grandiose: can heal someone just from touching them
• Individuals may experience:
> Impulsive behaviors
> Rapid speech
> Racing thoughts
> Increased energy
• “Flight of ideas”
> Symptom of mania
> Accelerated speech that is incoherent and shifts from one topic to another
> Flooded with so many exciting ideas they can’t express them all at once
• Kayne: describing how he would organize the White House
> all of his ideas presented shift incoherently
• Increase in terms of energy and a reduced need for sleep
> Often wake up early in the morning after a short period of sleep and feel refreshed
MOOD DISORDERS AND SUICIDE

MANIA: THE OPPOSITE OF DEPRESSION

• Symptoms of hyperactivity and distraction can manifest as:
> an increased pace of typical daily tasks
> rapidly changing behaviours
> In severe cases, individuals can sometimes experience destructive agitation which can lead to hospitalization or incarceration
> So agitated that think people are getting in their way
• Impulsive behaviors can manifest as:
> Spending sprees
> Entering into unsound business ventures
> Sexual indiscretions
• Mania is a core feature of bipolar disorders since individuals alternate between manic and depressive episodes
• Unipolar mood disorder is possible (but not common):
> Where an individual experiences ONLY manic episodes with no presentation of depressive episodes
• Some researchers argue that mania should be an independent psychological disorder

BIPOLAR I AND BIPOLAR II DISORDER

• Bipolar I:
> Most commonly diagnosed among individuals who have full manic episodes that alternate with full depressive episodes
> Episodes of depression can be mild or severe *Periods of depression is not required for for this diagnosis
• Bipolar II:
> Rather than experiencing mania, these individuals experience hypomania
> Milder symptoms of mania that don’t interfere with day to day functioning and don’t involve hallucinations or delusions
> Individual experiences major depressive episodes

CYCLOTHYMIC DISORDER
• A chronic form of bipolar disorder:
> Less extreme mood states
> Too infrequent
> Periods of some depressive symptoms alternate with periods of some hypomanic symptoms
> Lasts for at least 2 years
> Function fairly well, can interfere but less severe than MDD
> Higher risk of being diagnosed with bipolar disorder
> Cyclothymic is most common disorder but seldom diagnosed, this is true among children and adolescents

RAPID CYCLING BIPOLAR DISORDER

• Over the course of time, bipolar episodes:
> tend to become more frequent
> the time between episodes tends to shorten
• 90% of people diagnosed have many cycles throughout their lifetime, episode periods are variable
• Can be manic, hyper-manic, or major depressive
• Seasons can impact bipolar presentation, 25% present in a seasonal pattern
• Rapid cycling bipolar disorder occurs when:
> At least 4 mood episodes occur throughout one year

BIPOLAR DISORDER IN CHILDREN

• Peak onset for bipolar disorder occurs during late adolescents are early adulthood
• Controversial whether prepubertal bipolar disorder exists
• Some researchers proposed that chronic irritably and explosive temper in combination with ADHD can manifest bipolar disorder
• Kids with chronic symptoms present with severe irritability and temper tantrums, rarely go on to develop bipolar disorder
• Difficult to differentiate between ADHD, bipolar disorder, or oppositional defiant disorder

PREVALENCE AND COURSE OF BIPOLAR DISORDER

• International lifetime prevalence: 2.4%
• Males and females are equally vulnerable
• No significant differences across cultures or ethnic groups: biological factors could be a strong predictor than depressive disorders
• Average age of onset is 25 years
> Earlier onset age have longer delay in treatment, higher comorbity with substance use and anxiety, and higher depressive symptoms
• Because bipolar disorders tend to have a recurrent course, they are associated with poor outcomes
• Vast majority of individuals with bipolar disorder don’t receive treatment, particularity true in developing countries

CREATIVITY AND THE MOOD DISORDERS

• Some theorists have argued that mania and depression can be inspirational for artists
• Numerous political figures, artists, and religious figures have been affected by bipolar disorder or depression
> Abe Lincoln, Martin Luther
• Largely incapacitated during depression, but accomplished a lot during mania or hyper-mania
• Highs and lows can become unbearable and some commit suicide

BIOLOGICAL THEORIES OF DEPRESSION

• Genetic Factors:
> Family history studies reveal:
> First-degree relatives of individuals with major depressive disorder are 3-4 times more likely to have depression than first-degree relatives of individuals without major depressive
disorder
> The more genes you share, the more likely you are to have depression
> Polygenic trait, impacted by genetic barriers
> Twin studies reveal:
> The concordance rate for major depression is higher in monozygotic than dizygotic twins
> Serotonin transporter gene:
> Individuals who present with abnormalities on this gene are at a higher risk for depression when they face negative life events
• Lots of genes associated with depression operate through gene environment interactions
MOOD DISORDERS AND SUICIDE

BIOLOGICAL THEORIES OF DEPRESSION

• Neurotransmitter Theories:
> Monoamines are most often implicated in depression:
> Norepinephrine
> Serotonin
> Dopamine
> These neurotransmitters are found (in fairly high concentrations) in the limbic system
> Limbic system regulars sleep, appetite, and emotional reponses
> Abnormalites in synthesis of these neurotransmitters
> Release of these neurotransmitters aren’t the same
> Reuptake isn’t as sensitive
> Theories are not mutually exclusive
• Structural and Functional Brain Abnormalities:
> Neural plasticity is really important, depression has an impact on neural plasticity
> Abnormalities have been found in 4 areas of the brain among individuals with depression:
> Prefrontal cortex
> lower metabolic activity and reduction in grey matter volume (left hand side)
> responsible for working memory, attention, and problem solving
> motivation and goal orientation, lower activity in the left hand side shows depressive symptoms
> medication can be successful, higher brain wave activity in the left frontal cortex
> Anterior cingulate
> strong role in how the body responds to stress, express themselves emotionally, and social behaviour
> deviations in activity, reduced attention and coping
> activity in the cingulate normalizes
> Hippocampus
> smaller hippocampal volumes and lower metabolic activity
> critical in memory and fear related learning
> damage due to chronic arousal of stress responses and chronic elevated levels of cortisol
> decrease dendrite branching and plasticity
> Amygdala
> directing attention towards stimuli
> enlargement of this area of the brain and increased activity
> successful treatment: activity levels decrease to normal levels
> overactive can lead people to ruminate over negative memories or negative memories in their environment
• Neuroendocrine Factors:
> The neuroendocrineural activitysponsible for regulating numerous hormones which impact:
> Sleep
> Appetite
> Sexual drive
> Experience of pleasure
> How the body responds to stress
• Hypothalamic-pituitary-adrenal axis (HPA axis):
> Critical in our fight-or-flight response
> Activation of this axis leads to the secretion of glucocorticoids
> Act on organ systems in an effort to meet anticipated or active stressors
> Higher levels or cortisol and ACTH, suggest hyperactivty
> More difficult to return to baseline after episode of depression
> Chronic exposure to cortisol can impact prefrontal cortex, hippocampus, and amygdala
• Early traumatic stress:
> Associated with neuroendocrine abnormalities
> These may predispose individuals to depression
> Children who have been victims of abuse, separation from mother (in animals), supportive maternal care can reduce vulnerabilities
• Adverse childhood experiences (ACEs):
> Exposure to abuse, increase vulnerability of emotional and physical pathways that are critical for the development of chronic diseases
> Associated with higher risks for:
> Depression
> Smoking
> Alcohol use
• Hormonal factors may play a significant role in female vulnerability to depression:
> Fluctuations in estrogen and progesterone can impact serotonin and norepinephrine neurotransmitter systems
> Fluctuations occur during:
> Pregnancy
> Postpartum period
> Premenstrually
> Associated with hormonal factors
> Findings in this domain have not be consistent, could only be women with genetic dispositions that are more likely to develop depression
• The Gut Microbiome and Inflammation:
> The gut microbiome consists of:
> Bacteria
> Fungi
> Viruses
> The gut microbiome impacts the brain
> Stress, anxiety, depressive symptoms, and social behaviour
> Microorganisms can produce chemicals that modify hormone levels
> Disruption can result in neurotransmitter imbalances
> Strong associations between gut microbiome and autism, depression, and schizophrenia
MOOD DISORDERS AND SUICIDE

BIOLOGICAL THEORIES OF DEPRESSION

• Neuroinflammation:
> Inflammatory response in brain or spinal cord
> Happens as a result of disease, stress, injury, or infection
> Inflammatory processes tend to be associated with depression
> The mechanism underlying this association remains poorly understood
> Controlling inflammation can result in therapeutic benefits

PSYCHOLOGICAL THEORIES OF DEPRESSION

• Behavioral Theories:
> The majority of individuals with depression have a negative life event which occurs just prior to the onset of their depression
> 96% of individuals in 6 months
> Stress has a significant role in depression, finical hardships or stressful marriage
> Stress leads to the reduction of positive reinforcers in a person’s life and this can lead to depression, further reductions of reinforcers
> This can be further reinforced by sympathy and attention they receive from others, create a chain of events
> Women has depression, stops participating In actives around her job, reduces work performance, could have an impact on other areas of her life
• Behavioral Theories:
> Learned helplessness theory:
> uncontrollable negative events are most likely to lead to depression
> frequent and chronic negative events, lose motivations and reduce actions, low motivation, passivity
> Learned helplessness is a process of giving up because of the belief that nothing in life can change
> Individual might remain in an abusive relationship because they can’t do anything to get out of it
> Psychological flexibility: is the ability to adjust our thinking and behaviours in response to environmental demands
> Better flexibility tend to experience less psychological disfunction
> Plays a key role in psychological health and resiliency
• Cognitive Theories:
> Negative cognitive triad (Beck):
> Individuals with depression have negative views of:
> Themselves
> The world
> The future
> These individuals commit significant errors in thinking that lend support to the negative triad
> Ignore good information or emphasize negatives
> People with depression show negative ways of thinking, use CBT to cope
• Cognitive Theories:
> Reformulated learned helplessness theory:
> Individuals who have a tendency to explain negative events using causes that are internal, stable, and global tend to experience long-term learned helplessness, have the belief
these events will happen again
> A person believes they failed an exam because of their own incompetence, will spread to other subjects
> Hopelessness depression:
> When individuals make pessimistic attributions for the most fundamental elements of their lives
> Believe that they cannot cope with consequences of events in their lives
> Student who fails an exam can have the belief that there is no possible way they will be able to graduate
> Pessimistic style is very strongly associated with both first onset and relapse of depression among students
• Cognitive Theories:
> Rumination:
> When feeling upset, some individuals will focus strongly on those feelings, but do nothing about the causes of those feelings
> Very vulnerable to development of major depression
> Negative bias in thinking:
> Individuals who are depressed also show a bias towards negative thinking in attentional and memory processes
> Hard time disengaging their attention from negative stimuli
> When shown a list of words, depressed individuals recall more negative words than positive words
• Digital media use is associated with depression:
> Negative social comparison (that leads to negative self-evaluation) and cyberbullying are associated with negative mental health outcomes (depression, suicidal ideation, anxiety, and self
injury)
> Increased 70% over past 25 years
• Interpersonal Theories:
> Interpersonal challenges and losses are often reported as the stressors that trigger depression
> Some individuals with depression:
> Engage in excessive reassurance seeking, want to be told they are loved but don’t believe it
> Have rejection sensitivity, easily perceive rejection from others
> Chronic conflict in relationships
• Sociocultural Theories:
> Social conditions of different demographic groups can lead to differences in vulnerability to depression
> 3 demographic factors tend to have a strong impact on vulnerability to depression:
> Cohort effects (generational differences)
> More recent generations can be at a higher risk of depression, social changes and disintegration of family unit
> Young individuals more adapt to asking for help and talking about depression
> Technology can help individuals who are struggling to find others
> Younger generations can have higher expectations for themselves
> Gender
> Women are 2x more likely than men to experience depression
> Differences in coping style, men turn to alcohol, whereas women ruminate and this can be perpetuated through cultural expectations
> Gender socialization, women tend to be more interpersonally orientated, when they experience conflict they are more like to experience depression
> Women base self-wroth on strength of thier relationshions
> Women have less power and status than men, face abuse and structural issues
> Biological factors can also interact
> Ethnicity/race
> High rates of depression among native Americans, typically among youth (poverty, hopelessness, and alcoholism)
> Asian Americans show lower rates of depression, reflects cultural differences, may face depression in a more somatic form
MOOD DISORDERS AND SUICIDE

BIOLOGICAL THEORIES OF BIPOLAR DISORDER

• Genetic Factors:
> The development of bipolar disorder is very strongly linked with genetic factors
> Family history is the best predictor
> First degree relatives of individuals with bipolar are 5-10X more likely to develop bipolar disorder
> Identical twins of individuals with bipolar disorder are 45-75X more likely than individuals in the general population
> Approximately 2/3 of genetic influences tend to be shared across the following disorders:
> Schizophrenia
> Bipolar disorder
> MDD
• Structural and Functional Brain Abnormalities:
> Abnormalities have been found in the amygdala (emotional), prefrontal cortex (cognitive), and hippocampus (memory)
> Striatum: processing environmental cues in processing rewards, becomes activated with opportunities to earn money
> Activated abnormally among individuals with bipolar disorder, suggests that people with bipolar are hypersensitive to reward cues
> Excessively seek reward when manic, reward insensitivity when depressed
> Youth with bipolar have abnormalities in white matter, having a harder time exerting control over other parts of the brain
• Neurotransmitter Factors:
> Dysregulation in the dopamine (DA) system is associated with bipolar disorder
> High levels of DA: associated with high reward seeking
> Low levels of DA: associated with reward insensitivity

PSYCHOSOCIAL CONTRIBUTIORS TO BIPOLAR DISORDER

• Reward sensitivity:
> Individuals with bipolar disorder tend to show stronger sensitivity to rewards in comparison to controls
• Stress:
> Exposure to stressful life experiences or living in an unsupportive family can trigger episodes of bipolar disorder
• Changes in bodily rhythms or routines:
> Can trigger episodes among individuals with bipolar disorder
> Irregular or inadequate sleep is a really important factor when looking at increased symptoms

BIOLOGICAL TREATMENTS FOR MOOD DISORDERS

• Drug Treatments for Depression:
> Most common form of biological treatment
> Many classes of drugs are used in treating depressive disorders and the depressive symptoms of bipolar disorder:
> Selective serotonin and/or norepinephrine reuptake inhibitors
> Tricyclic antidepressants
> Monoamine oxidase inhibitors
> Though that these drugs were effective because it increase uptake in synapses, but don’t see real reductions for week
> Now thought that drugs work in processes and genes responsible for neural transmission, limbic system, and stress response
> 50-60% of individuals have a response
> More effective in severe depression compared to mild or moderate
• Selective Serotonin Reuptake Inhibitors (SSRIs):
> Widely used in order to relieve depressive symptoms
> A common drug of choice since they have fewer side-effects
> Gastro, nervousness, insomnia, lower sex drive
> Some individuals with bipolar disorder can develop manic symptoms when taking SSRIs
• Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
> Act on norepinephrine and serotonin, more effective than SSRIs
> More side effects
• Bupropion: A Norepinephrine-Dopamine Reuptake Inhibitor:
> Affects norepinephrine and dopamine systems
> Most helpful in acting on dopamine in terms of movement, pleasure, and reward
• Tricyclic Antidepressants:
> One of the first drugs used to relieve depression
> Cause blood pressure to drop and cardiac arthetmia, fatal if overdosed
> Used infrequently today since they have many side effects, especially if patients are suicidal
• Monoamine Oxidase Inhibitors:
> Older class of drugs which is rarely used to treat depression
> They are as effective as tricyclic antidepressants but dangerous side effects, especially when taken with aged cheese, red wine, and beer
> Interact with many other drugs, liver damage, weight gain, lowered blood pressure
• Mood Stabilizers:
• Lithium:
> Is useful in preventing and treating mania
> Prevents new depressive and manic episodes
> Reduces suicidal thoughts
> Rate of prescriptions have declined recently because of side effects
> Nausea, vomitting , toxicity, organ damage, kidney disfunction
> Effective and toxic dose difference is extremely small
• Anticonvulsant and Atypical Antipsychotic Medications:
> In the 1990s, researchers came to the realization that medications that reduce seizures can also be effective in stabilizing mood E.g. Depakote, Equetro
> Fatigue, nausea, drowsiness, but less severe side effects than lithum
> Restore balance of neurotransmitters within the amygdala
MOOD DISORDERS AND SUICIDE

