PSY 2414 Abnormal Psychology (GUARANTEED PASS) Notes | (Download To Score A)

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Abnormal Psychology Chapter 1: Introduction and Methods of Research 4 Definitions (p. 4-6) 4 How Do We Define Abnormal Behavior? (p. 6-10) 4 Historical Perspectives on Abnormal Behavior (p. 10-19)... 4 Research Methods in Abnormal Psychology (p. 19-32) 6 Chapter 2: Contemporary Perspectives on Abnormal Behavior 7 The Biological Perspective (p. 38-45) 7 The Psychological Perspective (p. 45-60) 10 The Sociocultural Perspective (p. 60-63) 13 The Biopsychosocial Perspective (p. 63-66) 14 Chapter 3: Classification and Assessment of Abnormal Behavior 14 How Are Abnormal Behavior Patterns Classified? (p. 70-77) 14 Standards of Assessment (p. 77-80) 16 Methods of Assessment (p. 80-99) 16 Sociocultural and Ethnic Factors in Assessment (p. 99-100) 21 Chapter 4: Methods of Treatment 21 Psychotherapy (p. 104-125) 22 Biomedical Therapies (p. 126-130) 25 Hospitalization and Community-Based Care 27 Chapter 5: Stress, Psychological Factors, and Health 28 Adjustment Disorders (p. 141-143) 28 Chapter 6: Anxiety Disorder 29 Overview of Anxiety Disorders (p. 171-172) 29 Panic Disorder (p. 172 - 179) 29 Phobic Disorders (p. 179-193) 31 Obsessive-Compulsive Disorder (p. 194-198) 32 Generalized Anxiety Disorder (p. 198-200) 33 Acute Stress Disorder and Posttraumatic Stress Disorder (p. 200-204)34 Ethnic Differences in Anxiety Disorders (p. 204-205) 35 Chapter 8: Mood Disorders and Suicide 35 Types of Mood Disorders (p. 248-259) 35 Causal Factors in Depressive Disorders (p. 259-269) 38 Causal Factors in Bipolar Disorders (p. 269-270) 40 Treatment of Mood Disorders (p. 270-278) 40 Suicide (p. 278-284) 41 Chapter 10: Eating Disorders 42 Eating Disorders (332-342) 42 Chapter 12: Schizophrenia and Other Psychotic Disorders 45 Schizophrenia (p. 397-426) 45 Subtypes of Schizophrenia 47 Theoretical Perspectives 48 Treatment Options 50 Other Psychotic Disorders (p. 426-429) 51 Chapter 13: Personality Disorders and Impulse Control Disorders 52 Types of Personality Disorders (p. 435-454) 52 Theoretical Perspectives (p. 454-463) 55 Treatment of Personality Disorders (p. 463-465) 57 Impulse Control Disorders (p. 465-469) 58 Chapter 14: Abnormal Behavior in Childhood and Adolescence58 Normal and Abnormal Behavior in Childhood and Adolescence (p. 475-478) 58 Pervasive Developmental Disorders (p. 478-485) 59 Mental Retardation (p. 485-489) 61 Learning Disorders (p. 489-492) 64 Communication Disorders (p. 492-493) 64 Attention-Deficit and Disruptive Behavior Disorders (p. 493-499) 65 Childhood Anxiety and Depression (p. 499-506) 67 Elimination Disorders (p. 506-509) 69 Appendix 71 Anxiety Disorders 71 Mood Disorders 73 Eating Disorders 74 Schizophrenia 75 Personality Disorders 76 Childhood and Adolescence 77 Chapter 1: Introduction and Methods of Research Definitions (p. 4-6) • Abnormal psychology is the branch of psychology that studies abnormal behavior, and how to help people affected by psychological disorders • A psychological disorder is an abnormal pattern which causes both emotional distress and impaired functionality • Itʼs noteworthy that the term psychological disorder is used, as opposed to the term mental illness, which is derived from the medical model perspective • The surgeon general points out a few things about mental health: • It is the complex interaction of brain and environment • Effective treatments exist for most mental disorders, which often involve different integrated therapies • Progress has been slow, because we are still working out underlying causes • Although 15% of Americans receive help, many more need • Mental health problems are better understood after context is taken into account How Do We Define Abnormal Behavior? (p. 6-10) • There are a few critera for determining abnormality: 1. This is an unusual occurrence 2. It deviates from the social norm • Itʼs worth remembering that differenct cultures have different definitions of mental health and illness 3. It involves a faulty perception of reality 4. It elicits significant personal distress 5. It involves maladaptive behavior 6. Itʼs potentially dangerous • Abnormal patterns express themselves differently in different cultures • Also, different cultures experience emotions differently Historical Perspectives on Abnormal Behavior (p. 10-19) • Demonological Model • Prehistoric ancestors seemed to think that abnormal behavior was caused by the inhabitation of evil spirits which would be removed through trephination • But at the same time, trephination may merely have been a surgery to remove shattered pieces of bone or blood clot from a head injury • This view remained prominent until the Age of Enlightenment • Origins of Medical Model in the “Ill Humor” concept • Philosopher/physicians like Hippocrates and Galen developed the humor model, which is like a predecessor for the medical model. It can be summarized as such: Humor Word for Excess Behavioral Results Phelgm Phlegmatic Lethargy Blood Sanguine Optimism Humor Word for Excess Behavioral Results Yellow bile Bilious/choleric Irritation Black bile Melancholy Depression • They also classified abnormal behavior: • Melancholia: excessive depression • Phrenitis: bizarre schizophrenic behavior • Mania: exceptional excitement • Medieval Times • This era went back to the “doctrine of posession” • The treatment of choice was exorcism • Witchcraft • The 15th to 17th centuries changed the focus from demonic possession to accusation of witchcraft • Its “diagnostic tests” were torture • Asylums • At the same time, there was a movement in England to look at physical causes of disorders • Asylums were built to care for the insane, but conditions were appalling • Some were even public spectacles • The Reform Movement/Moral Therapy • Jean-Baptiste Pussin and Philippe Pinel began the modern era of treatment in the late 18th century • They tried to treat mental disorder as an illness, not contain it like a threat to society • This sparked efforts of moral therapy where harsh practices ended and humane treatment began • In England and America, reformers such as William Tuke, Dorothea Dix and Benjamin Rush followed suit • Late 19th Century • This was a step backwards as mental institutions grew, but only covered custodial care • They aimed to restrain patients, not treat them • Outpatienting • In 1963, Congress established a nationwide system of community health centers to help patients leave the hospital • This, combined with new medications helped them return to society Contemporary Perspectives on Abnormal Behavior • Biological Perspective: • Wilhelm Griesinger argued that abnormal behavior comes from disease in the brain • Emil Kraepelin wrote an influential textbook fleshing out the medical model • He specified two main groups of mental disorders: • Dementia praecox (schizophrenia) - caused by a body chemical imbalance • Manic-depressive psychosis (bipolar disorder) - caused by an abnormality in the bodyʼs metabolism • According to the medical model, people behaving abnormally suffer from a mental illness which can be classified according to its distincitve causes and symptoms • Itʼs not necessarily biological • The medical model gained significant ground when syphilis was proven to lead to genral paresis • Thank goodness for syphilis • It is noteworthy that much of the terminology used now has been “medicalized” • Psychological Perspective: • Jean Martin Charcot used hypnosis to experiment with hysteria, showing that much of the disorder was not physical in nature • Joseph Breuer used hypnosis to treat a famous patient, Anna O. • Freud found similar uses in hypnosis, and further developed the psychodynamic model • At the time, emphasis was placed on catharsis, but the underlying point still stands • Sociocultural Perspective • Many problems come from environmental sources • Biopsychosocial Perspective • The integrative model that looks at interactions between the sources, as well as the sources themselves Research Methods in Abnormal Psychology (p. 19-32) • We try to perform research according to the scientific method, a systematic method of conducting research where theories are examined in light of evidence • A theory is a formulation of the relationships underlying observed events • We try and be as critical as possible by making our explanations as neutral as possible • Ideally, these theories also help predict future data, and control present behavior • The scientific method works as follows: 1. Formulate a research question 2. Frame the research question in the form of a hypothesis, or testable assumption 3. Test the hypotheses 4. Draw conclusions about the hypothesis Ethics • Ethical principles are “designed to promote the dignity of the individual, protect human welfare, and preserve scientific integrity” • In short, the psychologist may not inflict harm upon the subject/client • As such, experiments must be vetted through IRBs • They rely on two factors, among others: • Informed consent: people must be able to make a free, educated choice to participate in this study, and continue to participate in it • Confidentiality: the subjectʼs identity is secured Forms of Study: • Naturalistic observation • Correlational method • Longitudinal study • Experimental method • Iʼm assuming knowledge of this section. Here are the vocabulary words from the section: • Independent variables • Dependent variables • Experimental/control groups • Random assignment vs selection factors • Blind/double blind experiments • Placebo and placebo effects • Internal validity vs. confounds • External validity • Construct validity • We can never be absolutely certain about the construct validity of research, because weʼre never absolutely certain about the current theories • Epidemological studies • Examining the rates of occurrence of abnormal behavior in various settings and population groups • Survey method • Doing epidemological studyign through questionnaires • Incidence: the number of new cases • Prevalence: the overall number of cases • It relies on random sampling for its generalizability • Kinship studies • Genotype vs. phenotype • The first diagnosis is called an index case, or proband • This is relevant because the distribution of disorders in the family relative to the proband will help determine if it is genetically linked • A concordance rate refers to the percentage of cases in which both twins have the same trait or disorder • Adoptee studies • Case studies • Single-case experimental design • Often uses the reversal design, where A-B-A-B phases are enacted Chapter 2: Contemporary Perspectives on Abnormal Behavior The Biological Perspective (p. 38-45) • The best thing to do here is to memorize the diagram on p 39. Parts of the cell include: • Neurons, the messenger cells of the body • Dendrites, the short projections from the body which receive the messages • Axons, the trunklike projections which send messages • Most axons have a myelin sheath to insulate it and speed up the connection • Axon terminals, which connect to the dendrite • Neurotransmitters, the chemical substances which purvey the message • Receptor site, the area where the receiving neuron collects the neurotransmitters • Usually, only the correct neurotransmitter is able to activate any given receptor • Psychiatric drugs work by affecting the availability of neurotransmitters • Synapses, the space between the two neurons where the neurotransmitters travel • Neurotransmitters which arenʼt accepted are either metabolized and removed by enzymes, or reabsorbed back to the axon terminal (reuptake) to prevent more firing • Key neurotransmitters inclule: • Acetylcholine (ACh) which controls muscle contractions and memory formation • Dopamine, which regulates muscle contractions, learning, memory and emotions • Norepinephrine, which involves learning and memory • Serotonin, which regulates mood, satiety and sleep Nervous System • There are two parts of the nervous system: • Central Nervous System (CNS): the spinal chord and brain • Peripheral Nervous System (PNS): everything else The Brain • See the diagrams on p. 42 • Here are the parts of the brain: • Hindbrain: • Medulla - life-support functions, like