BIOLOGICAL TREATMENTS FOR MOOD DISORDERS

• Electroconvulsive Therapy:
> First introduced in early 20th century, originally used for schizophrenia
> Consists of treatments in which a seizure is induced, passing electrocurent between brain, muscle relaxants and anesthesia is used
> Used to treat severe and persistent mood disorders, 6-12 session
> Remains a controversial treatment
> Very effective for treatment-resistant depressive disorders (50-80% achieve remission) suicidal features, depression resistant to treatment
> Very effective treatment in both depression and bipolar disorder, but the mechanism of action is still unclear
> Use of ECT can induce plasticity including 4 main areas
> ECT can change functioning of neurotransmitters, mainly dopamine and serotonin
> Reduce brain inflammation and restructure brain
> Can lead to memory loss and challenges in learning new information in the days after treatment
> ECT only done on one side, typically right, not as strongly involved in learning and memory
> Extremely effective, but relapse rate is high
• Newer Methods of Brain Stimulation:
• Repetitive Transcranial Magnetic Stimulation (rTMS):
> Noninvasive, performed on outpatient basis
> Exposes patient to high-intensity magnetic pulses which target particular brain structures, left prefrontal cortex
> Side effects are minimal, minor headaches
> Effective and safe for patients with treatment-resistant depression
• Vagus Nerve Stimulation (VNS):
> Invasive
> Electrodes are surgically implanted in vagus nerve, carries information to neural locations, hypothalamus and amygdala
> The vagus nerve is stimulated by an electronic device, stimulates areas of the brain
> Good outcomes for treatment-resistant depression
• Deep Brain Stimulation (DBS):
> Electrodes are surgically implanted in specific regions of the brain
> Electrodes are connected to a pulse generator which stimulates these areas of the brain
> Utility in treatment-resistant depression
• Light Therapy:
> In cases of SAD, individuals become depressed during winter months (when there are few hours of daylight)
> Moods improve during summer months
> It is theorized that individuals with SAD may have deficient retinal sensitivity to light
> Body reacts more strongly to variations of light available
> Exposure to bright light in the winter can help relieve symptoms
> 57% of individuals showed remission with only light therapy, 79% showed increase when using both light therapy and CBT

PSYCHOLOGICAL TREATMENTS FOR MOOD DISORDERS

• Behavioral Therapy:
> Focus:
> Increasing positive reinforcers
> Decreasing aversive experiences
> *Achieved by assisting the individual to change their interactions with other people and their environment
> First step involves a functional analysis of the associations between a persons circumstances and their depression
> Highlighting the connections between symptoms and circumstances
> Isolation associated with negative feelings, can help client to reach out to have more social time
• Cognitive-Behavioral Therapy:
> Two primary goals:
> Alter negative, hopeless patterns of thinking
> Assist individuals in developing coping skills and interacting with others and their environment in more effective ways
> Designed to be brief and time-limited (typically 6-12 weeks)
> Goals focus of specific issues, issues of marriage
> 3 main steps:
> 1) Identify negative thoughts and understand linkages that exist between thoughts and depression, when they felt depressed and what they were thinking
> 2) Challenge negative thoughts
> Questions to considerer alternate ways of thinking
> 3 ) Recognize deeper beliefs they have which fuel depression.
> If im not successful at anything my life is worthless, assessing whether they want to base their life off of these beliefs
> Challenge these beliefs
> Behavioural component: learn more skills to cope effectively, exercises and homework to learn strategies such as assertiveness
• Interpersonal Therapy:
> Therapists assist clients:
> In facing interpersonal loss
> In exploring their emotions surrounding relationships
> In assisting the client in forming new, healthier relationships

NTERPERSONAL AND SOCIAL RHYTHM THERAPY

• Interpersonal and social rhythm therapy (ISRT):
> A variation of Interpersonal Therapy that is used specifically among individuals with bipolar disorder
> Uses interpersonal therapy along with behavioural to keep regular routines
> Patients self monitor and can learn how changes in patterns can lead to increased symtpoms
> Learn to stabilize routines to reduce symptoms
> Patients also monitor stressors in family or relationships that impact their moods
> Both ISRT and medication, fewer relapses and fewer symptoms
> Emphasis solely on sleep helps to reduce relapses and helps individuals

FAMILY-FOCUSED THERAPY
• Targets individuals with bipolar disorder
> Reducing interpersonal stress in context of families
> Clients and their families are educated about bipolar disorder
> They are trained specifically in communication and problem-solving skills
> Family focused therapy show lower relapse rates, helpful for adolescents to improve functioning and development
MOOD DISORDERS AND SUICIDE

COMPARISON OF TREATMENTS
• Among individuals with depression, the following treatments are fairly equally effective:
> Behavioral
> Cognitive-behavioral
> Interpersonal
> Drug therapies
• A combination of psychotherapy and medication leads to best outcomes
• Relapses rate in depression tend to be high, matinee level of therapy even when levels subside (typically medical but once a month meeting with therapists can help)
• Relapse rate highest among individuals with placebo, rates lower for those in CBT than only medication
• Among individuals with bipolar disorder:
> Combination of drug treatment with psychological therapy tends to assist individuals to achieve full remission and reduces the rate that patients stop taking their medications
> Psychotherpay useful in helping clients understadn and accept the need for drug treatment
> Prevention programs can be helpful in delaying symptom onset

DEFINING AND MEASURING SUICIDE

• Suicide (according to the CDC):
> “death from injury, poisoning, or suffocation where there is evidence (either explicit or implicit) that the injury was self-inflicted and that the decedent intended to kill themself”
• Suicide rates are difficult to obtain since there is likely to be stigma against suicide
• Important to distinguish between the following terms:
> Completed suicide: one that ends in death
> Suicide attempt: may or may mot end in death
> Suicidal ideation: thinking about suicide
> Suicide attempts about 20X more common than completed suicide
• Approximately 3% of the population makes a suicide attempt at some point in their lives
> More than 13% of individuals report having suicidal thoughts
> Internationally, approximately 800,000 people die by suicide every year
> Attend to suicide risk early on in treatment and continually over treatment process
• Women are more likely to attempt suicide
> Increase dramatically among young women, higher prevalence rates of depression and PTSD
• Men have higher rates of completed suicide
> Choose more violent methods
> Less likely to receive diagnosis and treatment
• Rates of suicide tend to be higher among:
> Non-Hispanic White
> Native Americans
> Poverty, lack of education, discrimination, and substance abuse
> Among racial/ethnic minority populations suicide risk tends to be highest among youth
> Minority emerging adults who are most vunerable to the effects of discrimination
> Under 30 years for people of colour, 40-50 years for white
> Cross national differences, higher rates in Europe and China, lower rates in Latin America and Suuth America
> Australia, Canada, and US fall in the middle or the extremes
> In cultures and religions that forbid suicide, its less likely to occur

SUICIDE IN CHILDREN AND ADOLESCENTS

• Second leading cause of death among youth aged 10-18 years
> Link of self harm and risk of future suicide (50%)
> Self harm increases the death of suicide by 10
> Males are 6x more likely to complete suicide
> Children with mood disturbances show irritability as a sign of depression
> Strongly associated with mental health problems, peer victimization, bullying, biological factors
• Suicide in this group is strongly associated with:
> Mental health problems
> Family history of suicidal behavior
> Biological factors
> Family problems
> Peer victimization and bullying
• Why does suicide become more common in adolescence?
> Rates of psychopathology increase among adolescent years
> Adolescents are more sophisticated in their thinking, contemplating suicide more clearly
> Easier access to means to commit suicide
• Rates of suicide doubled between the 1950s and 1990s, but since the mid 1990s have declined gradually
> Increase due to substance use and accessibility of firearms
> Decrease due to increase use of antidepressants
> Importantly, there has been an increase in adolescent suicide rates since 2004
> SSRI warnings in youth, less prescriptions, warnings were to physicians that they would result in an increase of sucidical symptoms and suicidal behaviour

LESBIAN, GAY, BISEXUAL, TRANSGENDER, QUEER, AND INTERSEX

• LGBTQI individuals are at a high risk for suicidal ideations and behavior
> They often face significant:
> Discrimination
> Prejudice
> Denial of civil and human rights
> Harassment
> Family rejection
> Depression tends to be the strongest predictor of suicidal ideation (approximately 85% of individuals with MDD experience suicidal ideation)
> LGBTQ youth have higher levels of depression compared to non-LGBTQ youth
> 2-6X more often
> Suicide risk is highest among adolescent and into early 20’s
 239
PSYCH 239
MOOD DISORDERS AND SUICIDE

COLLEGE/UNIVERSITY STUDENTS
• The transition to college/university can be challenging:
> It is associated with a significant increase in social and academic pressure
> 2nd leading cause of death, 14 deaths per 100000
> It is also associated with an increased risk of suicidality
> More likely to experiment depression, loneliness, and issues with their parents
> Only 20% of suicidal contemplation saw help in forms of counselling

SUICIDE IN OLDER ADULTS

• In the past few decades, there has been a 50% decline in suicide rates among adults 65 years and older
> Older men are still at a high risk for suicide, European males 85 and older
> More likely than younger individuals to be more successful
> Full intentions to die
• Some commit suicide because:
> They have difficulty losing their partner or loved ones, highest among significant lost
> They want to escape the pain from illness, motivating for males among those who don’t want to become a burden for their family

NONSUICIDAL SELF-INJURY
• Some individuals engage in nonsuicidal self-injury (NSSI):
> Cutting
> Burning
> Puncturing
> Injuring
• These behaviours are quite common (approximately 18% of individuals engage in these behaviours internationally)
> Adolescents most common, also among individuals who have mood and anxiety disorders and borderline personality disorders
> Serves as a way to regulate emotion, seeing blood and feeling pain calms them down, regulate feeling of distress
> Impact social environment by drawing sympathy from others or punishing others
• These behaviours do not reflect an intent to die
> BUT individuals who engage in NSSI are at a higher risk for suicide attempts

UNDERSTANDING SUICIDE
• Psychological Disorders and Suicide:
> Depression increases the likelihood of a suicide attempt by 6x
> Bipolar disorder increases the likelihood of a suicide attempt by 7x
> Substance abuse and anxiety disorders also increase risk of suicidal behaviour
> 90% have liked been suffering
> 1/4 with bipolar I and 1/5 of bipolar II attempt suicide
> Past suicidal thoughts are critical in implementing help strategies

STRESSFUL LIFE EVENTS AND SUICIDE

• Across cultures, the risk of suicide is elevated following events related to:
> Abuse: interpersonal violence, sexual abuse most strongly associated, physical abuse by a pattner
> Interpersonal loss: death, divorce, they can’t go on without a person or end thier suffering
> Perceived failure: loss of a job, African American males where income inequality is stronger
> Economic hardship
> Physical illness: happens earlier in life, illness most strongly associated with suicide attempts is epilepsy

PERSONALITY AND COGNITIVE FACTORS IN SUICIDE

• Impulsivity tends to be a predictor of suicide, particularly alongside other psychological challenges such as:
> Depression
> Substance abuse
> Living in a stressful environment
• Children of parents with a mood disorder who score high on impulsivity are at a high risk for suicide attempts
• Hopelessness is strongest cognitive factor
> Others include perfectionism, rumination, and poor problem solving

BIOLOGICAL FACTORS IN SUICIDE

• Biological predictors of suicide:
> Genetic predisposition
> Risk of suicide goes up 5.6x if monozygotic twin has attempted and 4x if dizygotic twin has attempted
> Neurotransmitter dysfunction
> Strong associated between suicide and low levels of serotonin
> Family history of suicide are more likely to have abnormalities on the genes for monitoring serotonin
> Association between serotonin and suicide isn’t connected directly to depression

TREATMENT AND PREVENTION

• Intervention programs:
> Target individuals who are immediately at risk of suicide, suicide hotlines, critical
• Prevention programs:
> Target the general public or individuals who are at risk but not in crisis, focus on education
> Steps that they can take of they become suicidal or someone they know is suicidal
• For individuals who are suicidal:
> Sometimes individuals require hospitalization, sometimes against will
> Community based crisis intervention programs are sometimes used, emotions in short term, walk in clinics
> Education of the risk of immense suicide, someone who can be understanding, councillors, make a plan
> Contract if suicidal thoughts occurs that they will reach out to councillor
> SSRIs can help reduce the risk, regulate serotonin
> Dialectical behavior therapy is sometimes used (DBT)
> Manning negative emotions, controlling impulsive bevjaours, increasing interpersonal skills and increasing problem solving skills
> Developed originally for borderline personality disorder which are at a high risk of suicide
MOOD DISORDERS AND SUICIDE
SUICIDE PREVENTION
• Many prevention programs are based in schools or colleges:
> Students are given information about risk factors for suicide and how to help a loved one if they are suicidal
> Evidence is mixed for the effectiveness of these programs
> Often target both general population and those who are high risk
> Destigmatize, students more comfortable seeking help, but makes it seem that suicide is a common response to stress
> Adolescents who have committed show a negative response to these programs and are less likely to seek help
> Parents and teachers worry that asking adolescences about suicide put the idea of suicide in their head, no evidence for this
 ▫

psychology
Schizophrenia spectrum and other psychotic disorders along the
continum
What comes to mind:
• Hallucinations(see, hear or feel things that aren’t real) and
delusions (false beliefs)
• Both are very common
• Psychosis is also a prominent feature (inability to be able to
recognize the difference between reality and fiction)
• common feature of all psychotic disorders
• prevalence of psychotic symptoms: around 5-8% of general
population
• Individual with schizophrenia may believe ex. That there is
conspiracy to harm them that has been created by a
government agency
• Other common symptoms in schizophrenia and other spectrum
psychotic disorders: speaking in coherently, acting unpredicatble,
communication issues, hard time w/ emotion expression, a-
SYMPTOMS, DIAGNOSIS, AND COURSE: typical facial grimaces, ticks and issues with gate
• schizophrenia is a complex neuro-psychiatric disorder • Schizophrenia spectrum: includes group of psychotic disorders
• psychosis is the foundational diagnostic syptom, has a strong impact on perception, cognition. that are similar to schizophrenia but often not as severe and
And emotions persistant
• The DSM-5 uses schizophrenia spectrum to highlight the 5 domains of symptoms • Episodes can be scary, often don’t know who to trust or what
• Duration and severity help distinguish disorders from one another is real
• There are 5 main domains: 4 types of pos: Delusions, hallucinations, disorganized thought and
Speech, and disorganized/abnormal motor behaviour including catatonia
• neg: restricted emotion affect or restricted expression
• often have cognitive deficits, can be associated with declines in functioning, at times they can function well
but often have difficulty taking care of themselves
Positive Symptoms: positive as they are in addition to behaviours that are common
• Positive symptoms of schizophrenia:
Delusions: false beliefs, tend to hold belief with strong conviction even with contradictory evidence (goes against reality)
• content of delusions: persecutory themes, religious, themes of grandiosity
• Some researchers believe that those with delusional thoughts tend to put alot of meaning into irrelevant events (might focus significantly on insignificant events, tribute
importance to events that are inconsequential (ex. People with blue hats are trying to send them a message, blue hat is a significant cue and think about what that means
to them
• - self-deceptions (ex. Thinking that you might win the lottery are different from delusions cause 1. they are possible and 2. aren’t preoccupied by thoughts on daily basis
and 3. Can admit we are wrong
Hallucinations
Disorganized thought and speech
Delusions
• Persecutory delusions (aka paranoid delusions):
The most commonly experienced delusions among individuals with schizophrenia (can occur in severe forms of depression and PTSD ex. Individuals who are in manic state
might believe they are adidy,
• paranoid delusions are distressing and often accompanied by disturbed sleep, anxiety and depression
• very common in first episodes of psychosis and experienced by 70% of individuals in their first psychotic break, the presence of worry tends to predict new
instances of paranoid thoughts
They may believe that others are plotting to cause harm to them and may be convinced that others are watching, harassing, or conspiring against them.
• These beliefs are unshakable and as a result, they cannot be convinced otherwise
• Grandiose delusions:
False beliefs that an individual is more important or powerful than they truly are
• may hold the belief that they are special or have unique powers, wealth, identity, abilities even if evidence exists for the contrary
• pretty common, occur in 50% of patients who are diagnosed with schizophrenia and 66% of individuals with bipolar
• Both harm and distress are common, an individual may believe they are invincible and step into traffic,
• commonly report paranoia and feelings of self-loathing, these are a form of compensation for negative self beliefs
E.g. an individual may believe that they are a God
• Delusions of reference:
Individuals hold the belief that random events or comments that are made by others are directed towards them.
• E.g. holding the belief that a bird flying above you is sending important messages from God
• might result from a heightened attention to irrelevant cues and assigning incorrect importance to neutral stimuli
• Lots of types of delusions can work together in an individuals delusions
 ▫

psychology
Hallucinations
• Hallucinations:
False perceptions
• ex. Might have thought you saw someone when you didn’t, common in dark when seeing shadow, feeling someone touch you when they didn’t
• Common to experience momentary confusion when perceptional systems create a feeling of reality, even if the stimuli doesn’t align with perception
Can occur in all sensory modalities
• Auditory verbal hallucinations are the most commonly reported (70-80% of individuals with schizophrenia)
• The perception of voices can be frightening and distressing
• core symptom of psychotic illness and prediction of poor mental health
• may consist of voices giving command, running commentary on individuals behaviour, voice can seem like its coming from inside head or elsewhere, often have
negative qualities
• It is typical for individuals to report that the voices:
• Speak directly to them
• Are not in their control
• Are evil
Auditory Verbal Hallucinations (AVHs)
• Alterations in brain structure and function are associated with AVHs and these neuro alterations tend to be located in regions of the brain associated with auditory visual
stimuli and also executive functioning
• The presence of spontaneous activation in speech production areas in the right hemisphere may underlie these hallucinations
• speech production areas include: prefrontal cortex, and the auditory cortex and spontaneous activation may lead to a single word or a basic sentence
• hearing voices occurs transdiagnostically, found among individuals with borderline personality disorder, major depression, bipolar, dissociative, PTSD, etc
• around 2-10% of general population report voice hearing experiences but don’t meet the criteria for psychiatric diagnosis
Visual Hallucinations (VHs)
• Visual hallucinations:
Often occur with auditory hallucinations
2nd most common type of hallucination among individuals with psychosis
• Ta ta hallucinations: perception that something is happening to outside of body (common: individuals have bugs crawling on them)
• Somatic hallucinations: perception that something in happening to inside of body (worms eating intestines)
Disorganized Thought and Speech
• Formal thought disorder:
The disorganized thinking that is a common feature of individuals with schizophrenia
• Loose associations (aka derailment): Individuals may slip from one topic to another with little coherence
• when an individual is asked why they are in the hospital they may answer spaghetti looks like worms, I really think its worms, gofers dig tunnels
• neologism common, individuals might make up words that are meaningful to them
• Clangs: individual makes up associations about words based on the sound of the words instead of their content
• Individual may repeat same word or statement lots of times, males with schizophrenia deal with more severe deficits in terms of language cause language is controlled
more bilaterally with women, they can use both sides of brain better to compensate for any deficits they may have
• “Much of abstraction has been left unsaid and undone in these products milk syrup, and others, due to economics, differentials, subsidies,
bankruptcy.. ” (Maher, 1966, p.395)
Disorganized or Catatonic Behavior
• Individuals with schizophrenia may suddenly shout, swear, or pace, usually responses to hallucinations or delusions (ex. Individual may think they are being persecuted, they
might see a hallucination of someone chasing them)
These are typically responses to hallucinations or delusions
Attention and memory issues are common:
• Individuals with schizophrenia tend to have difficulties with daily routines
• bathing, dressing, eating regularly
• Catatonia:
Disorganized behavior that reveals psychomotor disfunction, can range from unresponsiveness to agitation
• negativism: lack of response to instructions, mutism: lack of motor or verbal responses, or catatonic excitement: excessive or purposely motor activity with no reason
Negative Symptoms
• Negative symptoms:
Involve the absence of a capacity
• severe negative symptoms are associated with poor outcomes in comparison to severe positive symptoms, seems to be due to the negative symptoms tend to be more
difficult to treat and more persistent and are less common in other psychotic disorders
Restricted affect and avolition/asociality are common: reduction or absence of emotional expression (might show fewer facial or physical expression or flat vocal tone to
show emotional expression)
• self-report questionnaires: they suggest that individuals with schizophrenia report anhedonia (loss of the experience of pleasure) however lab studies show no
difference in terms of positive affect in response to pos stimuli
• Thought that they might experience intense emotions that they aren’t able to express
• contradictory self-report data might reflect depression
• Avolition : inability to initiate or persist in common goal activites (ex. Work)
• can be expressed a-sociality: lacking desire to interact with others, typically tend to be socially isolated, this may be due to stigma as lots of individuals with
schizophrenia feel rejected from their family
• a-sociality is diagnosed when an individual has a welcoming group of individuals within their lives but the individual with schizophrenia shows no interest to get to
know them
 ▫

Negative Symptoms cont’d:

-
Deficits are common in many basic cognitive processes including:
Attention: have hard time focusing and maintaining
psychology
Memory: hard time holding info and manipulating it
Processing speed
• because of this, individuals with schizophrenia have a hard time paying attention to relevant info and suppressing unwanted and irrelevant info
• It is thought that these deficits may contribute to hallucinations or delusions, disorganized thinking and behaviours
• Immediate relatives of individuals with schizophrenia might show deficits but to lesser degree
• longitudinal studies show that individuals that go on to develop schizophrenia do suggest that the cognitive deficits might pre-seed the acute symptoms of schizophrennia
Diagnosis
• Schizophrenia has been recognized as a psychological disorder since the 1800s
Emil Kraepelin termed the disorder dementia praecox (precocious dementia) in 1883 thought the disorder was result of premature brain deterioration. He viewed the
disorder as always leading to severe chronic and irreversible deterioration
Eugen Bleuler introduced the term schizophrenia and made the argument that the disorder doesn’t always lead to deterioration
• the term schizophrenia comes from the greek word schizo' (splitting) and 'phren' (mind)
• In order to be diagnosed: the individual must show 2 or more symptoms of psychosis (at least one should be hallucinations, delusions, disorganized speach and symptoms
should be acutely present for at least 1 month and this is apart of the acute stage, some symptoms should be present for 6 months
• Prodromal symptoms:
Exist before the acute phase
• Residual symptoms:
Exist after the acute phase
• during the 6 months before and after the active stage, individuals with schizophrenia might show mainly negative symptoms and milk positive
• If left untreated, schizophrenia is episodic and chronic
• Difficulties in terms of functioning, are heavily tied to negative symptoms and positive symptoms
• Individuals with predominately negative symptoms, tend to have lower education, less success (keeping job), weaker performance on cognitive tasks, worst prognosis in
comparison with individuals with mostly positive
• Negative symptoms tend to be less responsive to medications, even in the DSM-5, no subtypes of schizophrenia are included since evidence noted diagnostic stability and
validity for these subtypes are weak
Course of Schizophrenia
• Global prevalence:
0.33-0.75%
• Risk is significantly higher when relatives have the disorder
• Psychotic features usually emerge during the late teens – mid-30s (the development before adolescents is extremely uncommon)
• early on-set schizophrenia is diagnosed in childhood in adolescent before the age of 13 and occurs in 1 in 10 thousand children (poor outcomes, lots of neg symptoms
and comorbidity with other disorders
• psychotic symptoms can develop rapidly but more commonly develop gradually
• Only 13.5% meet full recovery criteria
• Schizophrenia is one of the top 15 leading causes of disability (globally):
It is associated with impairments in psychosocial functioning which increases the likelihood of:
• Unemployment
• Homelessness
• Poverty
• Difficulty with self care
• the largest economic burden is from individuals from 25-54 years, this age is typically the most economically productive but among individuals with schizophrenia have
significant economic issues due to losses in productivity
• International studies say that around 3% of health care budgets are use to treat individuals with psychotic disorders
• Schizophrenia is associated with higher rates of comorbid illness and mortality rates (due to underlying illnesses like stroke, diabetes, or coronary heart disease)
Prognosis
• Life expectancy: 10-20 years shorter than individuals without schizophrenia
• More likely to suffer from infectious and circulatory diseases, due to higher rates of smoking, overweight, and side effects of meds
• 5-10% of individuals with schizophrenia commit suicide, highest rate of suicide is among those recently diagnosed or those in their first psychotic episode
• Fewer than 1/7 fully recover
• progressive course of schizophrenia explains this
• 70-80% of people with first epsiode will experience remission of their symptoms within a year of treatment, risk of symptom occurance a year after remission
from first episode is around 0-5% among individuals who receive maintenance anti-psychotic treatment but around 78% among those without medication
• medication plays a strong role in whether symptoms will reoccur
• some individuals tend to stabilize within 5-10 years of the first episode and show very little relapses
• research does suggest that cognitive deficits improve in the first year following treatment and can remain stable or improve
 ▫

psychology
Gender and Age Factors
• Men tend to present with:
Earlier age of onset
More negative symptoms including social withdrawal and blunted affect
Lower social functioning
More comorbid substance abuse
• studies show that males with schizophrenia have more abnormalities in neural structure and functioning in comparison to females
• Women tend to present with:
Later age of onset (3-5 years later than males)
More affective symptoms (mood disturbances and depressive symptoms)
• women that have late onset of schizophrenia tend to have less severe negative symptoms and more positive
• Women overall have a better prognosis (reason: unclear, thought that women are more likely have better history (education, social, relationship) and less likely to
show cognitive deficits)
• Also thought that estrogen might regulate dopamine in ways that might be protective for women
• Peak onset for males: early to mid 20s (1 peak at 20-25 years), peak onset for females: late 20s (2 peaks, 1st between 25-30 and 2nd after 45)
Cultural Influences
• Types of hallucinations and delusions are similar across cultures but the specific contents of hallucinations and delusions differs across cultures
• themes of delusions tend to relate to cultural beliefs and social background (ex. Religious delusions are common in christian societies and more rare in Buddhist or hindu
societies)
• delusional content in US was highly focused on Germans in the second world war, strongly focused on communists during the cold war, and technology in recent eras
OTHER PSYCHOTIC DISORDERS: schizophrenia is most common and well known, heavily depicted on television and media
Schizoaffective disorder
• Schizoaffective disorder:
Combination of schizophrenia and a mood disorder
Psychotic symptoms:
• Delusions, hallucinations, disorganized speech and behavior, negative symptoms
Mood symptoms:
• These meet the criteria for a major depressive or a manic episode
Diagnosis: requires the person experiences 2 weeks of hallucinations or delusions with no mood symptoms
Schizophreniform disorder
• Individuals meet Criteria A, D, and E for schizophrenia
They show symptoms that last only 1-6 months (represents intermediate between schizophrenia and brief psychotic disorder)
• functional impairments are not necessary for diagnosis
• Good prognosis is associated with quick onset of symptoms previously functioning well and experiencing confusion but not blunted affect
• 2/3 of individuals with this go on to be diagnosed with schizophrenia or schizoaffective disorder
Brief Psychotic Disorder
• Individuals diagnosed with Brief Psychotic Disorder have a sudden onset of:
Delusions
Hallucinations
Disorganized speech
Disorganized behavior
Episode lasts 1 day-1 month (after this, symptoms remit completely)
• symptoms will sometimes reoccur after a stressor (like an accident)
• 1 in 10 thousand women tend to experience brief psychotic episodes after birth, relapse tend to be high but outcomes tend to be quite good
Delusional Disorder
• Individuals with delusional disorder:
Delusions lasting at least 1 month (these delusions pertain to events that happen in real life, like having a disease, being follow)
Only show delusions: no other psychotic symptoms (different from schizophrenia) they don’t act oddly in terms of functioning
• less likely to seek help with mental health functioning and will usually only seek assistance if pushed to do so by family/friends
• Age of onset: 40 years, but range 18-90
• Males: persecutory and jealous subtypes common
• Females: erotomaniac is common
• Symptoms tend to improve with psycho-therapy and anti-psychotic medication
Prevalence: 0.05-0.2%
Good prognosis is associated with:
• Early onset of symptoms (before 30 years)
• Higher occupational functioning
• Higher social functioning
• Sudden onset of symptoms
 ▫
Schizotypal Personality Disorder
• Schizotypal Personality Disorder:
A personality disorder, NOT a psychotic disorder
• On the continuum of schizophrenia spectrum of disorders psychology
Lifelong pattern of unusual behaviours (have an impact on personality, self-concept, thinking and interpersonal relationships)
Exhibit pathological personality traits such as:
• Psychoticism
• Eccentricity (eccentric behaviours and disturbed thought and affect is similar to schizophrenia but the development tends to align better with personality disorders)
• Cognitive dysregulation
• Perceptual dysregulation
• Restricted affect
• Emotional withdrawal
• prevalence around 1.9%
• these individuals tend to have very few close relationships and challenges in understanding others (often perceive others as being deceitful and hostile and suspicious)
• Might also believe that random circumstances are significant (accident happened at intersection that they were at yesterday, they would find significance in that
intersection)
• Neurological tests: show challenges with working memory, learning and recall tend to be pervasive and they will go on to develop schizophrenia
BIOLOGICAL THEORIES: since symptoms and prevalence are similar, many researchers state that biological explanations are the best for the development of schizophrenia
Genetic Contributors to Schizophrenia
• Family, twin, and adoption studies: support the argument that genetic transmission is a critical risk factor for schizophrenia
• overall, genes tend to strongest risk factor, schizophrenia is strongly impacted by susceptibility genes, epigenetic processes and environmental factors
• Environmental factors that may increase the risk of schizophrenia:
Pregnancy and birth complications
Childhood trauma
Social isolation
Substance abuse
• both genes and environment are associated with the development, but the nature of this interaction is unclear
• Family Studies:
Genetic relatedness is strongly associated with the risk of developing schizophrenia
• the risk of developing schizophrenia to the general population is less than 1 %
• Family history is associated with higher risk of schizophrenia, also mood disorders, mood disorders and bipolar disorders
• Adoption Studies:
Biological relatives of adoptees with schizophrenia:
• Are approximately 10 times more likely to have schizophrenia in comparison to biological relatives of adoptees without schizophrenia
- one study: kids who were given up for adoption were tracked, around half had biological mothers with schizophrenia and half didn’t, around 10% of the kids whos
biological mother had schizophrenia went on to develop it, or another psychotic disorder. Only 1% of those kids whose biological mother did not have schizophrenia went on
to develop schizophrenia or another psychotic disorder
• Twin Studies:
Have revealed high rates of heritability (up to 81%)
• quadruplets who shared genes and family environment all went on to develop schizophrenia (the specific symptoms and outcomes varied)
Concordance rate for MZ (monozygotic) twins = 46%
Concordance rate for DZ (dizygotic) twins = 14%
• epigenetic: when you compare MZ twins, discordance for schizophrenia (so when one has it and other doesn’t), to MZ who both have it, researchers found that MZ
twins who are discordance to schizophrenia, tend to show differences in molecular structures of DNA, especially on genes that regulate dopamine systems
• the MZ twins that were concordant for schizophrenia tended to show fewer differences
• reasons for epigenetic is unclear, likely that it might involve stress
Structural and Functional Brain Abnormalities
• most researchers believe that schizophrenia is a neuro developmental disorders where many factors are related to abnormal development of the brain during
gestation and also in early life
• Most consistent finding:
Significant reduction in gray matter in the cortex of individuals with schizophrenia
• reduction tends to be pronounced in the medial, temporal, superior temporal and prefrontal regions
• individuals at risk for schizophrenia due to family history, tend to show abnormal activity in prefrontal cortex
• neural imaging studies of individuals who have gone on to develop schizophrenia in adolescence, have gone on to show structural changes within prefrontal
cortex from before to after symptom development
• Other findings have shown differences in:
Prefrontal cortex
Hippocampus: some studies show that individuals with schizophrenia tend to show abnormal activation in the hippocampus when completing tasks that require the
encoding on information, and the retrieval of info
white matter: found in areas of the brain associated with working memory
ventricles: enlargement if often seen (means atrophy or deterioration in other brain tissue)
• Damage to the Developing Brain:
• the neuro developmental theory of schizophrenia suggests that there is damage that happens during neuro development that can have long-term impacts on the
brain
Birth complications:
• E.g. hypoxia
• birth complication where the baby doesn’t get enough oxygen to brain before, during or after delivery
• research has shown neuro abnormalities among individuals with schizophrenia who have experienced hypoxia
• this might contribute to a reduction in grey matter or enlarged ventricle regulations
• infants with perinatal hypoxia, they are 2 times more likely to develop schizophrenia later on in life
 ▫

Structural and Functional Brain Abnormalities

• Damage to the Developing Brain:
psychology
Maternal illness and prenatal exposure:
• High rates of schizophrenia are found among individuals whose mothers were exposed to diseases and infections throughout pregnancy or delivery
• ex. Influenza, rubella, toxoplasmosis, and herpes
• Individuals with schizophrenia are more likely to be born in spring, and the exposure to the flu in the fall/winter when critical phases of fetal development is taking
place might be a risk factor
• Maternal and fetal inflammatory responses to the infections are having a strong impact on fetal neuro development
• Anti-inflammatory diets: leafy green vegetables (kale or broccoli) for pregnant women with infections might reduce those risks
• Localized bacterial infection tends to be associated with 1.6 fold increased risk for developing a psychotic disorder, system Y bacterial infection is associated with a 3
fold risk in terms of developing a psychotic disorder
Neurotransmitters
• Dopamine: plays a critical role in schizophrenia
• original dopamine theory: schizophrenia is caused by too much dopamine in the prefrontal cortex and the limbic system
• Diathesis stress model: argues that HPA (hypothalamic pituitary adrenal) access triggers a cascade of events that results in neural circuit disfunction which impacts
dopamine reproduction
• The stress induced HPA action tends to be associated with dopamine release (this is supported by the utility of anti-psychotic drugs that work by blocking dopamine
• Dopamine doesn’t;t fully explain the negative schizophrenia symptoms, many individuals who take anti-psychotic drugs do show relief from positive symptoms but
often show little relief from negative
Medications that reduce schizophrenia symptoms:
• Block dopamine receptors
Medications that increase dopamine levels (like amphetamines):
• Typically lead to an increase in positive symptoms of schizophrenia
• Serotonin:
regulates dopamine neurons within the mesolimbic system
• interaction between serotonin and dopamine is important in understanding schizophrenia symptoms
• Glutamate (excitatory) and GABA (inhibitory):
Deficiencies may be associated with emotional and cognitive symptoms
• drugs like ketamine that block glutamate receptors can cause delusions and hallucinations in individuals with no psychological disorders
PSYCHOSOCIAL PERSPECTIVES:
Social Drift, Trauma, and Urban Living
• Social drift theory:
• `the symptoms of schizophrenia typically interfere with individuals ability to complete education and job and can drift to lower economic status
• some research supports, some research supports the opposite
• social status and environmental factors might impact schizophrenia, but likely bidirectional relation
Cumulative exposure to environmental risk factors in deprived and urban areas can increase the likelihood of psychological disorders (especially among those with
genetic risk factors):
• Common risk factors:
• Lack of social support
• Poverty
• High neighborhood crime rates
• Low access to health care
• Trauma and social adversity:
Childhood adversity is associated with a higher risk of psychosis in adulthood (might include sexual abuse, physical abuse, emotional abuse, psychological abuse, neglect,
parental death or bullying)
• among those with schizophrenia the most common adversity is emotional neglect
Childhood abuse and neglect are associated with the later development of schizophrenia
Individuals have an increased risk for schizophrenia when they grow up and/or live in urban environments that have higher levels of deprivation or poverty
• theories like social deprivation, income inequality and social fragmentation have all been proposed but none have been conclusive
• overcrowding is another explanation (this would increase the risk of pregnant women and also newborns being exposed to infectious agents)
• Trauma and social adversity:
Childhood adversity is associated with a higher risk of psychosis in adulthood
Childhood abuse and neglect are associated with the later development of schizophrenia
Individuals have an increased risk for schizophrenia when they grow up and/or live in urban environments
Stress and Relapse
• Stress can trigger new episodes of schizophrenia among individuals with the disorder (higher levels of stress will often occur before the onset of a new episode
Stressful life events (e.g. adult trauma, conflict, bereavement, financial difficulties) worsen psychotic symptoms
• one significant stressor that is associated with increased risk of new episodes is immigration. Recent immigrants leave behind a support system and may
experience financial stress. First and second generation immigrants have a higher rate of acute symptoms of schizophrenia in comparison to individuals from the same
ethnic group who have been in the country for a longer time
• risk might be especially higher for refugees in comparison to non-refugee migrants
• Protective factor that reduces the risk for developing schizophrenia:
Household pets (particularly dogs) throughout infancy and early childhood
• exposure pet dog in pregnancy, infancy, and childhood is associated with less inflammation and fewer immune mediated disorder example, Asthma, allergies and it
might be doing this because of cortisol release, so exposure can change intestinal micro biom of family members and suggests that pet dogs can impact intestinal
inflammation and can alter the risk of schizophrenia through changes in the gut brain access
 ▫