breathing and heartbeat • Pons - information about body movement, attention, sleep and respiration • Cerebellum - balance and motor coordination • Midbrain: • Reticular formation - the cluster of neurons that carry information from the hindbrain to the forebrain • Reticular activating system (RAS) - a network of neurons that carry information, that also plays a role in regulating states of arousal, from sleep to attention • Depressant drugs like alcohol dampen RAS activity • Forebrain: • Limbic system - critical to emotional processing and memory • Thalamus - the tip of the RAS that also does its jobs • Hypothalamus - higher bodily functions, like body temperature, reproductive processes, emotional and motivational states • Basal ganglia - important for postural movements and coordination • Cerebrum - higher mental functions, like thinking and problem solving • Has ridges to give it more surface area. This areaʼs called the cerebral cortex • Cerebral Cortex: • Divided into hemispheres • Occipital lobe is involved in processing visual stimuli • Temporal lobe is involved in processing auditory stimuli • Parietal lobe is involved in processing touch, temperature and pain • Sensory area is involved in processing sensation from the skin • The motor area/motor cortex of the frontal lobe is involved in controlling muscular responses • The prefrontal cortex is involved in regulating higher mental functions Peripheral Nervous System • Broken down into two subsystems: • Somatic nervous system - transmits messages from sensory organs to the brain for processing, and from the brain to the muscles for action • Autonomic nervous system - used for emotional processing, involuntary processes, and states of arousal • Sympathetic nervous system - activity leads to heightened arousal • Parasympathetic nervous system - activity leads to declining arousal • These systems work against each other, affecting heart rate, breathing rate, digestion, etc • For some disorders, like Alzheimerʼs, this method works wonders • On the other hand, most disorders involve environmental factors as well • But in the end, we can at least have these four things to say about genetics: 1. Genes do not dictate behavioral outcomes 2. Genetic factors create predisposition - not certainty 3. Multigenic determinism affects psychological disorders 4. Genetic factors and environmental influence interact with each other in shaping our personalities and determining our vulnerability to a range of psychological disorders The Psychological Perspective (p. 45-60) Psychodynamic Theory • Freudʼs psychoanalytic theory views personality as being influenced by the interplay of conflicting forces within the individual • Abnormal behavior or psychosis represents “symptoms” of these dynamic struggles - which often stem from childhood - taking place within the unconscious mind which interfere with reality • He emphasizes the conscious, preconscious and unconscious as well as the place that the id, ego and superego take place within it (see diagram) • The unconscious is where the illogical and socially unacceptable parts of the mind stay hidden, while still influencing our behavior • The id begins at birth and operates according to the pleasure principle of instant gratification • During the first year of life, delay of gratification becomes apparent, and the ego develops to organize reasonable coping mechanisms • As such, the ego operates along the reality principle • Its main job is to be rational, negotiating and capable of making decisions • The superego develops as moral standards are internalized • When the id and superego conflict, the ego activates different defense mechanisms to relieve the psychic tension which ensues • When even they donʼt help, or they become maladaptive, behavioral problems result • Major defense mechanisms include: • Repression - expulsion from awareness of unacceptable ideas or motives • Regression - the return of behavior that is typical of earlier stages of development • Displacement - the transfer of unacceptable impulses away from their original objects to safer/less threatening objects • Denial - refusal to recognize a threatening impulse or desire • Reaction formation - behaving in a way that is the opposite of oneʼs true wishes to keep these repressed • Rationalization - the use of self-justification to explain away unacceptable behavior • Projection - imposing oneʼs own impulses onto another person • Sublimation - the channeling of unacceptable impulses into socially constructive pursuits • In order to ease the psychic tension, Freud would aim to uncover the source of the tension in order to resolve it • Children develop through psychosexual phases which are: • Oral • Anal • Phallic • Latent • Genital • During these stages, the libido or sexual energy focuses on certain erogenous zones, or areas of growth • If there is an area where people fail, they become fixated on it and cannot move on • See slides for details • There were other theorists as well • Carl Jung made a spin-off called analytical psychology which focused on the need for self-awareness and self-direction • He believed in a “collective unconscious” which spawns certain archetypes which we use to reflect on the history of our species • Alfred Adler focused on the inferiority complex in his individual psychology • He also spoke of the creative self, where each person has their own unique concept of how to fulfill their potential • Karen Horney stressed the importance of parent-child relationships • They could end in developing a basic anxiety or basic hostility towards the world • More recently, there is a greater emphasis on the conscious self, and less on sexual instinct • Heinz Hartmann even termed the new movement ego psychology • Erik Erikson focused on psychosocial development in the light of facing challenges at different stages in life • Margaret Mahler brought about object-relations theory which suggested that we introject our parents into own personalities and that by dissecting this introjection, we learn about how we approach the world • According to Freud, mental health is the result of psychodynamic balance • Psychological disorders originate in childhood and are buried in the depths of the unconscious • When the urges of the id spill forth, psychosis results • Mental health is the abilities to love and be productive • Others also emphasized the importance of developing a differentiated self • Psychodynamic models are useful for introducing the fact that our knowledge of ourself is limited • On the other hand, his notion of childhood sexualityʼs controversial and overstated • Also, his theory does not work according to the scientific method • While the theory had major impact in the field of psychology, its influence is waning Learning Models • After the inexactitude of psychoanalysis and the subconscious, the field swung in the total opposite direction, with behaviorism, which defines psychology as the study of only observable behavior • From the behaviorist perspective, abnormal behavior is the acquisition of maladaptive behaviors • Meaning, whereas psychodynamics and the medical model consider abnormal behavior symptomatic of an underlying issue, behaviorism considers the abnormal behavior itself the issue • Major names are Ivan Pavlov, John B Watson and B F Skinner • Pavlov did the dog salivating experiment and invented classical conditioning • Watson tested it on humans with the “little Albert” experiment • Skinner did the operant conditioning experiment • Vocabulary words include: • Positive vs. Negative reinforcers • Primary vs. Secondary reinforcers • Punishment • Social-cognitive theory is a learning-based theory which emphasizes modeling, or observational learning, and also incorporates roles for cognitive variables in determining behavior • Major names are Albert Bandura, Julian Rotter and Walter Mischel • It also emphasizes the fact that people impact their environment the same way their environment impacts them • They also discuss that expectancies, beliefs about expected outcomes, should be taken into account as well • Learning theory led to behavior modification therapy where principles of learning are used to affect behavior • Itʼs very useful in improving childrenʼs behavior • At the same time, behaviorism is criticized for being too mechanistic, not looking into the human experience enough, which should be taken into account because it ultimately affects behavior Humanistic Models • Carl Rogers and Abraham Maslow believed that people have an internal, subjective experience of the world that must be discovered • Abnormal behavior comes from distorted views of the self • Maslow proposed the hierarchy of needs • Psychologists should show unconditional positive regard if parents have not • Conditional positive regard leads to children developing conditions of worth, leading to anxiety • They should aim for a process of self-discovery and acceptance • Self-actualization is the tendency to strive to become all one is capable of being • Often, a distorted self-concept leads to anxiety in facing an insurmountable task • This will bridle the authentic self • People hurt others when they feel they must choose between what the others want and their authentic selves • This theory led to client-centered therapy or person-centered therapy • Strengths: • Focus on conscious experience, self-discovery and self-acceptance • Brought about concepts of free choice, inherent goodness, personal responsibility and authenticity • Weaknesses: • Not scientific • Often yields circular explanations for behavior Cognitive Models • Cognitive theory studies the thoughts, beliefs, expectations and attitudes that accompany/underlie behavior • Major names include Albert Ellis and Aaron Beck • It often uses computer-related metaphors for information processing: • Storage • Memory • Manipulation • Retrieval • Output • Abnormal behavior is a result of a glitch in the information processing called a cognitive distortion • Similar to what was said above, social-cognitive theorists focus on the way social information is encoded • Ellis emphasized that troubling events themselves do not lead to being disturbed, but rather how they are perceived and interpreted. He called it the ABC approach: • Activating event => Belief => Consequences • Ellis used Rational Emotive Behavior Therapy (REBT) to help his clients • It would dissect peopleʼs beliefs and allow them to realize which ones are maladaptive, or incorrect • Beck believed there were four basic types of cognitive distortions: • Selective abstraction - focusing exclusively on the negative parts of an experience • Overgeneralization - taking a few isolated experiences as indications of a greater rule • Magnification - blowing an event out of proportion • Absolutist thinking - looking at the world in black and white • Beckʼs model of therapy is called cognitive therapy • Eventually it merged with learning therapy to make the popular therapy of today, cognitive-behavioral therapy (CBT) • Itʼs especially effective against emotional disorders, like anxiety and depression The Sociocultural Perspective (p. 60-63) • This perspective takes society into account • Some, like Thomas Szasz, take it to such an extreme, they argue that there is no such thing as abnormal behavior, and rather itʼs just a societal condemnation of deviating from the norm • Everyone agrees that SES should be taken into account • Along these lines, traditionally disadvantaged groups (blacks and Hispanics) have as many incidents of psychological disorder as whites, but they usually last much longer because they go improperly treated • Native Americans have the highest rate of mental disorder • Asians show lower rates • People from lower incomes tend to be institutionalized more. But this is a controversial fact. There are two explanations: • Social causation model: social stressors like poverty bring about more severe psychological disorders • Downward drift hypothesis: psychological disorders lead to SES plummeting • Some data lean in favor of the social causation model The Biopsychosocial Perspective (p. 63-66) • The diathesis-stress model combines all the other perspectives • People have diatheses, or vulnerabilities, which