Schizophrenia and the Family

- psychology
• Individuals with schizophrenia who have families that are high in expressed emotion:
Are more likely to suffer relapses of psychosis
Are more likely to be rehospitalized
• individuals and families who are high in expressed emotions, tend to overly involved with each other, protective of member who has schizophrenia, and tends to be
critical, hostile and resentful towards them (found cross culturally)
• lower levels of expressed emotions are often found in families in developing countries and there tends to be lower relapse rates among individuals with schizophrenia
within these countries
• Families have tendency of being more understanding of positive than negative symptoms (might view positive symptoms as uncontrollable and negative as controllable)
• Interventions that reduce family expressed emotions often lead to reduction in relapse rate among family members with schizophrenia
Cognitive Perspectives
• Beck and Rector (2005):
Argued that individuals with schizophrenia have fundamental difficulties in:
• Attention
• Inhibition
• Adherence to rules of communication
*Because of these difficulties, they may use different thinking styles in order to cope with the overwhelming information they are trying to process
• it is thought from this perspective that delusions happen when a person tries to explain bizarre perceptual experiences and jump to conclusions with little
evidence
• thought that hallucinations might happen when a person is hyper-sensitive to perceptual input and might attribute experiences to external sources
• from a cognitive perspective, negative symptoms might result from expectations that interactions with others might be negative and the need to conserve limited
cognitive resources, which might lead them to withdrawal
• cognitive therapies have been beneficial in terms of helping patients cope with stressful factors that are associated with their symptoms and helping them to
dispute delusions and hallucinations, negative symptoms tend to be treated by helping individuals with schizophrenia develop an expectation that there are positive benefits to
interacting more with others
TREATMENT: typically involves medications, therapies and social services
• medications typically help in reducing psychotic symptoms and reduce the likelihood of relapse
• Therapy: helps individuals cope with impacts of the disorder
• Social services: helps to provide support with community integration and resource access
Biological Treatments
• (First Generation) Typical Antipsychotic Drugs: historically, most individuals with schizophrenia were warehoused
Chlorpromazine (Thorazine):
• In the 1950s (50% of individuals housed in psychiatric hospitals were diagnosed with schizophrenia. These individuals were fed, bathed, and often restrained from hurting
themselves using physical restraints. No treatment was provided that improved functioning) French researchers found that this drug could reduce agitation, hallucinations,
and delusions among individuals with schizophrenia
• anti-psychotic drugs (neuroleptics), currently a-typical antipsychotic are most useful in terms of relieving positive symptoms while having few intolerable side
effects
• From a class of antipsychotic drugs called phenothiazines (block dopamine receptors, tends to reduce impact on brain but don’t help with neg symptoms)
• Other types of phenothiazines became widely used
• Other classes of antipsychotic drugs have been introduced:
• Butyrophenones (e.g. Haldol)
• Thioxanthenes (e.g. Navane)
• Individuals with schizophrenia usually need to take an antipsychotic drug all the time to prevent new episodes
• if these drugs are discontinued, around 70% relapse within 1 year, around 98% will relapse within 2 years
• around 30% of people who continue their medication will relapse
• There are many side effects associated with these drugs including:
• grogginess, blurred vision, sexual disfunction, visual disturbances, depression
Akinesia (slowed motor activity, expressionless face, monotonous speech
Akathesis (agitation that causes people to be unable to sit still)
• Parkinson’s disease: caused by too little dopamine in the brain, side effects highlight that the drugs reduce functioning levels of dopamine within the brain
• Tardive dyskinesia:
Permanent side effect of typical antipsychotic drugs
• involves involuntary movements of the tongue, mouth, face, jaw
• individuals might involuntarily make sucking sounds, smack their lips, or might stick out tongue repeatedly (happens in around 20% of people who have long-term
use of phenothiazines
• side effects of neuroleptics can be lowered by reducing dosages and most doctors will prescribe the lowest dose possible that will keep active symptoms
controlled (maintenance dose)
• issue with maintenance dose: neg symptoms might be strongly present and mild pos might persist, could make it hard for a person to function in their day
to day lives
Neurological disorder
 ▫

psychology
• (Second Generation) Atypical Antipsychotics:
More effective than neuroleptics in treating schizophrenia
• Do not cause the neurological side effects that first generation drugs tend to cause
• clozapine is most common and it impacts both dopamine and serotonin receptors
• research has shown that clozapine is effective in treating schizophrenia spectrum disorders and is as effective in reducing both negative and positive
symptoms
• side effects: dizziness, nausea, sedation, seizures, tachycardia, agranulocytosis (deficiency of granulocytes, which fight infections, it can be fatal so patients need
to be heavily monitored)
• Limitations:
10-60% of individuals have little or no response to first- or second- generation antipsychotics
• higher rates of non-response tend to be associated with earlier onset of schizophrenia, and early onset is a strong predictor of poor response to antipsychotic
treatment
• benefits of antipsychotics in terms of symptom reduction, tend to be the greatest in patients that have the most severe symptoms
• antipsychotic use is associated with lower mortality in comparison to no antipsychotic use in individuals with schizophrenia
• the vast majority of those with psychotic disorders don’t benefit from rehab programs without the use of psychotic drug therapies
Behavioral, Cognitive, and Social Treatments: the need cant be overstated
• A comprehensive approach to treatment tailored to the individual should consist of:
Cognitive treatments : help people with schizophrenia to help identify and change negative attitudes towards their mental illness, also help them seek help and
participate socially when possible
Behavioral treatments : make use of operant conditioning and modelling to teach skills like starting and ending conversations, asking help from physicians and completing
activities like cooking, cleaning and self-care
Social interventions: helps increase contact between those with schizophrenia and support resources like support groups
Family Therapy:
• Family therapy approaches focus on:
Basic education concerning schizophrenia (families will be taught about the biological causes, symptoms, medications associated with schizophrenia (goal is to reduce self-
blame in families and increase tolerance for uncontrollable symptoms, they will also learn how to communicate more effectively, to reduce harsh interactions and to increase
problem solving symptoms
• outcomes: ofer increased carer well-being and reduction in terms of patient directly criticism and hostility
Training family members in coping with inappropriate behaviors
Training family members in coping with the disorder’s impact upon their lives
Stigma
• individuals with a mental illness are often subjected to stigmatizing, discriminative behaviours in social situations and even within families
• Negative impacts of stigma: lower quality of life, lower likelihood to seek help, discontinuation of treatment
• Across cultures, individuals are more likely to believe that schizophrenia is caused by biological factors in comparison to depression
• individuals who contribute biological causes to psychological disorders tend to be more likely to have a greater desire for social distance from those individuals
• Individuals with psychotic disorders are more likely to experience stigma and isolation because of public judgement in comparison to other mental health disorders
• Individuals in the general population often perceive people with psychological disorders as:
Dangerous
Unpredictable
Out of control
psychology
DSM-5 types of delusions:

DSM-5 for schizophrenia

DSM-5 diagnostic criteria for schizoaffective disorder

DSM-5 for schizophreniform disorder

DSM-5 diagnostic criteria for brief psychotic disorder

DSM-5 diagnostic criteria for delusional disorder

DSM-5 for diagnostic criteria for schioztypal personality disorder

As genetic similarity to an individual with schizophrenia increases, an

individuals risk for developing schizophrenia also increases
 Two-hit model: psychiatric conditions result from disturbance in
neural development in the weeks before or after birth
• this impacts neural circuits and creates vulnerability
• Then psycho-social stressors experiences later on in life
can end up triggering symptoms onset

Areas of abnormal dopamine activity:

• in terms of the original theory of dopamine: revises theory is that there
are different types of dopamine receptors and different levels of
dopamine in a variety of neural regions that can explain schizophrenia
• Excess levels of dopamine have been found in the mesolimbic pathway,
this part is critical for processing the salience of stimuli and reward
• Abnormal function in mesolimbic pathway can be associated with
attributing importance to insignificant stimuli and associated with
hallucinations and delusions
• Abnormal low levels of dopamine in the prefrontal cortex might lead to
neg symptoms like low motivation, restriction of affect, and inability to
care for self (this explains why dopamine antagonists don’t tend to
alleviate negative symptoms of schizophrenia
• disregulation within the dopamine system has been implicated in form of
psychosis and mood disorders

Psychological and social treatments:

• many individuals who can control the positive symptoms of schizophrenia with medication will see experience a lot of negative symptoms, issues with motivation and social
interactions
• psychological interventions can really help increase social skills and can reduce social isolation and feelings of apathy
• Lack of effectiveness of anti-psychotic drugs is in part associated with the discontinuation of the drugs because, often, individuals feel like they don’t need them or
because they find the side effects to be intolerable
• Psychological interventions can help people understand the need to maintain on these medications persistently and help manage their side effects as well
• Because schizophrenia is so severe, lots of people can have a difficult time keeping a job, sheltering themselves and maintaining proper medical attention and care

In terms of what happened, experiencing prodromal or early symptoms of

schizophrenia, which were negative and given anti-psychotic medication
• He remained apathetic and isolated, stopped taking meds, and 2 months
Interaction of biological and psychosocial factors in terms of impacting the later had horrible thoughts that he thought was put there by his father,
development of schizophrenia grabbed a knife and threatened to kill his father if he didn’t stop torment
him, positive symptoms after medication declined and negative persisted
 ▫
Persoanlity disorders along the continuum
One core aspect of personality is our sense of
identity
• functional end: stable sense of self, distinct
from others as it can adapt to social situations
Another core: How we relate to people
• Adaptive personalities: empathize with others,
cooperate
In healthy personalities, traits are not fixed or rigid
but they fluctuate depending on social context
If personality traits are inflexible they usually cause
lots of social and personal disfunctions and
psychological distress

Issues with capacity of interpersonal relationships or

identity are sometimes diagnosed with a personality
disorder

PERSONALITY:
• Personality: enduring patterns of feeling, perceiving, thinking about, and relating to yourself and to your environment
• might describe others as emotional, outgoing etc
5 factor model: dimensional perspective that everyone’s personality exists along 5 personality traits, each factor has many dimensions and they vary
Significant among of research supports 5 factor models and these traits capture variation in terms of personalities, research has also been replicated across cultures,
numerous facets of personalities are impacted by genes
• Personality trait:
A core element of personality that tends to be consistent across settings and time (e.g. being caring, outgoing)\

GENERAL DEFINITION OF PERSONALITY DISORDER

• The DSM-5 uses a categorical perspective of personality disorder but importantly in the section for further study it does have a continuum model
• the general criteria for personality disorder is that the individual deviates significantly from expectations of culture, styles of thinking, emotional experiences,
interpersonal functioning and/or impulse control
• This personality pattern should be pervasive and inflexible across situations, onset in adolescents or early adulthood, lead to significant distress or functional
impairment
• Pattern of functioning shouldn’t be better explained by other mental disorders, medical or substance abuse
• Personality disorder to be diagnosed in kids younger than 18, personality patterns need to be present for 1 year, anti social personality disorder cannot be diagnosed
before 18 years
• Personality Disorder: an enduring pattern of feeling, thinking, and behaving that is fairly stable over the course of time
Personality features of concern must be displayed by early adulthood
Clinicians need to assess personality traits across time and across situations while considering ethnic, cultural and social factors

CLUSTER A: ODD-ECCENTRIC PERSONALITY DISORDERS:

• Behavior of individuals with odd-eccentric personality disorders:
Similar to the behavior of individuals with schizophrenia, main difference is they know reality
• Difference: they retain their grasp on reality to a greater extent
• ex. Common to be paranoid, speak in weird ways that make it difficult to understand, challenges relating to others, bizarre beliefs or perceptual experiences
• Part of schizophrenia spectrum, specifically schizotypal
• Symptoms are below threshold of psychotic disorder
• Can be pre to schizophrenia in a small proportion of individuals
• More common among people who have first degree relatives with schizophrenia or a persecutory type of delusion disorder

PARANOID PERSONALITY DISORDER:

• Characterized by a pattern of suspiciousness and distrust of others
Frequently preoccupied with concerns that they are being mistreated or victimized, hyper vigilant and look among environment
• ex. Much more likely to notice a sudden grimace on partners face or slip of the tongue, spend a lot of time trying to understand them
• Sensitive and angrily reactive to criticism, even if it is perceived or real, also hold grudges
• Because this has a strong effect on social relationships, they are likely to experience challenges in social settings which can lead to withdrawal or isolation
• In romantic relationships, hard to maintain without accusing partner of being disloyal, tend to be resistant to rational arguments against suspicions and see argument
as evidence that their partner is apart of a conspiracy against them
• Individuals with paranoid personality disorder are suspicious and distrustful of others, often believing that unrelated events have personal significance to them
• There is a dearth of research examining PPD and many embers of the psychiatric community have called for its removal from the DSM-5
• Known, really hard to treat since the primary characteristics include suspicions, rumination, jealousy which can limit treatment
• Symptoms don’t include psychotic symptoms like paranoid delusions and hallucinations, rates: 1.2-4.4% of individuals in general pop
• Overall, challenging to get along with and unstable relationships
• Strong predictor of aggressive behaviour and strongly associated with violence, stalking and litigation
• Comorbidity: people diagnosed are at higher risk for major depression, anxiety, substance abuse and psychotic episodes
• suicide risk is unclear due to limited data
 ▫
THEORIES OF PARANOID PERSONALITY DISORDER: not strong enough evidence to link paranoid personality disorder in schizophrenia
• Genetic theories:
Currently there is not strong enough evidence to demonstrate a linkage between PPD and schizophrenia
• Family studies show that it tends to be more common in relatives with unipolar depression in comparison to schizophrenia effected individuals
• Children of parents with schizophrenia are at high risk for avoidant and schizotypal disorder but not paranoid personality
• Cognitive theories:
PPD results when individuals hold the underlying belief that others are malevolent and deceptive and when individuals believe they are unable to defend themselves
against others
• tend to focus on signs of hostility and danger, personalize blame and tends to leave them with the belief of being alone and unprotected in a dangerous world
TREATMENT OF PARANOID PERSONALITY DISORDER
• Because they have a fundamental distrust of others, individuals with PPD usually only access mental health resources when they are in crisis
• limited knowledge of best therapeutic options, research on CBT, psychoanalysis, transference focus therapy, conditioned avoidance response and dialectical behavioural
therapy do show promise in helping, but not enough evidence shows the most effective
• Cognitive therapy approach tends to focus on increasing sense of self efficacy in terms of facing challenging situations, this tends to decrease fear and hostility
towards others
• Suspicious approach to thinking can often undercut the development of trusting therapeutic relationships and also a therapist attempts to challenge paranoid thinking
can be misinterpreting in line with the paranoid belief system

SCHIZOID PERSONALITY DISORDER

• People with Schizoid Personality Disorder:
> Tend to be indifferent to developing close relationships with others
> Seem to derive little to no pleasure from social interactions
> Show a pattern of detachment from social relationships
> Tend to display a restricted range of emotional expression in their social interactions
> Emotional coldness and detachment might be associated with an inability to process emotions
> Research has shown higher rates of alexithymia: impaired ability to recognize and express emotions > Emotional dysregulation, suicide ideation, and comorbity
> At a high risk for major depression
> Inescapable feeling of loneliness and also social withdrawal; weaken their ability to cope with mental pain and increase suicide attempts > Violent crime is more likely
among Cluster A, specifically schizoid personality and schizotypal
• SPD is highly treatment-resistant:
> These individuals are typically indifferent to others’ praise or criticism > Take pleasure in very few actives
> View relationships as messy, unrewarding, and intrusive
• One of the most understudied, also least common
• 5% of general population, no strong consensus
• More common in men than women
• Function adequately in society that don’t require frequent interpersonal interactions

THEORIES AND TREATMENT OF SCHIZOID PERSONALITY DISORDER

• Genetic theories:
> There is a slightly higher rate of SPD among relatives of individuals with schizophrenia > Sociability, low warmth might be inherited
• Treatment:
> Individuals with SPD are not often motivated to seek treatment
> Interpersonal closeness of therapy is stressful instead of being supportive
> Psychosocial treatments tend to focus on increasing the individuals awareness of their feelings, social skills, and social contract
> Model the expression of feelings for a client, identify and express these feelings
> Social skills training is done using role play with therapist and homework assignments
> Group therapy, model interpersonal relationship and practice social skills with other group members
SCHIZOTYPAL PERSONALITY DISORDER
• Individuals with schizotypal personality disorder (STPD):
> Have enduring patterns of peculiar behaviours and/or appearance that have a strong impact upon their behaviour, thinking, and interpersonal functioning > Only personality
disorder included in schizophrenia spectrum; display similar symptoms
> Symptoms development and course can be quite different
> Socially isolated, uncomfortable with interpersonal interactions, limited range of emotions, odd and magical thinking
• Symptoms:
> Social interaction challenges are very common among individuals with STPD > lead to isolation and socially anxious behaviour
> Cognitive and perceptual distortions (but they maintain their grasp on reality)
> easily lost in thought and fantasy, believe that random events are strongly related to them
> Tangential speech
• Men more affected, likelihood is higher among those who are separated, divorce, widowed, and those with low income
• Comorbidity is really complicated and important to understanding the course of the behaviour
PERSONALITY DISORDER
THEORIES OF SCHIZOTYPAL PERSONALITY DISORDER
• Biological factors:
> Research supports heritability of STPD
> Family history, adoption, twin studies show genetic
> .81 which is very high, significantly more common among first degree relatives with schizophrenia > STPD is mild form of schizophrenia
> On neuropsychological tests individuals with STPD have difficulties with working memory, learning and recall (less severe than individuals with schizophrenia)
> People with both STPD and schizophrenia show grey matter reduction in areas of the temporal lobe, but reductions are less severe among those with one or the other
> Dysregulation of dopamine in the brain
> High levels on dopamine in striatal and cortical that play a strong role in the develop of the symptoms
• Environmental factors:
> Childhood trauma and adversity (sexual, physical, emotional)
> More likely to have a parent who has battered, abused substances, or been incarcerated
> Disruption in interpersonal and social functioning
> Exposure to this trauma has an impact on long-term outcomes including: > Paranoid ideation
> Social cognitive abilities
> Working memory, verbal fluency, and visual learning

TREATMENT OF SCHIZOTYPAL PERSONALITY DISORDER

• Typically treated with the same drugs used to treat schizophrenia (neuroleptics and a-typical antipsychotics)
> reduce psychotic like symptoms (distorted ideas of references, magial thinking, illusions)
> Antidepressants sometimes used for those who have significant distress
• In psychotherapy the focus is on establishing a good relationship with client and social skills training
> very few close relationship sand struggle with social anxiety and paranoid thoughts
> learn socially appropriate behaviour and increase social contracts
• Cognitive therapy focuses on assisting individuals with STPD to look for objective evidence in their environment to support their thoughts and disregard bizarre and odd
thoughts

CLUSTER B: DRAMATIC-EMOTIONAL PERSONALITY DISORDERS

• Individuals with Cluster B personality disorders:
> Have a hard time regulating their emotions and behaviours
> Show challenges in impulsivity, inflated sense of self, tendency to seek stimulation, strong disregard for personal safety or the safety of others > Hostile, dramatic,
impulsive
> Others perceive their behaviours as dramatic, emotional, and impulsive

BORDERLINE PERSONALITY DISORDER

• This disorder is characterized by:
> Instability of emotions, relationships, and image
> Strong impact on personals ability to function
> Regulate emotions; emotional extremes in boats of anger, depression, or anxiety (can last for a few hours or a few days
> Go from content, to feeling suicidal in a matter of hours > Difficulty regulating their emotions
> often experience emotional extremes revealed in bouts of anger, depression and anxiety > Volatile emotionality: extreme sensitivity to perceived emotional slights
> In combination in a unstable sense of self and impulsivity can lead to destructive actions
• Typically emerges during early puberty
• The symptoms: progressively impact numerous areas of an individuals life
• Interpersonal relationships are very unstable
> Idealizing others to disposing them without being provoked
• Feelings of emptiness; lead to cling onto new acquittances and therapists to fill that void
• Worry about abandonment
• Understands typical actions as rejection; therapist cancelling appointment when they are sick is taken by the patient as rejection and they become very angry

THEORIES OF BORDERLINE PERSONALITY DISORDER

• Individuals with BPD:
> have significant challenges with regulating emotion
> Are hyperattentive to negative stimuli
> It is thought that these issues may stem from childhood instability, neglect, and psychopathology among their caregivers
> Sexual and physical abuse, lead to challenges in terms of emotional regulation and in terms of attaining a positive and stable identity
• Marsha Linehan:
> argues that a history of exposure to emotional invalidation, abuse, and neglect inhibits proper learning of emotion-regulation skills
> dialectal behaviour therapy
> tend to rely on others to help them in terms of coping, but don’t have confidence to request help in mature ways: manipulative and immature (injuring themselves) >
extreme emotional reactions to situations often lead to impulsive actions
• Psychoanalytic theories:
> Object relations theorists have argued that individuals with BPD never learned to differentiate their perspectives of themselves from their perspectives of others
> This leads to extreme reactivity to others opinions and fears of abandonment
> Perceive others as rejecting them, then they reject themselves; results in self-punishment or self mutilation
> Hard time integrating positive and negative qualities; early caregivers tend to reward them when they remained dependent and punished when trying to separate >
Tend to see themselves and others as either all good or all bad, splitting: vasolating between the two
> Can view their partner as incredibly caring and kind, but when the partner is late for dinner they are selfish and uncaring
THEORIES OF BORDERLINE PERSONALITY DISORDER CONT’D:
• Biological theories:
> Amygdala and hippocampus among individuals with BPD are smaller in volume in comparison to individuals without this disorder > Amygdala: emotion
> Hippocampus: stress and memory
> Individuals with BPD have stronger activation in the amygdala in response to emotional faces
> There are structural and metabolic abnormalities in the prefrontal cortex of individuals with BPD > Prefrontal important for regulating of emotions and critical in
controlling impulsive behaviour > Impaired functioning tend to be associated with emotional dysfunction and emotionalbility
> Might be due to genetic factors in part, does run in families, twin studies support heritability > Early abuse and early maltreatment

PERSONALITY DISORDER
TREATMENT OF BORDERLINE PERSONALITY DISORDER
• Dialectical Behavior Therapy (DBT):
> This form of therapy shows the best support for treatment of BPD including reductions in: > Nonlethal self-injury
> Hospitalization
> Anger
> Gain a more realistic and positive sense of self, learn how to regulate their emotions, and also to correct their inclinations towards dichotomous thinking > Therapists
teach clients to monitor self discouraging thoughts, black and white analyzing, and challenge these thoughts
> This form of therapy also reduces anxiety, depression and increases interpersonal functioning
> Assertiveness skills: helps them to express emotions in a mature manner
> Monitoring situations that are most likely to lead to those behaviours and learning to cope
• Cognitive Therapy:
> Systems training for emotional predictability and problem solving (STEPPS) > Group intervention for individuals with BPD
> Uses both cognitive and behavioural techniques
> Cognitive techniques used to challenge the maladaptive and irrational cogntions
> Behavioural address problem solving and self-management
> STEPPS: reduce negative affect, impulsivity, and increases functioning
• Psychodynamic approaches:
> Transference-focused therapy:
> Uses the relationship between therapist and client to help them develop a stronger understanding of healthy relationships and themselves
> Reduce suicide, impulsivity, aggression, and anger > Mentalization-based treatment:
> Provides clients with validation and support
> Individuals with personality disorder have a fundamental challenge in terms of understanding the mental states of themselves and others due to early trauma and
attachment issues
> Appreciate alternatives to sense of self, focus on relationship between client snd therapist
> Make fewer suicide attempts and improve mood
• First-line treatment: > Psychotherapy
> Some medications may be useful though
> Mood stabilizers and A-typical antipyschotics
> SSRI’s not effective
> Medication only typically recommended for co-morbid disorders

HISTRONIC PERSONALITY DISORDER

• Individuals with histrionic personality disorder (HPD):
> Hav rapidly shifting emotions
> Have intense and unstable relationships
> Are often described as dramatic, excitable, erratic and volatile
> Are excessive in attention-seeking behavior
> BPD form HPD, BPD show self destruction and chronic feelings of emptiness whereas HPD behave in ways that draw attention to themselves > Use emoitla displays,
inappropriate sexual conduct, emotionality, provacative
> BPD hang onto others because of self doubt and negative self image, HPD want flattery, nurturing and attention
• Prevalence:
> HPD affects 1-3% of the general population
• Sex difference:
> Women are 2x as likely to be diagnosed
• They have an increased risk for:
> Depression and substance use disorders
• More likely to be separated or divorced
• Tend to exaggerate medical problems, more medical visits
> Higher risk for somatic disorder, panic attacks, and conversion disorders
• Attention seeking behaviour associated with suicidal threats and acts
• Not enough information, debates about validity of HPD, proposed to be eliminated in DSM because of proposed support against it

TREATMENT OF HISTRIONIC PERSONALITY DISORDER

• Psychodynamic psychotherapy:
> Helps clients to uncover repressed emotions and needs
> Helps clients to express themselves in a more socially appropriate manner
• Cognitive therapy:
> Focuses on helping clients to reduce dramatic evaluations of situations and adopt more adaptive ones
> Helps clients to formulate goals and plans that don’t depend on the approval of others
• Group and family are not recommend, they want attention so this approach distracts them
NARCISSITIC PERSONALITY DISORDER
• Individuals with Narcissistic Personality Disorder (NPD):
> Believe they are better than everyone else and walk over others to achieve their goals
> They act in a dramatic manner, tend to be shallow in emotional expressions, and seek admiration from others
• Grandiosity, preoccupied with own self importance, lack empathy, strong belief that others should admire them
• In relationships, make entitled demands of others to support their own wishes and ignore the needs of others, also exploring them
• Individuals with NPD can be very successful in societies that value assertiveness and self confidence (e.g. United States, Canada)
> High functioning NPD display their traits of self-confidence as workaholics, express as perfection but failure to reach can become overbearing and controlling
> Alienate others in their lives
• They tend to seek treatment for:
> Depression
> Challenges adjusting to life stressors
• Prevalence: 6.2% (in the US)
• Males: 7.7%, Females: 4.8%
• NPD tends to be more prevalent among younger adults, suggests that NPD on the rise due to social and economic environments that support extreme self-foucs
• High rates of mood and anxiety, as well as substance abuse
• Higher rates pf physical and violent aggression, suicidal thoughts, and suicidal behaviours

PERSONONALITY DISORDER
THEORIES OF NARCISSISTIC PERSONALITY DISORDER
• Psychodynamic oriented theorists argue that individuals with NPD rely on dominating others for their self-esteem since they didn’t develop adaptive strategies
for managing distress as children
• Two main subtypes
> GRANDIOSE: cope with challenges by thinking of themselves as superior and unique, exploitative, manipulative, particularly when they feel distressed,
sometimes engage in violent action
> VULNERABLE: cope by ending in grandiose fantasies to reduce their own feelings of shame, hypersensitive to criticism, tend to avoid others
> Interpersonal antagonism: common in both types
• Associated with childhood adversity (abuse and neglect)
• Overly permissive or overly controlling could cause grandiose or vulnerable NPD, respectably

TREATMENT OF NARCISSISTIC PERSONALITY DISORDER

• Individuals with NPD typically don’t seek treatment except when they experience:
> Depression
> Significant interpersonal challenges > Therapists using cognitive techniques:
> Help clients to develop more realistic expectations concerning abilities and more sensitivity to the needs of others
> They teach clients to challenge their self-aggrandizing methods of interpreting situations
• Individuals with NPD tend to view their issues as being weaknesses within others
> Make it hard for therapists to form a working alliance
• Don’t have an easy time challenging their self-serving biases, usually don’t stay in therapy once their acute symptoms are reduced

CLUSTER C: ANXIOUS-FEARFUL PERSONALITY DISORDERS

AVOIDANT PERSONALITY DISORDER (AVPD)
• Individuals with avoidant personality disorder tend to:
> Excessively avoid interpersonal interactions
> Have low self-esteem, are very anxious about being criticized by others and tend to experience a lot of shame > Symptoms overlap with social anxiety
disorder
> Choose occupations that are socially isolated or have less interactions with others
> When they do have to interact with others, they feel nervous, inhibited, and hypersensitive to being criticized > View themselves as being inferior, socially
inept, isolated and lonely
> The 2 pathological personality traits that highlight this disorder are:
> Negative affectivity
> Detachment
> *They crave relationships with others, but feel unworthy of these relationships and end up isolating themselves
> 2.4%, more common in females
> Co-morbid with depression, substance abuse, and anxiety
> Co-morbid with cluster C disorders
> So much overlap between social anxiety and AVPD, if individuals have both they are highly self-critical of themselves
> AVPD more chronically impaired than social anxiety, and tend to have fantasies about having these types of relationships
THEORIES OF AVOIDANT PERSONALITY DISORDER
• Biological theories:
> Twin studies suggest that genes play a role in AVPD (the same genes are likely implicated in both AVPD and SAD)
• Cognitive theories:
> Individuals with AVPD adopt dysfunctional beliefs about being worthless because of rejection by caregivers early in life
• AVPD does not have a relation to sexual or physical abuse, but do report more emotional neglect
• Describe parents as less affectionate, more rejecting, less encouraging, and guilt in gendering
> Could be recall bias due to hypersensitivity
• “If my own parents don’t like me, how could anyone” nervous when talking to others, believe criticism is inevitable
TREATMENT OF AVOIDANT PERSONALITY DISORDER • This disorder is chronic and begins early in life
• Cognitive and behavioral therapies are useful
> Increases in social contacts, reduction in avoidance behaviours, and more comfort engaging in social situations
> SSRI’s sometimes used to reduce social anxiety
• Gradual expose to social settings along with social skills training and challenging negative thoughts about self and situations
DEPENDENT PERSONALITY DISORDER
• Individuals with dependent personality disorder (DPD):
> Have a pathological and excessive need to be taken care of by others > They tend to be clingy, and they strongly fear separation
> Lead to issues in social interactions and cause psychological distress
> Worry about displeasing others and losing the approval from others
> Submit to unreasonable demands in an attempt to avoid seperation
> Difficulty making decisions and rely on others for advice and reassurance
> Tend to crave continual reassurance and emotional support
> They tend to have pathological attachments to particular individuals. They often display significant insecurity and separation anxiety
• Prevalence: 0.78%
> Higher rates are found in self-report methods rather than interviews, suggests that people have these disorders but clinicians don’t diagnose
• More women are diagnosed than men
• Common comorbidities:
> Depressive and anxiety disorders, often triggered by interpersonal conflict or disruption in relationships
• Increased risk for physical illness, child abuse, partner abuse, suicidal behaviour, and functional impairment

THEORIES OF DEPENDENT PERSONALITY DISORDER

• Biological theories:
> DPD tends to run in families, .81
> Adolescent with separation anxiety or chronic illness are more likely to develop
• Cognitive and behavioural theories:
> Behavioral:
> Pathological dependence may be learned behaviours that are used to elicit care > Learned behaviours generalized into adult relationships
> Cognitive:
> Individuals with DPD have inflexible beliefs concerning their dependence, which drive their dependent behaviours > Believe they are needy and week, can drive their
behaviours to reflect these beliefs
• Early attachment theories:
> Anxious-insecure attachment style in infancy can lead to anxious attachment in adulthood
> Dependency characterized with high levels of anxiety and insecurity and low levels of risk taking and perceived competence

TREATMENT OF DEPENDENT PERSONALITY DISORDER

• Individuals with DPD often seek treatment and show a significant degree of insight and self-awareness in comparison to other PDs • Goal in psychotherapy:
> Increase client self-confidence
> Teach appropriate independence skills
> How early experiences with caregivers impacted their dependent behaviours
> Assessing relationship style that exists between patient and therapist
> CBT: assert supportive behaviours and reduce anxiety, challenge client assumptions
> Making decisions, hierarchy, move up this hierarchy from easiest to hardest decisions
• Marital and family therapy can sometimes be useful to see how nuture patterns plays a role in anxiety
• Useful: short term dynamic psychotherapy, psychodynamic therapy, cognitive therapy, CBT, and logo therapy: not one is the best approach

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (OCPD)