activate once stressors reach a certain threshold • A diathesis can be biological, like genetics, or psychological, like personality or cognitive beliefs • The complexity of this model is both its strength and weakness Chapter 3: Classification and Assessment of Abnormal Behavior How Are Abnormal Behavior Patterns Classified? (p. 70-77) • In the 19th century, Emil Kraepelin began developing a comprehensive model of classification • In 1952, the American Psychiatric Association continued his work with the Diagnostic and Statistical Manual of Mental Disorders (DSM) • By now itʼs up to the DSM IV-TR (text revision) • The World Health Organization has its own version called the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) which is mainly used for compiling statistics • But itʼs made to be compatible with the DSM • Because itʼs based off of the medical model, abnormal behavior is classified as “mental disorders”, involving: • Emotional distress • Significantly impaired functioning • Behavior that places people at risk • The DSM is descriptive, not explanatory. Itʼs used only to diagnose • It is comprised of five axes: • Axis I: clinical disorders and other conditions that may be a focus of clinical attention • These are the clinical syndromes which are not permanent, and therefore treatable • Ex. Mood disorders, anxiety disorders, etc. • It also includes other conditions that may be a focus of clinical attention • Ex. Academic, vocational or social problems, psychological factors which will affect medical conditions • Axis II: personality disorders and mental retardation • These are enduring and rigid patterns of maladaptive behavior that are generally considered beyond treatment • They can undergo therapy to minimize their effects, however • Axis III: general medical conditions • Only the ones useful for the understanding/treatment of the mental disorder • Axis IV: psychosocial and environmental problems • These are potential stressors • Ex. Problems with primary support group, social environment, education, occupation, housing, economic status, access to services, etc. • Axis V: Global Assessment of Functioning (GAF) • This is a subjective rating of the current level of independent functioning • Some clinicians also take the potential GAF to set a goal to aim for • Thereʼs also a childrenʼs GAF (CGAF) • Culture-bound syndromes occur in some cultures, but are rare in others. For example: • TKS: an Asian excessive fear of offending others • Anorexia and dissociative identity disorder • See table 3.6 on page 76 for other examples • Strengths: • Classification is the core of science • It makes a shorthand to allow professionals to communicate more efficiently • It organizes research • Allows multiple diagnoses • Insurances use it as a reference guide • It helps identify populations with similar patterns of abnormal behavior • It is both very reliable and valid • It even usually has predictive validity • Its greatest advantage is its designation of specific diagnostic criteria, and ways to identify them • The multiaxal system integrates many different spheres of information and paints a full picture of the patient • Weaknesses: • It relies very strongly on the medical model • The validity of axes II and V have been questioned • Some feel it should be more sensitive to diversity • But the latest edition has placed a greater emphasis • Despite the way itʼs used as the bible of defining mental health, itʼs still in need of tweaking • Itʼs too focused on the binary of “disorder” and not the many shades of gray which may exist • For example, anxiety and depression are normal emotions taken to an extreme, yet the medicalized DSM gives off the impression of a disease to be totally abolished • It may promote sanism Standards of Assessment (p. 77-80) • Reliability: the extent to which a test yields consistent results • Internal consistency - the different parts of the test yield consistent results • Test-retest reliability - if the test is administered again to the same person, it will yield the same results • Interrater reliability - different raters yield similar results • Validity: the extent to which the test is identifying what itʼs aiming to • Content validity - the test represents the behaviors associated with what itʼs testing for • Ex. A depression test asks “how often are you sad?” • Criterion validity - the test correlates with other criteria and standards which identify what itʼs testing for • Ex. A depression test is verified by other tests which test for it • Predictive validity - the test predicts what will happen in terms of what itʼs testing for • Ex. A positive on a depression test can be treated with regular therapies for depression • Construct validity - the test corresponds to the theoretical models • Ex. Depression is tested according to accepted methods like self-report and physiological detection • Sensitivity vs. Specificity • A test should be sensitive enough to detect what itʼs testing for, so as not to produce false negatives • It should also be specific enough that it wonʼt over-diagnose, producing false positives Methods of Assessment (p. 80-99) Clinical Interview • Most cover these topics: • Identifying data • Description of presenting problems • Psychosocial history • Medical/psychiatric history • Medical problems/medication • They take a range of formats, which could be unstructured, semi-structured and structured • The more structured, the more exact and reliable the diagnosis • The more unstructured, the more room for personalizing the interview to expand on relevant issues • There is a shift towards computerizing the initial interview because it covers the same points, and people will reveal more about themselves to a non-judgemental screen • But at the same time, they may be too structured, and lack the human touch • And sometimes, they yield misleading findings Psychological tests • These are usually standardized on large numbers of subjects • They are on par with many medical tests in their predictive ability • Intelligence tests • They began with Binet in the early 20th century to help identify children who needed special help • Eventually it was co-opted by Stanford to make the Stanford-Binet Intelligence Scale, a scale still widely used • It yields an IQ score which is standardized at 100, with a standard deviation of 15 • This means that 68% fall within 1 SD, 95% within 2 and 99% within 3 • Thereʼs also the Weschler scales • Theyʼre divided into the Weschler Adult Intelligence Scale (WAIS), the Weschler Intelligence Scale for Children (WISC) and the Weschler Preschool Primary Scale of Intelligence (WPPSI) • Itʼs most used because it divides its results into subscales as well (see diagram) Objective Tests • These are self-report personality tests that can be scored objectively and are based on research and immense standardization • Theyʼre objective in the sense that they limit the range of possible responses and can therefore be scored objectively • Minnesota Multiphasic Personality Inventory (MMPI-2) • Consists of 500 T-F statements • Widely used personality test • Its success comes from its standardization, because it doesnʼt always have content validity • It includes many scales, including a validity scale to measure the participantʼs honesty, and content scales to measure specific complaints • It also has various clinical scales (see chart) • The scales are regarded as a part of a continuum of personality trait (making up for one of the criticisms of the DSM) • The MMPI profiles can also be used to help with diagnosis • Millon Clinical Multiaxial Inventory (MCMI) • This was developed specifically to test for DSM disorders, especially along Axis II • Strengths: • Easy to administer • Very reliable • Quantifies and reveals new information • Weaknesses: • Ultimately, still self-report and ultimately subjective • Tells little about motives • Limited to high functioning individuals Projective Tests • These psychodynamically oriented tests use indirect methods of assessment to circumvent ego defenses by having patients project onto vague images • They have a few characteristics: • Unstructured • Open direction • Involves free interpretation • Free response style • Rorscharch Test • Peopleʼs “percepts” influence what they see • Useful for reality testing, or seeing how in touch people are with reality • This is the only time Dr Isaacs ever got any use out of the test • Thematic Apperception Test (TAT) • Henry Murray came up with this test where subjects would interpret an ambiguous picture • Theoretically, their cognitive structures and relevant past experiences would affect the interpretation in a way that can be analyzed • Also, according to psychodynamics, people identify with the protagonist, so the story in the picture is always biographical • Strengths: • Could reveal new information • Some find it on par with the MMPI, at least for axes I and II • Circumvents tendency to offer socially desirable responses • Weaknesses: • May not work (zero validity) • Horribly unreliable • Acklin tried improving it, but then it became horribly complicated and time- consuming • Its strengths can be brought about in other, easier ways • The TAT picture itself may serve as a prime • If itʼs painted in sad colors, of course the interpretation will be sad Neuropsychological Assessment • Measurement of behavior/performance that may be indicative of brain damage • Bender Visual Motor Gestalt Test • Now in its second version, the Bender-Gestalt II • Geometric figures illustrate that illustrate various Gestalt principles must be memorized and copied • It tests for spacial perception • Halstead-Reitan Neurppsychological Battery • Measures perceptual, intellectual and motor sklls • Itʼs divided into subtests: • Category Test: measures abstract thinking ability, by identifying how different stimuli relate • Activates the frontal lobe of the cerebral cortex • Rhythm Test: measures concentration and attention by identifying whether different beat-pairs in tape recordings are the same or different • Activates right temporal lobe of the cerebral cortex • Tactual Performance Test: measures visual memory by having the blindfolded subject fit wooden blocks into corresponding holes Behavioral Assessment • This method focuses on the objective recording and description of problem behavior • Functional analysis: breaking down problem behavior to its antecedents and results • Behavioral interview: posing questions to perform a functional analysis • Direct observation: done in real life or simulated environment • Limits of observation: • Somewhat unreliable • Observer drift: the tendency for observers to deviate from coding system as time elapses • May show response bias • Reactivity: the tendency of the response to be influenced by the method of observation • But self-monitoring is very accurate • Self-monitoring: clients are the ones who assess the problem behavior, as itʼs naturally occurring. • Done in a few formats: • Behavioral diary • Through a PDA which sends out reminders • May actually improve certain desirable but low-frequency behaviors • Limits of self-monitoring: • Clients may be unreliable, sloppy or embarrassed • Clinicians may need to separately corroborate it • Analogue measures: simulating settings in which a behavior occurs • Ex. Role playing, etc. • Behavioral Approach Task (BAT) is a common therapy for phobias • Behavioral Rating Scale: a checklist that provides information about the frequency, intensity and range of problem behaviors • A popular one is the Child Behavior Checklist (CBCL) Cognitive Assessment • Measures thoughts, beliefs and attitudes which may lead to emotional and behavioral problems • Often involves a “thought diary” • A popular one is Aaron Beckʼs “Daily Record of Dysfunctional Thoughts” where each time the client experiences a negative emotion they should write: 1. The situation in which it occurred 2. The automatic thoughts which took place 3. The category of disordered thinking 4. The rational response 5. The emotional outcome • The Automatic Thoughts Questionnaire has clients rate the frequency of different cognitions • Sorted into four factors: 1. Personal maladjustment and desire for change 2. Negative self-concept and