• Individuals with OCPD tend to display:
> Rigidity
> Perfectionism
> Dogmatism
> Rumination
> Emotional and interpersonal difficulties
> They also tend to be compulsive and preoccupied with rules > Inflexibility, cause impairment and interpersonal difficulties
• Not related to high occurrences of disabilities
• Individuals are productive and base their feelings of self-esteem on productivity
• Have issues interpersonally in terms of appreciating others and tolerating the quirks of other people
• This disorder shares some features with OCD but only has a small to moderate comorbidity with OCD
> OCPD, more general manner, prone to rigidity, not as much one specific thought
> Individuals with OCD view thoughts as intrusive, whereas OCPD view as facets of thier personalites > OCPD come across as grim, strict, and tightly in control of thier
emotions
> rarely spontaneous and workaholic, don’t appreciate friendships or leisure time
• Some researchers have argued that OCPD may be a subtype of OCD
• OCPD is the most prevalent PD: 2-8%
• Some studies show that men are twice as likely as women to be affected, other show no sex differences
• More likely in individuals over the age of 30, but traits often begin in childhood
• High risk for depression, anxiety, and eating disorders
• Majority of OCD do not have OCPD, but when they do occur OCD and OCPD with depression symptoms tend to be more severe
THEORIES OF OBSESSIVE COMPULSIVE PERSONALITY DISORDER
• OCPD is related to genetic factors which are similar to those in OCD
> OCPD is more common among relatives of individuals with OCD > Reduced grey matter in the prefrontal cortex, singulet, and insula
> Abnormalities in the prefrontal cortex among individuals with OCD and OCPD suggest there is a shared mechanism that relates to decision making in both
of these disorders
• Individuals with OCPD have a stronger history of neglect
TREATMENT OF OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
• Individuals with OCPD often seek treatment. (feel psychological distress and impairment) Treatments that seem effective include:
> Behavioral therapies:
> can reduce their compulsive behaviors
> client given assignment of altering rigid schedule, taught to use relaxation techniques
> Cognitive therapies:
> can help to evaluate and challenge negative automatic thoughts
> provide evidence for and against negative automatic thoughts, eventually the hope is that rigid expectations will be replaced with more flexible > *Sometimes SSRIs are use
to reduce obsessionally
The big 5 personality factors
• within each factor there are facets that are under factors
• Description of individuals who are high and low on the facte
• Ex. Extroversion vs introversion one facet here is gregariousness
• individuals who are highly gregarious are outgoing and sociable and
individuals who are low gregarious are withdrawn and isolated

In the DSM-5 there are two different models of personality disorders, the first is
categorical and defines 10 personality disorders in terms of really specific criteria
The dimensional model is in DSM-5 for further study and uses the continuum model
of personality disorders which is similar in the big 5 model
• this approach makes the fundamental assumption that the normal and
abnormal personality falls along a continuum within personality disorders
representing extreme and maladaptive personality trait variants

Personality Disorder Clusters:

• The DSM-5 groups 10 PDs into 3 clusters based upon their similarities.
• The DSM-5 recognizes the limitations to the cluster system, not validated,
doesn’t account the fact that people display co-occurring personality
disorders from diff clusters
Cluster A: display odd eccentric behaviours and thinking, paranoid personality
disorder, schizo personality disorder, schizotypal personality disorders
• All have some features of schizophrenia but not out of touch with reality,
instead, suspicious of others
Cluster B: dramatic, erratic and emotional behaviour and erratic interpersonal
relationships, includes anti-social personality disorder, histrionic, boarder line and
narcissistic personality disorder
Cluster C: anxious, fearful and chronic self doubt
• dependent personality disorder, avoidant personality disorder, and obsessive
compulsive
• Tend to have little self confidence and difficulty in relationships

Cluster A: Odd eccentric personality disorders

 Felix

Therapist and ann

• Therapist doesn’t directly challenge ann’s beliefs about her co workers
intentions but instead tries to reduce the sense of danger ann was feeling by
defining the situation as aggravating instead of threatening
• IN order to gain the trust of a person with paranoid personality disorder, the
therapist has to remain calm, respectful and straight forward, indirectly raise
questions about how the client may be interpreting situations

Roy case study

• schizoid personality disorder

41 year old case study

• schizotypal personality disorder
•

Schizotypal personality disorder:

• men are slightly more effected rate 4.2%
• Women 3.7%
• Likelihood tends to be higher in separated, divorced or widowed individuals and
those with low income
• Some have episodes of brief psychotic disorder and some go on to develop
schizophrenia
• Common differentials diagnoses: ADHD, social anxiety, and autism spectrum
• comorbidities: complicate the understandings of the course and treatment
 Cluster B personality disorders: dramatic-emotional:
• borderline and antisocial have been focus of research

Cindy case study:

• cindy symptoms highlight intense out of control emotions that cannot
be managed
• Hyper sensitivity to abandonment
• The tendency to cling to others, and strong history of self harm
• Individuals who have borderline personality disorder will often engage
in para-suicidal gestures (non-lethal but intentional self-harm, lethal
suicide attempts)
• 70-75% of people with borderline personality disorder have
engaged at least once with self harm
• Greatest risk for suicide is within the first 2 years of diagnosis
• suicide rates among individuals with borderline personality disorder
tend to be 8-10%, around 50% higher than general pop
• most common personality disorder and uses intensive use of mental
health services

Borderline Personality Disorder:

• more likely to experience long-term negative outcomes including severe and
persistent functional disability, physical illness and reduced life expectancy
(due to suicide and natural causes)
• Diagnosed with other mental disorders like depression, generalized anxiety
disorder, specific phobia, PTSD, agoraphobia and psychotic disorders
• Studies show the symptoms will usually decrease with age and spontaneous
remission will happen in about 25-41% of people with borderline,
schizotypal, avoidant, and obsessive-compulsive personality disorders
• Stabilization will often occur with age but some features persist in older
patients including emotional disregulation and challenges in interpersonal
relationships
• In over 85% of diagnosed will end up show remission within 10-15 years and
only a minority in remission will relapse
Amygdala and
the prefrontal
cortex have
been implicated
in borderline
personality
disorder

Debbie case study on histrionic personality disorder

 Cluster C: Anxious-fearful personality disorders:
• all of these are characterized by a strong sense of anxiety or fearfulness as
well as behaviours that are meant to reduce the fear
• all three are characterized by diff fears but all result in personal distress and
dysfunction

Avoidant Personality Disorder:

• comorbid with depression, anxiety and substance abuse
• Elevates risk of suicide aviation and suicide attempts
• Comborbid with cluster C
• Overlap between avoidant and social anxiety that they might be alternate
forms of the same disorder, both highly self-critical of social interactions
• have more generalized anxiety and more severe anxiety about social
situations in comparison to those with social anxiety
• More chronically impaired by anxiety
• Desire affection and fantasize about ideal relationships

Ruthann case study on avoidant personality

Francesco case study on dependent personality

Ronald case study on obsessive-compulsive personality disorder (OCPD)

Biological and environmental factors collectively work together to either

increase or decrease the likelihood of an individual developing a personality
disorder
 ▫
• human brain changes dramatically cross life
• Infancy/childhood: significant growth in size and
complexity
• Early adulthood: further changes and maturation
• Changes are strongly impacted by health, life style
and experiences
• Older: gradual decline in structural and functional
integrity of the brain but the brain still adapts (allows
people to function well in older age)
• Lots of variability in development of the brain and
related cognitive, emotional and behavioural functioning
• Some kids, significant challenges in academic skills
(reading, writing, math) and others have more global
cognitive deficits that make it hard to function
• Some have deficits in regulating emotion and
behaviours
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: • Many differences and are strongly impacted by
• There are 3 subtypes of ADHD in the DSM-5: environmental experiences and biological factors
Combined presentation:
> requires that an individual experiences 6 of more symptoms of inattention and 6 or more symptoms of hyperactivity impulsivity
Predominantly inattentive presentation
> requires experiences 6 or more symptoms of inattention but less than 6 symptoms in hyperactivity impulsivity
Predominantly hyperactive/impulsive presentation
> requires experiences 6 or more symptoms of hyperactivity impulsivity but less than 6 symptoms of inattention
• Prevalence: 3.4-6% of school-aged children (increasing)
> ADHD starts in childhood and the symptoms must be present before the age of 12 in a variety of settings
> challenges can continue into adulthood
• Males are more than 2x as likely to be diagnosed with ADHD in childhood and adolescence (the sex difference narrow with age as individuals move into adulthood)
Females tend to present with inattentive features and have less disruptive behavior than boys
> females might be under-diagnosed because they primarily have inattentive features
> parents underrate impulsive and hyperactive symptoms in girls and overrate in boys, bias may have a strong impact on sex ratio and diagnostic rate of AHDH
• ADHD is found globally
• Most kids with ADHD are diagnosed in elementary school
• Symptoms of ADHD are strongly correlated with:
Challenges in school performance
> ex. Children with ADHD tend to have lower scores on achievement tests, lower GPA and more likely to repeat grades
Difficulties in peer relationships
> tend to be disrupted and kids with ADHD are more likely to experience rejection and teasing because of impulsivity and hyperactivity
> when engaging with other kids, kids with ADHD tend to be irritable, intrusive and demanding
• Learning disorders are commonly comorbid with ADHD
> particularly reading disorder, disorder of written expression and developmental coordination disorder
> around 20-25% of kids with ADHD have a specific learning disorder that makes in hard to focus and learn in school
• Behavioral challenges can become worse over development
> sometimes, the increasing behavioural issues are eventually diagnosed as conduct disorder (most likely among children diagnose with combined ADHD presentation)
> between 45-65% of children with ADHD develop a conduct disorder, abused drugs or alcohol or break the law
• Challenging symptoms which interfere with everyday functioning tend to persist into adulthood in 50-78% of individuals
> adults who were diagnosed with ADHD as children, are at a high risk for antisocial personality disorder, substance abuse, mood and anxiety disorder, marital issues,
traffic accidents and frequent job changes
>ADHD has a significant impact on the quality of life of the child, parents and siblings and can double the change of premature death from unnatural causes like accidents

BIOLOGICAL FACTORS:
• Abnormal activity has been documented in a variety of neural regions:
Prefrontal cortex
> cognitive, motivation and behaviour
Striatum
> working memory and planning
Cerebellum
> motor behaviours
Cerebral cortex
> smaller in volume in comparison to kids vs adults and there is less conductivity between the frontal region of the cortex and regions of the brain that impact motor
behaviour, emotional reactions and attention
> continues to develop into adolescence
> kids with ADHD have brains that are slower to develop, which may lead to them unable to control their behaviour and maintain attention at an age appropriate level
> this helps to explain why some kids with ADHD show a reduction in symptoms, particularly hyperactivity, with age
• challenges such as impulse control, attention among those with ADHD tend to related to fundamental abnormalities in the prefrontal cortex, striatum, cerebellum and the
cerebral cortex
 ▫
BIOLOGICAL FACTORS CONT’D
• Catecholamine neurotransmitters (particularly dopamine and norepinephrine) function abnormally among individuals with ADHD
These neurotransmitters play an important role in:
• Sustained attention
• Inhibiting impulses
• Processing errors
> drugs that target levels of dopamine and norepinephrine seem to be useful in terms of treating ADHD)
• ADHD is highly heritable:
Genes that impact dopamine, noradrenaline, and serotonin may have abnormalities among individuals with ADHD
>siblings of children with ADHD are 3-4x more likely to develop ADHD in comparison to children without siblings with ADHD
> autism spectrum disorder and ADHD often co-occur and research has suggested a genetic linkage
• Prenatal and birth complications are associated with ADHD
> ADHD tends to be associated with low birth weight, difficult delivery leading to oxygen deprivation and premature delivery

PSYCHOLOGICAL AND SOCIAL FACTORS:

• Children with ADHD are more likely to belong to families in which:
Parents engage in hostile and sometimes aggressive behavior
Parents engage in substance abuse
• thought that the genetic factors associated with ADHD may catalyze disruptive behaviour in kids and this may lead to hostile parenting, even in adoptive parents

TREATMENTS FOR ADHD:

• Most children diagnosed with ADHD are treated with stimulant drugs (e.g. Ritalin, Dexedrine, Adderall)
> around 70-80% of kids with ADHD respond well the drugs and show decreasing results of demanding, non-compliant, and disruptive behaviour and increases in positive
mood, gaol-directed behaviour, and quality of social interactions
> it is thought that these work to increase dopamine in the synapses in the brain, but they also come along with side effects
• Side effects of stimulants:
Reduced appetite
Insomnia
Edginess
Gastrointestinal upset
Increased frequency of tics
> concern that stimulates might stunt growth, kids with ADHD who take stimulants sometimes have a decreased growth rate
> risk of abuse from individuals who want the high, money on resale or for individuals who want an edge for school or work
• Antidepressant medications:
Often prescribed to children and adolescents with ADHD since both anxiety and depressive disorders tend to be quite common among this population
> anti depressants help with cognitive performance but they are not as effective as stimulus
> bupropion is an antidepressant with strong impact on dopamine levels and seems to be more effective for ADHD in comparison to other anti depressants
> as soon as these medications are stopped, symptoms will almost always return
• Behavioral therapies can be effective
Parents and teachers will often work collaboratively to alter both rewards and punishments for a child
• strong focus on pro-social, goal-directed and attentive behaviour, and on extinguishing hyperactive and impulse behaviours.
• Ex. A child and parent may have an agreement that they will earn a chip every-time they obey a request to put away toys or clothes, and at end of week they can
exchange the chips for fun activities, if they refuse to comply with a request, they will lose a chip
• kids learn to anticipate the consequences of behaviours and tend to make less impulse behaviours, also taught appropriate social interaction skills (like listening to
others, waiting their turn, expressing frustration in non-aggressive ways)
• For adults with ADHD, cognitive behavioural therapies and treatments tend to focus on planning and time management skills and this is quite effective

AUTISM SPECTRUM DISORDER (ASD):

• ASD involves impairment in 2 behavioral domains:
Social interactions and communication
Restricted and repetitive patterns of behaviors, activities and interests
• Deficits in communication and social interaction sometimes first appear in infant and toddler interactions with their caregivers
> in comparison to typically developing kids, infants with ASD might not smile or coo when responding to caregivers
> they also might not cuddle even when scared, may rarely make eye contact and joined attention
> other early symptoms: delayed language development (when older, kids with ASD might prefer solitary play and don’t seem to react typically to other peoples
emotions
• Approximately 25-30% of people with ASD do not develop useful speech by school age
> those who do, often don’t use it as expected for age
> often use a small number of single words or fixed phrases
• Children with ASD tend to be preoccupied with one feature of a toy or an object
> might engage in repetitive or odd behaviours with their toys ex. Instead of playing regularly with a car, a child with ASD might take off a wheel and pass it in hands
• Routines and rituals tend to be very important to children with ASD
> when routine is changed, can become distressed and frightened ex. If a parent stops at grocery store from school it can cause distress if its not normal
• Stereotyped and repetitive behaviours are common (often use part of body, ex banging head on wall, flapping arms and hands (self-stimulatory behaviours)
>self-stimulatory behaviours: assumptions that kids engage in these behaviours for self stimulation, it really remains unclear what purpose is
 ▫
AUTISM SPECTRUM DISORDER (ASD) CONT’D:
• Children with ASD often have challenges on measures of intellectual ability
> ex. IQ tests - around 50% of children with ASD showing at least a moderate intellectual disability
> some children only show challenges with skills like require language and understanding of peoples perspectives
> language skills and the ability to engage socially significantly contribute to academic performance
• Verbal skills: tend to be a strong predictor of long-term outcomes for children with ASD
> particularly with psychosocial adjustment and overall well-being
> often, in popular media, children with special talents with ASD will be highlighted
>ex. The ability to draw extremely well or exceptional memory (these children are referred as savants) these are quite rare
• For an ASD diagnosis:
Symptoms must have onset in early childhood (typically seen by 2 years of age)
> variability in terms of severity and outcomes of ASD, best predictor of ASD outcomes is the IQ of the child and the language development of the child before 6 years
of age

CONTRIBUTORS TO AUTISM SPECTRUM DISORDER:

• Leo Kanner (1943): the psychiatrist who was the first to describe autism
> believed that autism was caused by poor parenting and biological factors
> many psychoanalytic theorists argue that parents with children with ASD were uncaring, distant and cold and children’s symptoms were viewed to as a retreat
inward bc of unavailable caregivers
> research has shown that unresponsive parenting plays little to no role of the development of ASD
• Biological factors:
Genes play a role in the development of ASD
> family and twin studies have strongly supported the role of genetics
> siblings of children with ASD are 50x more likely to have the disorder
> concordance rates for ASD are around 60% for monozygotic twins and 0-30% for dizygotic twins
> children with ASD have a higher rate of other genetic disorders that are associated with cognitive impairment like fragile X syndrome and PKU
> no single gene causes ASD but abnormalities in many genes have been found to be associated with ASD
> differences have been found in terms of the levels of neurotransmitters of serotonin and dopamine
• Neurological factors seem to play a role in ASD
> around 30% of kids with ASD develop seizure disorders by the time they reach adolescence and this suggests neurological dysfunction
> greater head and brain size is found in children with ASD compared to children without it
• Structural abnormalities have been documented in:
Cerebellum
Cerebrum
Amygdala
Hippocampus
• Studies have shown that children with ASD: have a higher rate of prenatal and birth complications
• Imbalance of maternal gut microbiome is associated with neural abnormalities in offspring (occurs in response to infection, changes in diet and stress in pregnancy)
• Maternal immune activation (activation of the immune system due to stress, inflammation, infection, asthma or allergies and thought to be a vulnerability factor for
ASD) and inflammation are associated with many neurodevelopmental disorders (ASD, schizophrenia, cerebral palsy, depression and epilepsy)
• Microbiota-gut-brain axis:
Children with ASD tend to have more gastrointestinal (GI) symptoms in comparison to children without ASD
> GI symptoms are strongly associated with ASD symptom severity

TREATMENTS FOR AUTISM SPECTRUM DISORDER:

• Drug treatments are often used to improve symptoms of ASD such as:
Overactivity
Stereotyped behaviors
Sleep disturbances
Tension
> SSRI’s tend to reduce repetitive behaviours and aggression and might improve social interactions in some
> Atypical antipsychotics are used to reduce repetitive and obsessive behaviours and can also improve self control
> Stimulants tend to be used to improve attention
> overall, these drugs can make it easier for individuals with ASD to participate in behavioural treatments and school
*Evidence for utility of the drugs is very mixed
• Psychosocial therapies:
Behavioral techniques and structured educational services are often used
> operant conditioning can reduce repetitive and ritualistic behaviours, aggression, and tantrums
> challenges that the child portrays will be targeted and materials that reduce distractions will be used
> parents are sometimes taught to implement these techniques at home, *importantly these techniques must be implementing consistently
> research has found improvements in cognitive skills and behavioural control among children who were treated with behavioural therapy applied both parents and
teacher *especially effected if applied at an early age
Behavioral treatment models are often based on applied behavior analysis
> using this, attempt to reinforce good behaviours and decrease undesirable
> early intensive behavioural interventions tend to be strongly recommended and they can dramatically improve developmental outcomes
>ex. Daily living skills, communication and social skills
> many options for treatment using this approach and no universal approach works since developmental levels and symptoms vary drastically among individuals with ASD
 ▫
INTELLECTUAL DEVELOPMENT DISORDER (INTELLECTUAL DISORDER)
• The DSM-5-TR classifies ID into 4 different levels based on severity:
Mild
> children and adults have limitations with academic or job-related skills, mature with social interactions, can care for themselves except for complex occasions like legal or
health decisions
> hold jobs that don’t require complex conceptual skills
Moderate
> children have language delays like using 4-10 words by the age of 3, physically clumsy, challenges dressing and feeding themselves, usually don’t achieve past 2nd grade
level in terms of academic levels
> adults can hold jobs that require elementary level of skills but might require lots of assistance, with significant training they are able to care for themselves like hygiene,
eating *social interactions ate often impaired due to communication issues
Severe
> Limited vocabulary and speak 2-3 word sentences
> as children, tend to show significant deficits with motor development, adults can feed themselves with spoon, can dress themselves if clothing is straightforward (less
buttons), cannot shop or cook for themselves
> some may be able to learn unskilled manual behaviour, but many are unable
> socially they lack awareness of risk and require significant support for all elements of daily living
Profound
> sensory and motor impairments that can prevent the functional use of objects and tend to limit participation in activities to watching
> socially they can understand simple and concrete instructions and gestures, but strong degree of dependence that is characteristic of profound intellectual disorders
where even into adulthood they are fully dependent on others for their physical care and safety
• Intelligence tests measure: individually given in order to figure out the intellectual functioning of an individual who is suspected of having and intellectual disorder
Verbal comprehension
Working memory
Perceptual reasoning
Quantitative reasoning
Abstract thought
Processing speed
> individuals with intellectual disorder typically have scores that are 2 standard deviations below the average IQ for the general pop
> most IQ assessments have an IQ of 100 and standard deviation of 15 so the IQ score would be 70 or below
DSM-5-TR deemphasizes IQ scores in diagnostic criteria and instead puts them in focus of the individuals level of adaptive functioning across conceptual, practical, and social
domains - this is because IQ scores can be misleading and misused
Prevalence: 1-3% of the population has an intellectual development disorder

BIOLOGICAL CAUSES OF INTELLECTUAL DEVELOPMENT DISORDER:

• Numerous biological factors can cause ID:
Chromosomal disorders
Gestational disorders
Exposure to toxins prenatally
Exposure to toxins in early childhood
Infections
Brain injury
Brain malformations
Metabolism problems
Seizure disorders
• Genetic Factors:
Approximately 300 genes are implicated in the development of ID
> these genes tend to lead to one or more of the deficits seen within ID
> families of children with ID tend to have high rates of intellectual issues including intellectual disorder and autism
Genetically transmitted metabolic disorders can lead to ID
1. fenal ketonuria (PKU)
> individuals who are effected can not metabolize phenylalanine (amino acid) a build up of this amino acid in the body can lead to brain damage, but children that receive
a diet free of this can score average levels on intelligence tests
> if left untreated, children with PKU typically have IQ scores below 50 and severe or profound intellectual disorder
2. tay sachs disease
>primarily occurs in jewish populations
> when an infected child is 3-6 months old, a degeneration of the nervous system starts and lead to mental and physical deterioration, typically die before age of 6
and no known use of treatment
• Many types of chromosomal disorders result in ID:
Down syndrome
> born with 23 pairs, 22 are called autosomes and the 23rd pair contains the sex chromosomes
> down syndrome occurs when chromosomes 21 is a triplicate instead of duplicate (trisomy 21) occurs is 1 in every 800
> severity level of intellectual disorder varies from mild to profound, the ability to care for self and keep a job is contingent on the degree of intellectual deficits and
the support they receive
>. Almost all individuals with down syndrome live past 40 years develop thinking and memory issues that are characteristic of Alzheimer’s disease and they lose the
ability to care for themselves
• Many types of chromosomal disorders result in ID:
Fragile X syndrome: risk of chromosomal abnormalities increasing with age of parents, older the parent is the more likely degeneration of chromosomes have occured
and the more likely the chromosomes have been damaged by toxins
> occurs when a tip of the X chromosome breaks off and this tends to affect males more as they don’t have a second X chromosome to balance the mutation
> severe to profound intellectual disorder and severe deficits in terms of interpersonal connections
 ▫
BIOLOGICAL CAUSES OF INTELLECTUAL DEVELOPMENT DISORDER CONT’D:
• Brain Damage During Gestation and Early Life:
Diseases that the mother contracts during pregnancy can impact the risk of offspring developing ID
> ex. During pregnancy, if the mother contracts rubella, syphilis or herpes there is a chance that damage to the fetus can lead to ID
Chronic maternal disorders (diabetes and high blood pressure) are associated with ID
> can have a strong impact on fetal nutrition and development and if the disorder is treated throughout pregnancy, risk to the fetus is quite low
Exposure to alcohol can lead to fetal alcohol syndrome (FAS)
> alcohol can pass through the placenta barrier and can be associated with still birth, miscarriage, low birth weight and prematurity
> children with fetal alcohol syndrome have a below average IQ of around 68, easily distracted, poor judgement, challenges understanding social cues
> As adolescents, academic functioning is usually between 2nd and 4th grade levels - they will often experience academic failure, substance abuse, challenges with
independent living and difficulty holding down job
> 2-15 children per 10 thousand have fetal alcohol syndrome and 3x this are born with alcohol related neurological and birth defects
• Brain Damage During Gestation and Early Life:
Severe head traumas can lead to ID (e.g. shaken baby syndrome - results in inter-cranial injuries and retinol hemorrhaging)
> babies heads are large and heavy and neck muscles are weak and cannot control head with shaking, quick movement can lead brains to bang against inside of skull and
lead to bruising - bleeding inside and around brain and behind eyes can lead to seizures, blindness, paralyses, intellectual disorders and sometimes death
> can occur with 1 shake
Exposure to toxic substances
> toxic substances like lead, mercury, arsenic
Accidents
> motor vehicle

SOCIOCULTURAL FACTORS:
• Low socioeconomic backgrounds are a risk factor for ID
> parents have also had ID and haven’t been able to get employment
> social disadvantages of poverty can also lead
> poor mothers are less likely to receive optimal prenatal care and higher risk of premature births
> children in low SES areas are at higher risk for lead exposure (older buildings have lead paint and can chip off)
> poor children less likely to have caregivers read to them and more likely to have parents less involved in their schooling

TREATMENTS OF INTELLECTUAL DEVELOPMENTAL DISORDER:

*interventions have to be comprehensive, intensive and long-lasting in order to be effective
• Drug therapy:
Medications can be used in order to:
• Reduce seizures
• Control aggressive behavior
• Control self-injurious behavior
• Improve mood
* neuroleptic medications can reduce anti-social and aggressive behaviour but come with neurological side effects leading to controversy
> atypical antipsychotic can reduce self-injurious and aggressive behaviour in adults without having significant neurological defects
> anti-depressant can reduce self-injurious behaviour and minimize depressive symptoms and improve sleep
• Behavioral Strategies:
Behavioral strategies that increase positive behaviors and reduce negative behaviors can be implemented by caregivers and teachers
Communication and social skills can be taught
> ex. Individuals may be taught to initial conversations by asking questions and learn to communicate what they wnat to say more effectively
> rewards might be given as they get closer to mastering a skill
> most behavioural methods focus on a comprehensive program that is reared towards maximizing an individuals ability to function in community instead of only focusing
on isolating skills
• Social Programs: focus on integrating child into mainstream as much as possible, and sometimes placing individual into group home that can provide comprehensive care
> the earlier the intervention, the greater likelihood of positive outcomes
Early Intervention Programs
> intensive 1 on 1 interventions that nurture the development of basic skills and ensure proper medical care, nutrition, and reduction in any social conditions that may
negativity impact child development
Mainstreaming
> providing as many opportunities for inclusion as possible for students with ID and special education needs
> many kids spend time in special education and receive training to learn critical skills and spend time in reg. Classrooms as well
> research has shown the students who are placed in mainstream perform as well or better than students in self-contained special education classrooms
> possibly due to higher expectations on academic achievement
> social outcomes: research shown better relationships, others show more stigma (research has been mixed)
Group homes
> many adults with ID live in group home, in these contexts they receive assistance with daily tasks as well as training in social and vocational skills
> work in workshop performing unskilled or semiskilled labour, but more are being mainstreamed into general workforce, primarily in service related jobs (ex. Bagger in
grocery store or in fast food restaurants)
 ▫
LEARNING, COMMUNICATION AND MOTOR DISORDERS: instead of having deficits in larger ray of skills, kids with this disorder have challenges with specific skills or
behaviours and these disorders are not a result from intellectual disability, developmental delay, neurological disorders or environmental factors like economic disadvantage
• severity ranges from mild to severe
Specific Learning Disorder
• Individuals who have specific learning disorder have performance in one or more academic domain that is significantly lower than expected for their age, level of
intelligence, or schooling.
Academic domains that are commonly affected:
• Reading
• Written expression
• Mathematics
> have unexpected low performance on standardized tests and these tests have to be administered individually and must be culturally and linguistically appropriate and
usually used amongst school aged individuals
> threshold for diagnosis is to some degree arbitrary but often 1-1.5 standard deviation below age based population means is used as cut off
• Dyslexia:
Difficulties in reading
Typically apparent by 4th grade
The most common specific learning disorder
> challenges: poor reading accuracy, reading comprehension weakness, and slow reading rate
> prevalence: around 7% children, more common among male
• Challenges in math include issues of understanding math terms, recognizing numerical symbols, counting
> around 1% of kids are effected
• Challenges in written expression
> encompasses weakness in spelling, grammar and punctuation, creating sentences and paragraphs
• Children with learning disorders:
Tend to struggle with low academic performance
They often must put in extremely high levels of effort in order to achieve average grades
• Because of the challenges they sometimes become
demoralized
disruptive
• if untreated, at high risk for dropping out of school
• Around 40% of these individuals will never finish high school
• Adults might have challenges getting and keeping a job and often avoid major work activities that require reading, writing, or arithmetic
• Emotional side effects might impact social relationships

COMMUNICATION DISORDERS:
• Communication disorders are characterized by persistent challenges in acquiring and using language and other forms of communication
• Common communication disorders include:
Language disorder
> includes challenges with spoken, written and sign language
> symptoms/challenges with grammar, vocabulary, narrative (knowing how to put stories together) and other pragmatic language skills
Speech sound disorder
> challenges with producing speech
> might not use speech sound in an appropriate way for their age or dialect
> They will sometimes substitute one sound for another (ex. Might use a T for K sound, or omit sounds like the final consonant at the end of words)
> words come out sounding like baby talk (wabbit)
> most children with this disorder improve significantly with treatment and shortens duration of disorder
Childhood-onset fluency (stuttering)
> children who stutter have challenges speaking fluently and evenly
> often voice frequent repetition of sounds like (I..I. I see him) some repeat whole phrases (other children are mean because of because of because of…)
> severity is variable and contingent on situation but tends to be worse when pressure to speak well (providing oral report)
> start gradually and typically before the age of 10
> prevalence 0.3-5% with around 2x prevalence among males
> approx. 80% of children recover on their own by 16, but some continue into adulthood
> can have significant negative impact on self-esteem and limit person’s activities and goals
Social communication disorder
> children have challenges using verbal and non-verbal communications in social interactions (Ex. Sharing info in a way appropriate for context)
> challenges altering the communication in order to match need of listener or conversation rules
> as a result, their social relationships and participate tend to be neg. Impacted
> diagnosis only given if communication issues are not better explained by ASD and so kids cannot have restricted, repetitive patterns of behaviour, activities or interest
for this diagnosis
 ▫
CAUSES OF LEARNING AND COMMUNICATION DISORDERS:
• Genetic factors:
Associated with all learning and communication disorders but there isn;t specific change responsible for specific disorders
> genetic abnormalities may explain many different learning disorders
• Abnormalities in brain structure and functioning:
> ex. Individuals with reading difficulties seem to have difficulties functioning in 3 different regions of the brain
>1st is broca’s area: involved in ability to analyze and articulate words
>2nd: parietotemporal region: requires for mapping visual perception of printed words onto the structure of language
>3rd: occipitotemporal region: requires for quick, automatic, fluent identification of words
> dyslexia: neuro imaging revealed low activity in the parietotemporal and occipitotemporal regions
Implicated in learning disorders
• Many environmental factors have been implicated: ex. Lead poisoning, sensory deprivation, birth defects and low socioeconomic status(create risk for damage of critical
neural regions, when enviornmentals offer few enriching opportinutiies for langauage skill development, they are less likely to overcome biological contributors to these
challenges

TREATMENT OF LEARNING AND COMMUNICATION DISORDERS:

• Treatment involves therapies that focus on building on the relevant skills
• In Alberta, Individualized Program Plans (sometimes referred to as Individual Educational Plan) are mandatory for children with learning disabilities and special needs
> These will detail the specific learning challenges, appropriate teaching methods and goals for academic year
> these are revised, contingent upon child’s progress (ex. A child with dyslexia might receive systematic instruction for word recognition from school and at home they
might practice with caregivers and potentially given computerized exercises for further learning
> programs have a positive impact on skill development among kids with learning disorders
> can change neuro functioning - in one study, kdis with dyslexia who received individuals tutoring for 1 year showed more activation in parietotemporal region and
occipitotemporal regions of the brain

MOTOR DISORDERS:
• There are 4 neurodevelopmental motor disorders:
Tourette’s Disorder
Persistent Motor or Vocal Tic Disorder
Stereotypic Movement Disorder
Developmental Coordination Disorder
• Tourette’s Disorder and Persistent Motor or Vocal Tic Disorder: comorbid with other psychological disorders (especially OCD, ADHD, and ASD - all have similar biological and
genetic underpinnings) - tourettes: when complex vocal tics are present, tends to be more debilitating and more comorbid with other disorders in comparison to persistant
motor or vocal tic disorder
Are both tic disorders
Involve motor tics and/or vocal tics
Tics are present for at least 12 months
• Critical difference:
Individuals with Persistent Motor or Vocal Tic Disorder only have motor OR vocal tics, not both
> Prevalence: around 1% for tics and 3-4% for persistent motor or vocal tic
> tics: sudden, recurring, non-rhythmic, motor movements or vocalization
> common vocal tics: throat clearing, grunting and sniffing
> individuals with tics disorder have multiple motor tics and at least 1 vocal
> around 1% of individuals with tourettes have a complex form of vocal tic that involves shouting or uttering socially inappropriate words or phrases
> often feel a tic happening and experience urge to tic before the tic occurs and the urge to tic is temporarily weakened by the tic behaviour
> frequency of tics increases when individuals are in high degree of stress
• Individuals with stereotypic movement disorder often engage in repetitive and apparently purposeless motor behavior such as:
Head shaking
Hair twirling
Body rocking
Head banging
Self-biting
> these behaviours are different than tics since the individual can continue to engage in them for long period
> present among individuals with other disorder (Ex. ASD, intellectual developmental disorder and ADHD)
• Tourette’s Disorder, Persistent Motor or Vocal Tic Disorder and Stereotypic Movement Disorder:
Usually begin in childhood and increase in adolescence and then decline throughout the adulthood year
Highly comorbid with OCD and share underlying causes of OCD as well
> all three, including OCD, tend to co-occur in families and all associated with dysfunction in the dopamine systems in regions of the brain critical for control of motor
behaviour (ex. Basal ganglia, frontal cortex and cerebrum)
• Tourette’s and persistent motor or vocal tic disorder all respond well to drugs that act on dopamine systems (Ex. Atypical antipsychotics)
All can be treated with habit reversal therapy (a form of behavioral therapy)
> triggers for and signs of tics coming on are identified, after they are taught to use competing behaviours (ex. Taught to squeeze hand when vocal tic is coming on or
taught to cross arms if hand flapping is coming on)
>tic awareness training and relaxation training are also used in behavioural therapy
• Developmental coordination disorder:
Fundamental deficits or delays in developing basic motor skills (e.g. sitting, running, writing)
Prevalence: 5-6% of children
More likely to impact boys that girls
> these deficits can’t be explained better by medical condition like muscular dystrophy
> developmental coordination disorder tends to be comorbid with ADHD and causes are not known
> best treatment approach: physical or occupational therapy
 ▫
MAJOR AND MILD NEUROCOGNITIVE DISORDERS: arise later in life and result from medical conditions or substance, or medication use that lead to impairment in cognition
> cognitive issues include memory deficit, perceptual disturbances, language disturbances, etc
• Major neurocognitive disorder (Major NCD):
Commonly known as dementia
Associated with significant difficulties:
• Remembering fundamental life facts
• In expression via language
• In carrying out simple everyday tasks
• major NCD usually occurs late in life, most common type is due to Alzheimers disease with a prevalence of around 5-10% of individuals over the age of 65
• prevalence increases with age (around 30% of individuals 85 or older have a major NCD)
• Mild NCD:
Mild version of neurocognitive disorder
characterized by cognitive declined from previous levels
No significant impairments yet in functioning
SYMPTOMS OF MAJOR NEUROCOGNITIVE DISORDER:
• Symptoms: both cognitive and emotional
Significant cognitive decline:
• Memory lapses
> very common, in early stages it is similar to what we experience (ex. Forgetting name of someone, forgetting why we went to a room) but the difference is that for them,
the memory doesn’t return spontaneously and might not respond to reminders
> individuals with mild neurocognitive disorder tend to repeat questions because they don’t remember asking them or the answer, they also frequently misplace items like their
wallet or keys
> as memory gets worse, might get angry when questions are asked or fabricate answers to hide memory loss
> as memory loss increases, they might become lost in familiar places, and eventually long term memory becomes impaired
> individuals tend to forget the order of events of lives (birth of children, marriage) eventually they are unable to remember life events and may not remember their own
name
• Aphasia: common, deterioration of language
> lot of difficulty with coming up with names of things or people and often come up with vague terms like thing to refer to objects or people to hide their inability to member
terms
> in advance stages, individuals might repeat what they hear (echolalia) or repeat sounds over and over (palilalia
• Apraxia: common, impaired ability to engage in common actions (waving or putting on pants), these aren’t caused by issues in motor functioning, in sensory function or
understanding what action needs to be done, just simply unable to do the actions requested or want to complete
• Agnosia: common, challenges in recognizing people or objects
> not be able to identify common objects (table), at first issues with recognizing friends or family become prominent, but overtime issues recognizing spouse or kids or even
reflection become common
• Loss of executive functions, most individuals with MCD will lose neuro functioning required for planning and for initiating and stopping complex behaviours (ex. Cooking dinner
bc of issues with timing and preparation
> deficits are associated with challenges of abstract thinking that are required in evaluating and responding appropriately in novel situations
Changes in emotional functioning and personality
• Declines in judgement
• Difficulties controlling impulses
> both of these might lead to shop lifting or exhibitionism
> sometimes they don’t recognize or admit to the acts which can lead to dangerous actions like driving when too cognitively impaired, then they experience anger or paranoia
in response to friends and family who try to limit their activities like driving and they view them as trying to inhibit their freedom, and also accuse others of stealing when
they misplaced their own items
> silent outbursts may occur and more common in the moderate to severe stages of MCD
• Depression is common as individuals recognize their declines in cognitive processing