expectations 3. Low self-esteem 4. Helplessness • Identifies depression • The Dysfunctional Attitudes Scale (DAS) measures a 1-7 set of stable underlying attitudes associated with depression • Behaviorists object to cognitive techniques Physiological Measurement • Probes: • Electrodermal response/galvanic skin response (GSR): measures sweat • Electroencephalograph (EEG): measures brain waves • Electromyograph (EMG): monitors muscle tension • Brain imaging: • EEG • May be used to detect abnormal functioning and even tumors • Computed axial tomography (CAT) scan: targeted X-ray • Reveals abnormality in shape and structure • Because it takes the picture from many angles, it can make a 3-D image of the brain • Positron emission tomography (PET) scan: uses positrons, a radioactive tracer, in bloodstream to detect neuron activities based on how much blood it needs • Detects schizophrenia • Magnetic resonance imaging (MRI): uses radio waves instead of X rays • Also reveals abnormality in shape and structure • Ex. Schizophrenia and OCD • fMRI: works like a video to watch brain areas activate • Brain electrical activity mapping (BEAM): sophisticated type of EEG Sociocultural and Ethnic Factors in Assessment (p. 99-100) • We need to be conscious of the fact that assessment techniques in one culture are not always reliable or valid in another • The Chinese version of the Beck Depression Inventory works, but not the Chinese MMPI • But there is no cultural bias in the MMPI within America Chapter 4: Methods of Treatment • There are many types of helping professionals. A partial list includes: • Clinical psychologist • Counseling psychologist • Psychiatrist • Clinical/psychiatric social worker • Psychoanalyst • Counselor • Psychiatric nurse • Many states donʼt have any standards for calling yourself a professional therapist Psychotherapy (p. 104-125) • Psychotherapy is defined by: • A systematic interaction between client and therapist • Drawing on psychological principles • Aiming to bring about changes in the clientʼs affect, behavior and cognitions • Can be used for abnormal behavior, problem solving or merely personal growth • Always a “talking therapy” • Skillful therapists are active, empathetic listeners as well • Often instills clients with a sense of hope Psychodynamic Therapy • Psychoanalysis is the Freudian method of psychoanalysis which uses psychodynamic therapy to help clients gain insight into unconscious conflicts and resolve them • Methods include: • Free association • Dream analysis to differentiate manifest content and latent content • This is especially difficult because symbols change from person to person • Freud believed that the repressed impulses heʼs trying to reveal make a compulsion to utter • But since itʼs so personal, clients usually display resistance • One of the analystʼs jobs is to monitor the dynamic conflict between the compulsion to utter and resistance • A two-way transference relationship also develops, for the analyst to monitor • In order to be prepared for countertransference, psychoanalysts are expected to undergo psychoanalysis themselves • Due to the expense, modern psychodynamic approaches are briefer, less intensive and less costly • They focus on the clientʼs present relationships • The client and therapist generally face each other, with more give-and-take than Freud would have had • But there still is interpretation • Heinz Hartmann calls it ego analysis • Margaret Mahler does object-relations psychodynamics: • It focuses on how people need to separate their own ideas and feelings from the foreign ones they have introjected from others • 45% of psychologists report using psychodynamic techniques along with others Behavior Therapy • Behavior Therapy is the systematic application of learning theory to treat disorders • Itʼs relatively brief • Very effective against phobias, with systematic desensitization • It progresses from imaginary to real an distance to proximity through the method of gradual exposure • It runs along the fear-stimulus herarchy • Modeling is also an effective method • Token economies use the laws of operant conditioning to use secondary reinforcements as rewards for desired behaviors • Works especially in institutions and with disorderly children Humanistic Therapy • Humanistic therapists focus on clientsʼ subjective, conscious experiences • A goal of theirs is to expand clientsʼ self-insight • They champion person-centered therapy, where a warm, accepting therapeutic relationship frees clients to engage in self-exploration to achieve self-acceptance • Also referred to as client-centered therapy or Rogerian therapy • Carl Rogers emphasized that people have natural tendencies to self-knowledge and growth, and that only a misplaced need for social approval can mask that up • At worst, it can even lead to a distorted self-concept • Well-adjusted people, on the other hand, are able to take actions consistent with who they are • As such, the goal of a therapist is not to impose a framework, but rather to let the client figure out what theirs it • Hence, “client-centered” • The therapy is nondirective, with the client taking the lead for directing the course • To enable this, the therapist reflects, or rephrases, what the client is saying without any judgement • An effective humanist therapist has four qualities: 1. Unconditional positive regard: the expression of unconditional acceptance of another personʼs basic worth as a person 2. Empathy: the ability to understand someone elseʼs perspective 3. Genuineness: the ability to recognize and express oneʼs feelings 4. Congruence: the fit between oneʼs thoughts/feelings and behavior Cognitive Therapy • Cognitive therapy helps clients identify and correct faulty cognitions believed to underlie emotional problems and maladaptive behavior • Ellisʼs rational emotive behavior therapy (REBT) has the therapist actively disputing clientsʼ irrational beliefs and the premises on which they lie • It often involves behavioral homework assignments to bring the cognitions into practice • It also could involve role play to accomplish that goal • Beckʼs cognitive therapy is similar to Ellisʼs in that it aims to correct cognitive distortions • It also involves behavioral homework assignments • Another homework is reality testing where clients test their negative beliefs in light of reality • Less confrontational than REBT Cognitive-Behavioral Therapy • Cognitive-behavioral therapy (CBT) is a learning-based approach which incorporates both cognitive and behavioral techniques, depending on the situation • Most therapists identify with this method See table 4.2 on p 115 for a summary Eclectic Therapy • Eclectic therapy approaches psychotherapy with techniques from various theories • The majority of therapists identify as using eclectic therapies rather than one orientation • Especially those with more experience • Technical eclectics believe in tailoring the therapeutic experience to each client by using the techniques best suited for them • Integrative eclectics actively try to synthesize the different theories Group, Family and Couple Therapy • Group therapy • Itʼs less costly • Sometimes itʼs more effective if the clients have similar problems • At the same time, clients may feel uncomfortable disclosing their problems to a group • Family therapy • It looks at the family, not the individual, as the unit of treatment • Emphasizes communicaion • Helps ease familyʼs way through transitional points • Adopts a systems approach to understanding the family by seeing problem behaviors as a breakdown of the system, not the individual • Couple therapy • Similar to family therapy Evaluating Psychotherapy • Strengths: • It has strong support from research literature • The greatest gains take place in the first several months of treatment • Different forms of therapy all yield similar results because they all have nonspecific treatment factors like: • Active listening and empathy that alone are therapeutic • Often just the idea of therapy makes for a placebo effect of change • The therapeutic alliance • The working alliance • Ultimately, itʼs best to tailor the therapy based on the client and problem • Weaknesses: • Some therapies just arenʼt empirically supported to do anything special besides for the nonspecific treatment factors (see Table 4.3 for examples of ones that are) • These days, because of managed care systems, where health care companies impose limits on treatment, therapy must tailor itself to cost as well Multicultural Issues in Psychotherapy • Therapists should be sensitive to cultural differences and have accurate knowledge about them • Obviously, stereotyping is also out of the question • Multicultural competence is perceived as empathy and general competence • Blacks • It must be recognized that they face the most extreme racial discrimination • Some even internalize them • Tend to minimize vulnerability by being less self-disclosing • Marked by strong kinship bonds, even with those not biologically related • Strong religious/spiritual orientation • Distribution of child-care responsibilities • Asians • Difficult because they value restraint • Often somaticize psychological problems by expressing them in terms of physical symptoms • But this may just be a difference in communication style • Hispanics • Marked by adherence to a strong patriarchal family structure with strong kinship ties • Strongly value interdependency within family • Therapists should be trained to work within this community in particular because itʼs structured so differently • Native Americans • Tribal culture is still present Biomedical Therapies (p. 126-130) • This uses biological methods to help the patient • Often through the use of psychopharmacology since psychosurgery has been all but eliminated • The major classes of psychiatric drugs are antianxiety, antipsichotic and antidepressant • Antianxiety drugs combat anxiety and reduce states of muscle tension. • They include: • Mild tranquilizers, like Valium and Xanax • Hypnotic-sedatives, like Halcion and Dalmane • They depress the level of activity in the CNS, which decreases the activity of the sympathetic nervous system • Mild tranquilizers grew in popularity because psychiatrists grew concerned about the more potent depressants • But itʼs still potentially fatal when combined with alcohol • Side effects include: • Fatigue • Drowsiness • Impaired motor function • Drug tolerance • Addiction, followed by rebound anxiety when a person gets off it • Antipsychotic drugs are used to treat schizophrenia and other psychotic disorders • They include: • Thorazine and Prolixin which block dopamine action • Clozaril, if the other ones donʼt work • But it has potentially dangerous side effects • Their introduction in the 1950ʼs was one of the major factors that led to deinstitutionalization • Side effects include: • Motor issues which may be handled by other drugs • Tardive dyskinesia, a potentially irreversible and disabling motor disorder • Antidepressants affect the availablility of neurotransmitters in the brain • They include: • Tricyclics (TCA) and monoamine oxidase inhibitors (MAOI) which increase the availability of norepinephrine and serotonin, like Tofranil, Elavil. Sinequan and Nardil • TCAs are preferable because they cause fewer side effects • More than half of patients respond favorably • Selective serotonin-reuptake inhibitors (SSRI) specifically target serotonin, like Prozac and Zoloft • Overall response is modest at best, with full remission at 30% • No antidepressant works particularly better than others • They can treat a wide variety of disorders • Antimaniac drugs, like Lithium carbonate, helps stabilize dramatic mood swings • Electroconvulsive therapy (ECT) uses targeted shocks to the head to “reboot” the brain • Helps those with extreme depression • Controversial because: • Shocks seem cruel • Carries potential side effects, like memory loss • May not be more effective than strong antidepressants • We donʼt know why it works • It has a high relapse rate • Psychosurgery is rarely practiced today • Frontal lobotomies were popular • Now, in cases of last resort, targeted surgery is used to relieve extreme cases of OCD, bipolar disorder and depression • Strengths: • Could be very effective in getting somebody in a state to begin therapy • It has helped many people in ways therapy possibly could not • Weaknesses: • Itʼs tough to say whether drug therapy is conducive to working with psychotherapy • It may reduce the urgency of getting better • Itʼs tough to say whether the coping methods will work after the drugs are worn off • Some drugs may be as effective as psychotherapy, with no side effects • MDs have been blamed for being too quick to prescribe • They often feel pressured to do so Hospitalization and Community-Based Care • State mental hospitals care for people with severe psychological problems • Municipal/community-based hospitals focus more on short-term care for people with serious problems • Hospitalization may be followed by outpatient treatment • Todayʼs hospitals focus on deinstitutionalization, a policy shifting care away from the state hospital towards the community-based care • They aim their treatment at preparing residents to return to community living • They provide structure which is necessary for many • Community mental health centers (CMHCs) primarily function to help discharged mental patients adjust through therapy and consultative services. They can be: • Day hospitals • Halfway houses • Shelters • The Institute of Medicine divided up disorder into three parts: prevention, treatment and maintenance (see diagram on p 132) • Primary prevention efforts are designed to prevent problems from occurring in the general public or “at risk” groups. Ex. Sending in a social worker to a low-income public school • Secondary prevention efforts target specific people with developing problems. Ex. That social worker calls in a child from a one-parent home to discuss positive ways to cope • Minorities typically have less access to mental health care due to: 1. Cultural mistrust: they donʼt think the therapistʼs on their side 2. Institutional barriers 3. Cultural barriers: Latinos generally turn to friends and family for help, not professionals 4. Language barriers 5. Economic and accessibility barriers • Blacks are more likely to be admitted to a mental hospital • But at the same time, deinstitutionalization still has a long way to go • It often ends with just dumping the psychotic onto the streets with no support system or available housing to catch them • 1/3 of all homeless adults have psychological disorders • Thereʼs no integrated effort among the different groups of healthcare workers • Homeless typically do not seek out mental health services • While some CMHCs show promise, others are found lacking Chapter 5: Stress, Psychological Factors, and Health Adjustment Disorders (p. 141-143) • Health psychologists study the role of psychological factors in physical illness • Stress is a demand made on an organism to adapt or adjust which originates from a stressor • Adjustment disorders are maladaptive reactions to an identified stressor which occurs within a few months of the onset of the stressor • These are among the mildest of psychological disorders • Itʼs a catch-all disorder for any reaction which comes with significant impaired functionality or emotional distress • But at the same time, it cannot be sufficient enough to meet other clinical syndromes • And while it must start soon after a disorder, it must also subside within 6 months • Resolved by taking the stressor away, or learning to deal with it • 5 to 20% of people receiving outpatient mental health services present an adjustment disorder Diagnostic criteria: 1. Behavioral or emotional symptoms must develop in response to an identifiable event(s) & occur within 3 months of the onset of that event(s) / stressor(s). 2. These behaviors or symptoms must be clinically significant as evidenced by at least 1 of the following: 1. After exposure to the event(s) / stressor(s), the behavioral or emotional symptoms seem in excess of what would be normally expected. 2. Significant impairment in social or occupational (academic) functioning. 3. The disturbance does not meet the criteria for another specific Axis I disorder or is not part of a preexisting Axis I or Axis II disorder. 4. The behavioral or emotional symptoms do not represent Bereavement. 5. Once the stressor (or its consequences) has terminated , the symptoms do not last more than an additional six months. • There are also different levels of adjustment disorder: • Acute: symptoms last less than 6 months • Chronic: symptoms last more than 6 months • By definition, acute anxiety disorder may not last more than 6 months, but it may be in response to a chronic stressor • Also, see associated subtypes below Chapter 6: Anxiety Disorder Overview of Anxiety Disorders (p. 171-172) • Anxiety is a generalized state of apprehension or foreboding. It effects a few areas: • Physical - jumpiness, shortness of breath, nausea, etc • Behavioral - avoidance behavior, clinging behavior • Cognitive - worry, dread, fear, nervousness • Sometimes, anxiety disorders will overlap • Until 1980, they were referred to as “neuroses” because people thought to have resulted from the nervous system Panic Disorder (p. 172 - 179) • Panic disorder is a type of anxiety disorder characterized by repeated episodes of intense anxiety or fear • There is a stronger bodily component to panic attacks than to other forms of anxiety disorder • Itʼs usually accompanied by thoughts of losing control, going crazy, or dying • People can even think theyʼre having a heart attack • Diagnostic criteria for a panic attack are listed to the right. People must experience at least four criteria within ten minutes of onset • It often goes hand in hand with agoraphobia • But not all panic attacks are signs of a panic disorder - 10% of people may experience an isolated attack in a year. For it to be diagnosable, the following must be satisfied: • At least a month of persistent attacks • Worry about consequences of attack • Significant change in behavior Theoretical Etiology • See Appendix for summary • The prevailing view of panic disorder reflects a combination of misattributions (cognitive) and physiological (biological) factors • People feel a small physiological change, and work themselves up into a full panic attack • Eventually, they get in the habit of such attacks, and it turns into a full blown disorder • Biological factors: • Genetics come into play • Possibly from a sensitive alarm system involving the limbic system and frontal lobe • Donald Klein termed it the suffocation false alarm theory where a defect in the brainʼs respiratory alarm system triggers a false alarm in response to minor cues of suffocation • This specific theory has mixed support • Gamma-aminobutyric acid (GABA) is an inhibitory neurotransmitter which may be lowered in anxious people • Benzodiadepines like Valium and Xanax aim to make GABA receptors more receptive • Serotonin plays a significant role as well • Cognitive factors: • Anxiety sensitivity (AS) magnifies fear reactions to cues of body arousal • Asian and Hispanic students report higher levels of AS, but not proportionally equal levels of panic attacks • CBT aims to discount AS • The fact that panic attacks sometimes come out of the blue is evidence for a biological explanation • But that said, it very well may be an interplay between the two factors Treatment Approaches • Most treatment stems from a combination of drug therapy and CBT • Drug therapy: • Antidepressants aim to normalize neurotransmitters in the brain: • Tricyclics: Tofranil (imipramine) and Anafranil (clomipramine) • SSRIs: Paxil (paroxetine) and Zoloft (sertraline) • But they come with side effects, like heavy sweating and ironically, heart palpitations • The high-potency antianxiety drug Xanax (alprazolam) is a benzodiazepine • CBT: • Breathing retraining exercises • A medical examination to show the patient that they have no relevant health issues • CBT produces as good short-term results, and better long-term results • Development of coping responses • Exposure • Self-monitoring Phobic Disorders (p. 179-193) • A phobia is an excessive, irrational fear of a specific stimulus • Different types of phobias appear at different ages (see table) • Women are twice as likely as men to develop phobias • Specific phobias are persistent, excessive fears of a specific object or situation • They are the most common psychological disorder, affecting 9% of the population at some point • People with specific phobias are often aware of its irrationality • Social phobia is an excessive fear of social situations • The underlying problem is an excessive fear of evaluation from others • This is different from other phobias which can be for any reason at all • Itʼs associated with the diathesis-stress model, with childhood shyness as a particular indicator • It can last up about 16 years on average • Despite the fact that it first creeps up at about 15, people usually donʼt receive help until 27 • Agoraphobia is a fear of open spaces • Itʼs often a result of a panic disorder, but not necessarily • Panic disorder-agoraphobia affects 1.1% of the population at some point • But there is only a .17% lifetime prevalence of agoraphobia without panic disorder Theoretical Etiology • See Appendix for summary • Psychodynamic: anxiety is a danger signal that threatening impulses of a sexual or aggressive nature are nearing the level of awareness • Learning: O Herbert Mowrerʼs two-factor model incorporates both classical and operant conditioning into his theory • People begin with an avoidance of an object and receive negative reinforcement when they avoid anything associated with it • Then they become classically conditioned to fear it more through more reinforcement, and it continues until fully-realized phobia • Also, observational learning can come into play here • Biological: • Genetic predisposition • Over-active amygdala, and under-active pre-frontal cortex to quiet it down • There is also a belief that people are subject to prepared conditioning, where evolution favored certain fears, like snakes • Cognitive: Albert Ellis says that fearful people display more irrational beliefs than do nonfearful • Oversensitivity to threatening cues • Overprediction of danger/potential discomfort • Self-defeating thoughts and irrational beliefs Treatment Approaches • Psychoanalysis: awareness of how fears symbolize inner conflict • Learning: • Systematic desensitization - • Developed by Joseph Wolpe • Client learns relaxation technique • Client and therapist develop fear-stimulus herarchy • Client works along it with the help of therapist • Gradual exposure - imagined or in vivo exposure which involves experiencing and overcoming fear along the fear-stimulus hierarchy • The treatment of choice • Flooding - hardcore exposure therapy through exposure to high levels of fear- inducing stimuli • Virtual reality therapy is a new technology being used to perform these exposure therapies • Cognitive: • Ellis and others aimed to identify and correct dysfunctional or distorted beliefs • CT outperformed Prozac and self-administered exposure training • Cognitive restructuring is when the therapist helps the client pinpoint self- defeating thoughts and generate rational alternatives they can use to cope with anxiety-provoking situations • Drugs: • Zoloft and Paxil are the drugs of choice • Sometimes theyʼre used in concert with exposure therapy Obsessive-Compulsive Disorder (p. 194-198) • OCD is a disorder characterized by recurrent obsessions and compulsions. Also, they: • Cause marked distress • Take up more than an hour a day • Impair functioning • Obsessions are intrusive and recurrent thoughts • Compulsions are repetitive, and often ritualistic behaviors • Usually, theyʼre either cleaning rituals or checking rituals • Often, theyʼre reactions to obsessions • People with OCD often recognize how excessive or irrational their concerns are • Between 2% and 3% of people have it • Equally in men and women Diagnostic criteria: • Either obsessions or compulsions • Obsessions are defined by: • Recurrent, persistent thoughts that are experienced, at some time during the disturbance, as intrusive, inappropriate & cause distress • the thoughts, impulses, or images are not simply excessive worries about real-life