TYPES OF MAJOR AND MILD NEUROCOGNITIVE DISORDER:

• DSM: recommends that the type of NCD is specified based upon the specific cause (medical or substance/medication-induced)
• The most common NCD worldwide: Alzheimer’s Disease and this accounts for about 2/3 of all cases of neurocognitive disorders
> prevalence of alzheimers diseases is increasing because of higher life expectancy around the world
> NCD can be caused by vascular disease (ex. Stroke, traumatic brain injury, progressive diseases like Parkinson’s or HIV) and also from chronic substance abuse

NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE:

• Individuals with NCD due to AD:
Can meet the criteria for major or mild NCD
Show significant declines in memory and learning
> individuals with AD have cognitive declines that start with difficulty forming recent memories and eventually impacts all domains of intellectual functioning
> around 2/3 of AD patients show agitation, apathy, dysphoria and irritability (difficult for caregivers to contend with)
> as AD progresses, individuals will sometimes violent and experience delusions and hallucinations
> early on-set progresses faster than late on-set and overall
AD is chronic and incurable
Typically begins after the age of 65
Typically individuals with AD die within 8-10 years of diagnosis typically as a result of physical decline or other independent diseases popular in older age
 ▫
Neurocognitive disorder due to Alzheimer’s disease cont’d:
• Brain abnormalities in AD:
Neurofibrillary tangles
> common in brain of individuals with AD, but rare in normal brains
> made of a protein called tau (these tangles prevent nutrients and critical supplies from moving through cells to the point that cells die
Beta-amyloid plaques
> neuro toxic and accumulate in spaces between cells within neural areas that are required for memory and cognition (ex. Hippocampus and amygdala)
• Brain abnormalities in AD:
Shrinking cortex
Enlargement of ventricles
*among individuals with Alzheimers disease, significant degree of cell death in cortex, this results in the shrinking cortex and significant increase in size of the ventricles

CAUSES OF AD (Alzheimer’s disease):

• Genetic factors play a significant role:
AD is highly heritable
> family history studies suggest around 24-49% of first degree relatives of individuals with AD will eventually develop AD
> twin studies support the role of genetic factors in the development of neurocognitive disorders
> concordance rates for all neurocognitive disorders in monozygotic is around 44% for men and 58% for women
> concordance rates for dizygotic twins is 25% for men and 45% for women
e4 version of the ApoE gene
> on chromosome 19 and regulates ApoE protein which is important for passing cholesterol through the blood and binds to beta amyloid protein
> ApoE gene has three versions
1 E2
2.. E3
3. E4
> individuals with an E4 allele from 1 parent have a 2-4x greater risk in developing AD
> individuals with E4 alleles from both parents, have 8-12x greater risk
> individuals with the E4 version, have reduced cortex and hippocampus volume even as children, as adults they tend to show more significant deficts and earlier onset of AD
Gene on chromosome 21
> individuals with down syndrome tend to be more likely to develop AD later on in comparison to others
> close to gene responsible for making the precursor of the amyloid protein and deficits in this gene might lead to an abnormal production of amyloid protein
• Neurotransmitters are impacted:
Individuals with AD show deficits in:
• Acetylcholine
>places strong role in memory
>deficits are significantly associated with degree of cognitive decline
> drugs that enhance acetylcholine can slow down progression of AD among some individuals
• Norepinephrine
• Serotonin
• Somatostatin
• Peptide Y

VASCULAR NEUROCOGNITIVE DISORDER:

• Vascular Neurocognitive Disorder:
Common type of NCD
Most prominent symptoms include significant declines in:
• Processing speed
• Executive functioning
• Attention
* individuals with NCD can meet the criteria for major or mild neurocognitive disorder, contingent upon symptom severity
For diagnosis, there must be evidence of cerebrovascular disease or a recent vascular event
• individuals at high risk of NCD are those who are over age 80, less educated and have diabetes
> this disease happens when the blood supply to regions of the brain are locked, can lead to tissue damage within the brain
> PET Scan or MRI can confirm disease
• In terms of a stroke (sudden damage to a neural region because of blockage of blood or hemorrhaging, NCD can occur after just 1 stroke or after accumluation of many
small strokes
> causes of strokes: high blood pressure, accumulation of fatty deposits in arteries, complications of diseases which inflame the brain or traumatic brain injuries
> around 25% of people with strokes will develop cognitive deficits that will be severe enough to be classified as NCD

NEUROCOGNITIVE DISORDERS ASSOCIATED WITH OTHER MEDICAL CONDITION:

• minor and major NCD can be caused by cruz felt jakob disease, brain tumours, endocrine conditions (like hypothyroidism), nutritional conditions (like vitamin b12 defiency),
infections like syphilis), and other neurological diseases like MS, also chronic and heavy use of alcohol, inhalants and sedatives can also cause brain damage which lead to
NCD
• Many medical conditions can lead to NCDs:
Lewy body disease
> progressive cognitive impairments, motor dysfunction, sleep dysfunction and suppressive symptoms, vision hallucinations and delusions
> overlap with cognitive symptoms with lewy body dementia and parkinsons , this includes progressive issues in terms of executive functioning, visual spacial abnormalities and
memory deficits

CONTINUE TO NEXT PAGE

 ▫
Parkinson’s disease
> degenerative brain disorder
> prevalence around 0.3% of individuals in the general population , and 2% individuals over 65
> mohammad ali and michael j fox well-known examples
> primary symptoms: tremors, muscle rigidity, inability to initiate movements (symptoms are caused by death of brain cells responsible for producing dopamine)
> around 75% of individuals with Parkinson’s disease will go on to develop NCD
Human Immunodeficiency Virus (HIV)
> causes AIDS, can cause mild or major NC
> around 50% of HIV patients show neurocognitive dysfunction (recent of chronic low level inflammation due to HIV)
> symptoms: impairment in terms of memory and concentration, lowing of processing speed, difficulty with emotion (manifests as depression and apathy), motor deficits
(include weakness in hands and legs, lose of balance and lack of coordination)
> as mental processing slows down, hard time following convos and take long time completing simple tasks, as a result, often withdrawal socially
> As NCD progresses, speech becomes significantly impaired, individuals are eventually confined to bed and indifferent in environment
> as antiretroviral therapy becomes widely used, new onset of HIV related NCD have declined
Huntington’s disease
> rare genetic disorder, effects individuals around the ages of 25 and 55
> will eventually develop major NCD and chorea (consists of irregular jerks, twitches, and grimaces)
> transmitted by 1 single dominant gene on chromosome 4 (if a parent has the gene, children have a 50% chance of inheriting this disorder)
> impacts numerous nerotransmitters
> the specific changes associated with NCD and chorea remain unclear
Traumatic Brain Injury
> associated with development of NCD, the TBI that lead to NCDare falls, motor vehicle accidents, being struck with an object, violence and bike accidents
> individuals with NCD resulting from TBI often experience cognitive declines and impairments in social cognition, moral judgement and memory
> disruption in emotional function is common: personality changes and irritability
> sometimes experience neurological symptoms like gate and speech abnormalities (depression is also very commonly comorbid)

THE IMPACT OF GENDER, CULTURE, AND EDUCATION ON NEUROCOGNITIVE DISORDER:

Women tend to be more likely to develop AD and experience more cognitive impairment in comparison to men (reason is unclear
> these sex differences tend to increase as individuals age,might be due to the fact that women tend to live longer than men and live long enough to develop age-related
neurocognitive disorders
• Individuals with NCD who have less education show more neural deterioration
> may be that because of lower education they have lower SES which might impact nutrition and overall health
>might be that education and cognitive activity throughout life span seem to increase neuralresources that can delay the development of neurocognitive disorders
>cultural differences : probability a person will be institutionalized instead of being cared for at home is different across cultures (tends to be higher across white north
americans in comparison to native or latin X groups
> European Americans might have more financial resources for the prevision of care and asian and latin X cultures tend to put on high premium among caring for family
members

TREATMENT FOR AND PREVENTION OF NEUROCOGNITIVE DISORDER:

• Drugs that are used to treat the cognitive symptoms of NCD:
Drugs that prevent the breakdown of acetylcholine
Drugs that regulate the activity of glutamate
> in addition, anti-depressants and anti-anxiety drugs can help treat emotional symptoms of NCD and anti-psychotic drugs can help treat agitation, hallucinations and delusions
• Behavioral therapies are useful
> can help control angry outbursts and emotional instability
> family members who are given training in these techniques can help them in terms of taking care of patients at home
> can also reduce stress and emotional distress among family caregivers and tend to be associated with fewer behavioural issues among the family member affected
>Aerobic exercises and physical activity tends to be protective against declines in terms of cognition
> study was done of many hundred elderly nuns at schools sisters, found that nuns who enter old age with more intellectual strengths were less likely to have severe NCD
even when their brains had many neurofibrillary tangles and plaques
> linguistic skills revealed journal writings in their 20s tended to be a significant predictor of the risk of developing NCD later in life
DELIRIUM:
• Delirium is associated with:
Disorientation
Recent memory loss
Difficulty with attention
Disrupted sleep-wake cycles
Incoherent speech
Delusions
Hallucinations
> a person with delirium has a hard time focusing, sustaining or shifting attention
> signs usually happen within a few hours or days
> Sundowning: individuals tend to fluctuate their symptoms within the course of the day and often become worse at night
> duration: rarely longer than a month
> individuals who are in a state of delirium tend to be agitated and frightened
> likelihood increases with age around 11-42% of patients who are 65 or older in hospitals have delirium
CAUSES OF DELIRIUM:
• Neurocognitive disorder is a strong predictor of delirium
> individuals with a NCD are 5x more likely to develop delirium
• Many medical disorders are associated with a high risk of delirium
> stroke, congestive heart failure, infectious diseases, HIV, high fever
• Delirium can be caused when the level of acetylcholine in the brain is disrupted by a medical condition, toxic substance, or drug

TREATMENT FOR DELIRIUM:

• If a medical condition is the cause for the delirium, the medical condition must be treated
• Antipsychotic medications:
can be used to treat confusion and agitation
•Nursing Care:
can be necessary to monitor an individual’s state (helpful to prevent patients from ripping out IV tubes, tripping, or wandering off
> restraints for these patients are sometimes necessary
> providing a reinsuring atmosphere with providing personal belongings (pictures) can help patients feel more in control
>psychosocial treatments that improve sleep and encourage mobility can also be useful
> delirium is a common problem in older adult hospital patients

How biological, environmental and psychosocial factors impact

neurodevelopmental and neurocognitive disorders
 changes in cognitive processes with age:
• Some cognitive processes show decline with age, while word knowledge
increases with age
• as brains age into middle and older adult, tend to show decreases in size
and eficiency
• most people show reductions in terms of speed of processing
information and in working memory
• most people can use accumulated expertise in order to compensate
for the declines
• for some people, deterioration in the brain is more severe which can lead
to sigificant challenges in processing information and functioning in daily
lives
• Brain dysfunction has to be understood in the context of what is
functional for the people in those stages of life?
• Developmental psychopathologists focus on functional and dysfunctional
development in children
• geroplychologists focus on functional and dysfunctional changes in older age
• All future disorders and associated with dysfunction in the brain and are
classified in the DSM and neurodevelopment disorders (arise in childhood,
ex. ADHD, Austism, intellectual disabilities and learning communication and
motor disorders) and neurocognitive disorder(arise in older age, ex. Major
and minor neurocogntive disorders and delirium_

Wrote book of her life with autism and how she thinks

Sean case study:

• most elementary school kids his age can sit for a logn duration of
time and play games that take patience and time that can help inhibit
their impulses

DSM-5 Criteria for Attention-deficit/hyperactivity disorder

DSM-5-TR criteria for delirium
• delirium is often a sign of a very serious medical condition
• When the underlying medical condition is treated, delirium is
reversible and temporary
• The longer the delirium continues, the more likely it is that the
individual will suffer permanent brain damage
Case study Robyn
• robyn shows communication difficulties which is common among kids with
ASD
• Instead of generating her own words, she echoes what she already heard
which is called echolalia

DSM-5 for diagnostic criteria for autism spectrum disorder

Scans such as these help researchers to understand the brain activity of

autism spectrum disorder
• when children with ASD perform tasks that require perception, facial
expressions, empathy or joined attention, it is found that they show
abnormal functioning in the neural areas that are usually recruited for
these taks
> ex. When they are shown pictures of faces, show less activation of
the brain that is typically recruited for facial perception known as the
fusiform gyrus
• adults with ASD tend to show atypical patterns of neural activation when
they hear their own name
• Challenges in terms of understanding and perceiving facial expressions
and verbal communciation seems to signifcantly contribute to the deficits
in social interactions

DSM-5-TR. criteria for intellectual developmental disorder (intellectual disorder)

• significant deficits are present in a persons life functioning and intellectual
abilities
• DSM requires that the deficits are confirmed using formal and clinical
assessments like IQ tests
• The deficits and functioning of daily living make it so the personal cannot
live alone without support
• Overall, this disorder, 3 main domains are impacted
• 1. Conceptual domain: deficits in language, reasoning, memory,
problem-solving
• 2. Social domain: difficulty with interpersonal communication, the
ability to make and keep friends, and challenges regulating reactions
• 3. Practical domain: deficits in terms of managing personal care like
hygiene, cooking, cleaning, issues with transportation and holding jobs
 Abel doris case study

DSM-5-TR criteria for specific learning disorder

Diagnostic features of communication disorders

Criteria for motor disorders

DSM-5-TR criteria for major neurocognitive disorder

Neurofibrillary tangles and beta-amyloid plaques in Alzheimer’s disease
• protein deposits up and cause neurofibrillary tangles and beta-amyloid
plaques in neurons in the brain of people with Alzheimer’s disease

First discovered by alois alzheimer in 1906 in a 51 year old patient

• noticed she had severe memory loss and disorientation and after her death
at 55, the autopsy revealed that the filaments of nerve cells within her
brain were tangled and twisted

Cortical regions in Alzheimers disease, Cell death causes shrinkage of cortical

regions in the brains of people with advanced disease (left; compare to
healthy brain on right)

Among individuals with alzheimers disease, the cells start loosing dendrites
(branches that connect 1 cell to others)
• all the brain abnormalities including neurofibrillary tangles, beta amyloid
plaques, shrinking of the cortex, enlargement of the ventricles and the loss
of dendrites are associated with traumatic memory loss and inability in
engaging in daily activities and inability to care for self

Case study 41 year old factory worker LeLand

• showed changes in both cognitive and emotional function
• Although his symptoms seems to subside after numerous
months, many individuals with moderate to severe brain
injuries will never fully recover