problems • the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action • the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind and not imposed from without • Compulsions are defined by: • repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly • the behaviors or mental acts aimed at preventing or reducing distress or preventing some dreaded event or situation • however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or are clearly excessive Etiology • Psychodynamic - leakage of unconscious impulses into consciousness, accompanied by actions which try to repress them • Biological • There is genetic evidence for OCD and tic disorders • The neurotransmitter glutamate is deficient in people with OCD • It may be connected to the “worry circuit” in the brain • As are the frontal lobes and basal ganglia • Psychological • People with OCD are excessively inward-focused • They exaggerate the risk of events • They have the cognitive distortion of perfectionism Treatment • Behavioral - Exposure with response prevention • Cognitive - also exposure with response prevention, but with cognitive therapy as well • Medical - SSRIs (Prozac, Paxil, Anafranil) Generalized Anxiety Disorder (p. 198-200) • Generalized Anxiety Disorder (GAD) is characterized by persistent, free floating feelings of anxiety which interferes with daily life • Itʼs potentially a lifetime disorder • Frequently occurs with other disorders • Characterized by restlessness, tension, fatigue, difficulty concentrating, loss of sleep and irritability • No absolute terror, usually just worry • 4% of people have it, mostly women Diagnostic criteria: • The anxiety & worry are associated with 3+ of the following 6 symptoms (with at least some symptoms present for more days than not for the past 6 months; children don't need as many criteria). • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance • The anxiety may not be related to other disorders, like phobias, PTSDs, eating disorders, etc Etiology • Psychodynamic - leakage of unacceptable sexual or aggressive wishes • Learning - generalization of anxiety response across many stimuli • Cognitive - exaggerated or distorted worry-related cognitions • Biological - irregularities in the neurotransmitter activity of GABA and the amygdala Treatment • Medical - antidepressants (Zoloft, Paxil) • CBT - relaxation skills, un-learning catastrophizing cognitions, learning to replace bad cognitions with good ones Acute Stress Disorder and Posttraumatic Stress Disorder (p. 200-204) • Acute Stress Disorder (ASD) is a traumatic stress reaction occurring during the month following a traumatic event • Involves either extreme detachment from, or obsession with, event • Doesnʼt always develop into PTSD • It must take place within 4 weeks of a traumatic event and last between 2 and 4 weeks. Any longer, and itʼs PTSD • Posttraumatic Stress Disorder (PTSD) is a prolonged maladaptive reaction to a traumatic event • DSM-IV loosened the criteria to include a wide variety of traumas • More than 2/3 of people suffer a traumatic experience • Mostly from car accidents • 8% develop PTSD, 2% presently have it • Women are twice as likely, but this could be for a variety of reasons • There are various factors predictive of PTSD • Event itself: • Degree of exposure to trauma • Severity of trauma • Exposure to violence • Personal/environmental factors: • Childhood sexual abuse • Lack of social support • Lack of active coping responses • Feelings of shame • Detachment/dissociation • Lack of self-efficacy and other personality factors • Features of traumatic stress disorders: • Avoidance of cues associated with trauma • Reexperiencing of the trauma • Impaired functioning • Heightened arousal • Emotional numbing • This one is more associated with ASD Etiology • Psychodynamic - dealing with loss • Behavioral - a combination of classical and operant conditioning similar to phobias • But in this case, the one traumatic event is a very powerful conditioner Treatment • Behavioral - Exposure therapy • Cognitive - Stress/anger management skills • Medical - Antidepressants (Zoloft) • Eye movement desensitization and reprocessing (EMDR) is a controversial therapy that involves eye tracking a target while holding images of the traumatic experience in mind Ethnic Differences in Anxiety Disorders (p. 204-205) • White people have higher levels of anxiety disorders • But itʼs worth mentioning that cultural factors may play a role in determining how people manage and cope with trauma Chapter 8: Mood Disorders and Suicide Types of Mood Disorders (p. 248-259) Major depressive disorder is based on the occurrence of one or more major depressive episodes, in the absence of mania/hypomania • See Table 8.2 for details • Highlighted by: • Depressed mood • Loss of interest/pleasure in activities • For at least 2 weeks • Loss of appetite • Significant and sudden weight change • Disturbed sleeping patterns • Agitation/lethargy • Impaired functionality • Hallucinations • Only half the people with MDD receive treatment, and one a third from a mental health specialist • And only one fifth receive adequate treatment • Occurs in 12% of men, 21% of women, and 16.5% overall • It may resolve itself, but many professionals view it as a chronic disorder which will probably come back • Risk factors include: • Socioeconomic status • Young adulthood • Divorce • Seasonal affective disorder (SAD) is not a diagnostic category of the DSM-IV, but it is a subcategory of MDD • Treated with phototherapy, or seasonal usage of antidepressants • MDD often comes piggybacked on postpartum depression, which occurs in 13% of mothers Diagnostic Criteria: • Must have major depressive episode, which is denoted by the occurrence of five or more of the following features during a 2 week period: 1. Depressed mood during most of the day, nearly every day 2. Reduced sense of interest in almost all activities 3. Significant weight change 4. Daily insomnia/hypersomnia 5. Excessive agitation or slowing down of activity 6. Fatigue 7. Reduced concentration 8. Feelings of worthlessness/guilt 9. Recurrent suicidal thoughts • The symptoms should be relative to previous functioning • Must have one of the first two symptoms • Should cause impairment • Also, cannot be due to other causes like drugs, or natural grieving • If it only occurs once, itʼs called “Major Depressive Episode, Single Episode” while if itʼs recurrent, itʼs called “Major Depressive Episode, Recurrent” Dysthymic Disorder is a mild but chronic depressive disorder • Feelings of depression and social difficulties even after the person makes apparent recoveries • Affects 4% of the population • Double depression is when MDD is superimposed on a long-standing dysthymic disorder Diagnostic Criteria • Depressed mood for most of the day, for most days, for at least 2 years. Note: In children & adolescents, mood can be irritable & duration must be at least 1 year. • Presence, while depressed, of 2+ of the following: • poor appetite or overeating • Insomnia or hypersomnia • low energy or fatigue • low self-esteem • poor concentration or difficulty making decisions • feelings of hopelessness • During the period of the disturbance, the person has never been without the symptoms in Criteria A & B for more than 2 months at a time. • No Major Depressive Episode has been present during the disturbance; i.e., the disturbance is not better accounted for by chronic MDD, or MDD in Partial Remission. • Specifiers: • Early Onset: the onset of the dysthymic symptoms occurs before age 21 years. • Early onset dysthymics more likely to develop subsequent MDD. • Late Onset: the onset of the dysthymic symptoms occurs at age 21 or older. Bipolar Disorder is a psychological disorder marked by extreme mood swings • Typically develops around age 20, and equal in men and women • But men usually start out manic, while women usually start out depressed • Bipolar I disorder means a full manic episode • Bipolar I disorder can be diagnosed as any of the following subsets: • Single Manic Episode - Presence of only one Manic Episode & no past Major Depressive Episodes. • Most Recent Episode Hypomanic - Currently (or most recently) in a Hypomanic Episode. • There has previously been at least one Manic Episode or Mixed Episode. • Most Recent Episode Manic - Currently (or most recently) in a Manic Episode. • There has previously been at least one Major Depressive Episode, Manic Episode or Mixed Episode. • Most Recent Episode Mixed - Currently (or most recently) in a Mixed Episode. • There has previously been at least one Major Depressive Episode, Manic Episode or Mixed Episode. • Most Recent Episode Depressed - Currently (or most recently) in a Major Depressive Episode. • There has previously been at least one Manic Episode or Mixed Episode. • Most Recent Episode Unspecified - Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode. • There has previously been at least one Manic Episode or Mixed Episode. • Bipolar II disorder has less severe mania, or even hypomania, and more frequent MD episodes • Presence (or history) of 1 or more MD Episodes. • Presence (or history) of at least 1 Hypomanic Episode. • There has never been a Manic Episode or a Mixed Episode. • The mood symptoms are not better accounted for by Schizoaffective Disorder & are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Specifiers: • Hypomanic: the current (or most recent) episode is Hypomanic. • Depressed: the current (or most recent) episode is Major Depressive. • Itʼs unclear whether these two types of bipolar are qualitatively different disorders • Bipolar disorder is relatively uncommon, with .4-1.6% having bipolar I, and .5% having bipolar II • “Rapid cycling”, where an individual experiences four or more mood swings within a year, is even more uncommon • A mood swing is defined by either a polarity switch, or a return after 2 month remission • At least one must be manic • Women are more likely to have it • Itʼs often more severe Cyclothymic Disorder is a mood disorder characterized by chronic mood swings less severe than bipolar ones for at least 2 years • Usually begins around late adolescence/early adulthood • .4-1% have it, but 33% with the disorder usually develop bipolar disorder Diagnostic criteria • Mania: a distinct period of abnormally & persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). • During the period of mood disturbance, 3+ of the following symptoms have persisted (4 if the mood only irritable) & have been present to a significant degree: • inflated self-esteem or delusions of grandeur • decreased need for sleep (e.g., feels rested after only 3 hours of sleep) • more talkative than usual or pressured speech • flight of ideas or subjective experience that thoughts are racing • distractibility • increase in goal-directed activity or psychomotor agitation • excessive involvement in extremely risky pleasurable activities • Can last as long as a few months • Sufficiently severe mood disturbance to cause impaired functionality • Hypomania: A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood. (Manic requires at least 7 days or hospitalization) • The same symptoms as mania apply • The episode is not severe enough to cause marked impairment, or to necessitate hospitalization, & there are no psychotic features. Causal Factors in Depressive Disorders (p. 259-269) • Stress plays a huge role in depression • Diathesis-stress model • Major stressful events are often the catalyst for depression • As such, a strong marriage can help stave off depression • Psychodynamic theories • Depression is anger directed inward • Often occurs after we internalize something we lost, and then hate that aspect of ourselves • Freud differentiated between mourning which is a healthy reaction and melancholy which is an unhealthy one • Bipolar disorder is an externalized power struggle between the ego and superego • Recently, psychodynamics has also focused on the individualʼs self-worth, like in the self-focusing model, where the client considers how they allocate their attentional processes after a loss • There actually is research to support the link between loss/self-attention and depression • Humanistic theories • People become depressed because they canʼt imbue their existence with meaning and make authentic choices that lead to self-fulfillment • Humanistic theorists focus on the loss of self-esteem which arises after people experience loss • Learning theories • Loss of positive reinforcement • Peter Lewinsohn discussed the cycle which builds upon itself, where people lose reinforcement, and subsequently pull out of activities which could recoup the loss • Furthermore, their introversion and negative affect are reinforced through other peopleʼs sympathy • James Coyne proposed interactional theory, wherein the adjustment to living with a depressed person becomes so stressful that family members become less reinforcing • The depressed person becomes more demanding until the sympathy breaks, and the depression remains • Research supports this belief that people who suffer depression elicit rejection from others • Cognitive theories • Aaron Beck is very influential in this area, suggesting the cognitive triad of depression • Negative beliefs about oneself (“I suck”) • Negative beliefs about the environment (“The world sucks”) • Negative beliefs about the future (“And itʼll keep sucking”) • They also discuss the cognitive-specificity hypothesis which shows that certain automatic thought accompany depression, while others accompany anxiety • David Burns brought out ten different common cognitive distortions 1. All-or-nothing thinking - total perfectionism 2. Overgeneralization - every negative event is global 3. Mental filter/selective abstraction - only remembering the negative 4. Disqualifying the positive - discounting the positive 5. Jumping to conclusions - assuming that one bad thing will cause a total meltdown 6. Magnification and minimization 7. Emotional reasoning 8. “Should” statements 9. Labeling and mislabeling - anybody who eats candy is a “pig” 10. Personalization - assuming personal responsibility for everything • Learned Helplessness (Attributional) Theories • Martin Seligman suggested the model for learned helplessness, wherein people become depressed because they feel helpless to change their lives for the better • In a way, itʼs a cross-section between cognition and behavior, because situational forces lead to the cognitions which cause depression • See the sad puppy experiment • But, Seligmanʼs model only fits one type of depression. People also suffer from low self-esteem and can be spontaneously cured • They also have three attributional styles for explaining failure which will make a person more or less happy: • Internal vs external explanation • Stable vs unstable factors • Global vs specific issue • Biological • Genetic • The closer the genetic relationship, the more likely people are to share a depressive disorder • Itʼs probably that thereʼs an interaction between genetics and environment • Biochemical • Norepinephrine and serotonin shortage are linked with depression • But, itʼs not purely a result of these hormones because thereʼs a gap between med use and recovery • Neural • Depressed people show lower metabolic activity in the prefrontal cortex • Which coincidentally uses a lot of serotonin and norepinephrine Causal Factors in Bipolar Disorders (p. 269-270) • Genetics plays a major role • MZ twins have 43% concordance compared to 6% with DZ • It could very well be the diathesis-stress model Treatment of Mood Disorders (p. 270-278) Depression • Psychodynamic • Understanding ambivalent feelings towards others, especially those weʼve lost • Modern psychoanalysis focuses more on direct, present relationships with interpersonal psychotherapy (IPT) • IPT has been shown to work with MDD, dysthymic disorder, bulimia and PTSD • Behavioral • Behavioral activation focuses on developing effective social skills to increase participation in rewarding activities • Produces the highest remission rates in treating the severely depressed • Cognitive • Cognitive therapy focuses on correcting the cognitive distortions • Itʼs relatively brief, lasting 14-16 weekly sessions • Often involves a thought diary • At least equals medicationʼs effects, but a combination may work best • Biological • Antidepressant drugs: • Tricyclics (TCAs) • Tofranil (Imipramine) • Elavil (Amitriptyline) • Norpramin (Desipramine) • Sinequan (Doxepin) • Monoamine oxidase inhibitors (MAOIs) • Mardil (phenelzine) • MAOIs are used least frequently because they have the worst side effects • Selective serotonin reuptake inhibitors (SSRIs) • Prozac (Fluoxetine) • Zoloft (Sertraline) • SSRIs are the drug of choice now because theyʼre less toxic, and fewer side effects • Antidepressants help prevent recurrent episodes • But only 30% go into full remission with them • They only produce moderately stronger effects than placebos • And they sometimes increase suicidal thinking • St. Johnʼs Wort is said to increase levels of serotonin, but studies show mixed results • Electroconvulsive therapy (ECT) also shows mixed results, and is only used as a last ditch effort Bipolar Disorder • Most often treated biologically, especially with constant use of lithium carbonate • But we still donʼt know how it works • It has a 60-70% success rate • Anticonvulsant drugs are used as well • Tegretol (carbamazepine) • Depakote (divalproex) • Lamictal (lamotrigine) • As are atypical antipsychotics used to treat schizophrenia • Psychological • These are best used in concert with bipolar disorder • Therapy improves functionality and adherence to the drug regimen • It also lowers relapse rates Suicide (p. 278-284) • 13% of Americans report having had suicidal thoughts, while 4.6% have experienced it • Suicidal behavior is a symptom, not a diagnosis • 60% of suicides have a mood disorder • Suicide rates are highest among those 65 and older, especially widowed White males • Often comes hand in hand with helplessness, hopelessness and loneliness • More women attempt suicide, but more men succeed • Probably because male suicides are more likely to be effective • Itʼs most common among White and Native Americans • Hopelessness and exposure to other suicides greatly increases risk • Suicide often reflects a perceived lack of alternatives • Sometimes, itʼs as simple as a lack of problem-solving skills • Past suicidal behavior plays a role in predicting later suicidal behavior • Many “rational suicides” where people consciously decide to end their lives may be colored by undiagnosed mood disorders • Often, people signal their intentions beforehand Etiology • Psychodynamic - inward anger that turns murderous, or the “death instinct” • Humanism - people find life meaningless and hopeless • Emile Durkheim discusses anomie, or the loss of identity in urbanized environment • Behaviorism - lack of problem-solving skills • Social-cognitivism - incorrect personal expectancies and modeling effects • They look at suicide as a social contagion • Biological - suicide involves reduced serotonin production Chapter 10: Eating Disorders Eating Disorders (332-342) • Eating disorders are characterized by disturbed patterns of eating and maladaptive ways of controlling body weight • Anorexia nervosa is self-starvation resulting in a dangerously low body weight • Affects .9% of women and .3% of men • Often accompanies total revulsion to food • Develops in high school • Associated with: • An intense fear of obesity • Stressful change, like going to college • A society which cares about extremely low weight, like ballet and acting • Has two subtypes: • Binge-eating/purging type - bulimia which results in dangerously low body weight • Deals with issues of impulse control • Restrictive type - regular anorexia • Deals with issues of obsessive control over dieting • Anorexia causes many medical complications • Loss of 35% of body fat • Dermatological problems • Cardiovascular problems • Gastrointestinal problems • Menstrual irregularities • Muscular weakness • High rates of suicide • Bulimia nervosa is a cycle of disordered eating characterized by binge eating followed by maladaptive purging of the food • Affects 1-3% of women and .1-.3% of men • Perhaps 50% of women have tries purging once • Purging can be either vomiting, use of laxatives or excessive exercise • Usually comes up in late adolescence • Medical complications stem from the repeated vomiting or laxative use Diagnostic Criteria • Anorexia • Refusal to maintain weight at or above normal weight for oneʼs age and height • Strong fear of not being thin • Distorted body image • For females, loss of three or more consecutive menstrual periods • Bulimia • Recurrent episodes of binge eating as shown by both: • Unusually high food intake during a 2-hour period • Sense of lost control over food intake • Regular inappropriate behavior to prevent weight gain such as purging or excessive exercise • Two episodes a week of binging and purging over the course of 3 months • Persistent overconcern with the shape and weight of oneʼs body Etiology • Sociocultural • More pressures are placed on women to be thin • For example, Miss America winners are progressively having lower BMIs • Dieting has become the norm among girls • Eating disorders are less common in non-Western countries that donʼt place as strong an emphasis on thinness • Eating disorders are not necessarily linked to social class • More men are gaining disturbed eating behavior as well • Psychodynamic • Girls with anorexia have difficulty generating individual identities • Perhaps it also represents a girlʼs unonscious effort to return to prepubescence • Behavioral • It works as a weight phobia in terms of classical and operant conditioning • Bulimiaʼs also linked to problems in interpersonal relationships, and increasing social skills could help • Cognitive • Body dissatisfaction also comes into play • Young women with anorexia often hold perfectionist attitudes • Bulimic women often believe in black and white terms • Bulimia often accompanies other disorders like depression, OCD and substance abuse • Family • Eating disorders frequently develop against the backdrop of family disturbance • Some believe adolescents refuse to eat to punish their parents • It is often learned from the mothers as well • Kids who develop anorexia may be merely internalizing tension so it wonʼt be expressed • In this way, the anorexic is only the identified patient, but the whole family unit needs a systems analysis • Biological • Abnormalities in mechanisms controlling hunger come into play • Serotonin does as well • As do genetics Treatment • Usually with anorexia, theyʼll only be treated in a hospital, and a token economy is used to provide reinforcement • CBT has also emerged as an effective treatment for bulimia • Tackles self-defeating thoughts and unrealistic perfectionism and dichotomous thinking • Like with anxiety disorders, exposure with response prevention is used for bulimia as well • Interpersonal therapy has been proven to be effective, but not as much as CBT • Prozac has yielded results with bulimia, and mixed results with anorexia Binge Eating Disorder • Binge-Eating Disorder (BED) is characterized by recurring binges, without the purge afterwards • There must be at least 2 binges a week for 3 months • Closely associated with severe obesity • Itʼs not its own disorder, but often viewed as a compulsion • CBT has theraputic effects • As do antidepressants and appetites suppressants Chapter 12: Schizophrenia and Other Psychotic Disorders Schizophrenia (p. 397-426) • Schizophrenia is a chronic psychotic disorder characterized by disturbed behavior, thinking, emotions and perceptions • Much about this disorder remains a mystery except for the fact that it affects every facet of peopleʼs lives • It typically develops during late teens/young adulthood, as the brain is reaching full maturation • In about 3 out of 4 cases, first signs appear by 25, sometimes as quickly as within a few weeks • Usually, though, itʼs a slower decline in functioning • There are three phases which are traced: • Prodromal phase: the period of decline in functioning that precedes the first acute psychotic episode. It often involves: • Waning interest in social activities • Difficulty meeting the responsibilities of daily living • Worse hygiene • Odd behavior • Rambling speech • Acute phase: this is when the most bizarre behavior occurs • See below • Residual Phase: This is the phase that follows an acute phase, characterized by a return to prodromal functionality • Flagrant psychotic behaviors are absent, but significant cognitive, social and emotional deficits remain • Schizophrenia is a chronic disorder, with ½ - ⅓ never showing signs of significant recovery • Even those who show improvement, rarely return to full functioning • About 1% of the adult population has it • Men have a slightly higher risk of development • Particulars of the disorder vary from culture to culture • Men tend to get hit worse also • They have earlier onset, poorer level of adjustment and more impairment • See table for major diagnostic features of schizophrenia • Positive symptoms are flagrant symptoms • Hallucinations • Delusions • Disturbed thinking • Disorganized speech and behavior • Agitation • Negative symptoms are loss or reduction of normal functions • Attentional deficiencies • Lack of emotions/emotional expression • Loss of motivation (avolition) • Loss of pleasure in normally pleasant activities (anhedonia) • Social withdrawal • Impoverished speech • Aberrant thinking can be found in both content and form of thought • Aberrant content is usually a delusion like: • Persecution • Reference • Being controlled • Grandeur • Thought broadcasting • Thought insertion • Thought withdrawal • Aberrant forms of thought are made to be thought disorders: • Looseness of associations • Poverty of speech • This is more common and severe among older patients • Neologisms • Perseverations (repetition of the same word) • Clanging (senselessly rhyming) • Blocking (interruption of speech or thought) • Disconnected speech • This is more common and severe among younger patients Other symptoms: • Attentional deficiencies • Hypervigilance • Being acutely sensitive to extraneous stimuli • Eye movement dysfunction • ⅓ of patients have choppy movements in their eyes when they try to follow a moving object • It is probably a marker, or gene-related in a way not unique to schizophrenia • Abnormal brain wave patterns • Otherwise known as event-related potentials (ERPs) • Usually, the brain will naturally suppress them, but with schizophrenics, they will continue until the patient suffers continuous sensory overload • Hallucinations • Sensory perceptions experienced in the absence of external stimulation • Auditory hallucinations are most common (¾ schizophrenics) • Tactile and somatic are next common • Visual, gustatory and olfactory are rarest • Auditory hallucinations can be either gender • Command hallucinations tell people to perform certain acts • Theyʼll often go undetected by professionals because patients deny them • Hallucinations are not unique to schizophrenia • Sometimes, they can be encouraged by drugs, culture, disease or extreme sensory deprivation • But psychotic individuals do not realize that hallucinations arenʼt real • Drugs hallucinations are usually involving abstract visual shapes, while schizophrenic hallucinations are usually more fully formed and complex • Delerium tremens are alcohol-withdrawal-induced hallucinations • Dopamine is the major suspect in this case • Hallucinations may represent a type of inner speech • CBT techniques aim to teach hallucinators to properly attribute these voices to themselves, as an adjunct to drug therapy • Alternatively, they may be caused by disorder in the higher functioning parts of the brain, specifically the cortex • Emotional disturbances • Flat affect • Inappropriate affect • Itʼs unclear whether this is an issue of lack of emotion, or difficulty expressing it • Confused personal identities • Loss of ego boundaries • Difficulty adopting a third-party perspective and theory of mind • Disturbances of volition • Loss of goal-directed activities • Stupor • Impersonal relationship difficulty Subtypes of Schizophrenia • 4 subtypes: • Disorganized • Catatonic • Paranoid • Undifferentiated • Disorganized • Characterized by disorganized behavior, bizarre delusions, vivid hallucinations • Often sexual or religious themes • Extreme hygiene loss • Catatonic • Characterized by abrupt switch to agitated phase, gross disturbance in motor activity • Abrupt switching between agitated and catatonic phases • Unusual mannerisms • Maintenance of bizarre, apparently strenuous postures for hours • Waxy flexibility • Catatonia is also not unique to schizophrenia, as it can be brought about by drugs, brain disorders and metabolic disorders • Found more in people with mood disorders than with schizophrenia • Paranoid • Characterized by auditory hallucinations and systematized delusions • Often involving themes of paranoia, grandeur, persecution and jealously • Organized thoughts and normal affect • Another way to characterize schizophrenia is according to different types • Type I • More positive symptoms • Better response to antipsychotic medication • Involves a deficit in the inhibitory mechanisms • Type II • More negative symptoms • Looks more like the residual phase the whole time • Involves structural damage to the brain • But the distinction remains controversial Theoretical Perspectives • Psychodynamic: the id overwhelming the ego, where the person regresses to an early period of primary narcissism • Many neo-Freudians, like Harry Stack Sullivan place more of an emphasis on social factors, like an impaired mother-child relationship • Such relationships could cause the young child to retreat to a fantasy world, and remain there • The major issue with this theory is that while it explains the infantile behavior of the disorder, it leaves many other aspects undealt with • Learning: conditioning, observational learning and modeling lead the brain to rewire itself improperly • Inconclusive at best. It too can explain specific behaviors, but not the entire disorder • Biological: most recognize that schizophrenia is a largely biological disorder, which probably functions according to the diathesis-stress model • Genetic factors: • While MZ twins are at an incredibly high concordance rate (48%), they are not absolutely alike • This indicates some kind of environmental factor coming into play • But adoption studies do confirm the strong genetic effect, even when environments are different • In cross-fostering studies, a 2X2 manipulation is run. The first IV is whether the childʼs birth parents had schizophrenia, and the second IV is whether the adoptive parents had. It showed that children followed the genetic parents, and not the adoptive parents • It is believed that multiple genes come into play for schizophrenia • They probably all have minute effects on their own but when combine increase the likelihood • Biochemical factors: • The dopamine hypothesis states that schizophrenia involves the overactivity of dopamine receptors in the brain • A subset of antipsychotics called major tranquilizers ease symptoms by blocking dopamine receptors • Similarly, methamphetamines cause symptoms that mimic paranoid schizophrenia by raising dopamine levels • It is possible that aberrant dopamine levels cause different types of abnormalities • Excess of dopamine causes positive symptoms, while lack of dopamine causes negative symptoms • Other neurotransmitters, such as norepinephrine, serotonin and GABA also seem to be involved • Viral infection: • Prenatal rubella is a cause of later mental retardation • There is a link between schizophrenia and prenatal influenza • Brain abnormalities: • Schizophrenics have on average 5% less gray matter and enlarged ventricles • These may be a result of damage or developmental disturbance • The prefrontal cortex shows reduced activity • Cognitive training efforts do help overcome some of the cognitive hurdles brought on by these abnormalities • There is limbic disturbance as well • Family Theories: • The schizophrenic mother is an outdated myth that cold mothers cause schizophrenia • Communication deviance (CD) is a pattern of unclear and disruptive communication which is often found among family members of schizophrenics • Bateson suggested the double-bind hypothesis where kids have conflicted relationship with the parents. Overly-incongruent verbal and physical messages spiral into schizophrenia • Expressed emotion (EE) is a pattern where the family responds to schizophrenic members in unsupportive ways • High EE families are typically found in industrialized countries • They typically have to do with how mental disorder is conceptualized, like believing that the schizophrenics possess more self-control than they do • High CD and EE are one of the biggest stressors for schizophrenics, and lead to huge relapse rates • But this is culturally bound. No such findings have been found in Mexican American families, which focus more on family warmth • Intrusive critical comments are received as signs of caring in African-American cultures Treatment Options • There is no cure for schizophrenia, but there are many rehab approaches • Biological • This method boomed in the 1950s, with the advent of antipsychotic drugs in general, and major tranquilizers/neuroleptics in particular • Phenothiazines include chlorpromazine (Thorazine), thioridazine (Mellaril), trifluoperazine (Stelazine), and fluphenazine (Prolixin) • Haloperidol (Haldol) is a chemically distant drug which produces similar effects • A major risk of long-term treatment is tardive dyskinesia (TD), where the patient is marked by involuntary ticks, most commonly frequent eye blinking • There is no cure • TD is most common among older people and women • Also, Thorazine in particular has heavy sedative effects, where their morose walk is referred to as the “Thorazine shuffle” • Second generation drugs, or atypical antipsychotic drugs (clozapine, risperidone and olanzapine), have replaced the earlier generation because they are more responsive and have fewer side effects • Especially clozapine • Side effects include severe weight gain and metabolic problems • Drug therapy needs to be supplemented with psychological treatment, rehabilitation, and social services to help schizophrenia patients adjust to demands of community living • Sociocultural factors in treatment • Psychiatric medications differ with ethnicity • Asians and Hispanics require lower doses of neuroleptics, and experience more side effects • At the same time, African Americans are less likely to receive the second generation of antipsychotics • Asian-American family members are more involved in the treatment process • Psychodynamic therapy • Freud did not believe there was a suitable treatment for schizophrenia • Personal therapy, however, is grounded in the diathesis-stress model, and help patients cope with stress and build social skills • Learning-based therapy • These are shown to be effective in modifying schizophrenic behavior and help people develop prosocial behaviors. • It involves three main methods • Selective reinforcement of behavior • Token economy • These have largely fallen out of favor because theyʼre too staff-intensive • Social skills training (SST) • These programs involve role-playing exercises, modeling, direct instruction, shaping and coaching • CBT shows promise as an adjunct to drug therapy for both community living and even reduction of hallucinations • Psychosocial rehabilitation • Cognitive rehabilitation training helps rebuild cognitive skills • Many self-help clubs (“clubhouses”) help schizophrenics find a place in society • Family intervention programs • This trains families in methods for how to be less stressful and more supportive • It also gives problem-solving skills for coping with mental disorder in the family • Benefits of this program seem relatively modest, and itʼs not clear whether it prevents relapse or merely pushes it off Other Psychotic Disorders (p. 426-429) • Brief psychotic disorder lasts from a day to a month, often following a major stressor • It features at least one of the following features: • Delusions • Hallucinations • Disorganized speech • Disorganized/catatonic behavior • Eventually, there is a full return to prior level of functioning • Sometimes women experience this after childbirth • Schizophreniform disorder consists of abnormal behavior identical to schizophrenia that have persisted 1-6 months • Itʼs unclear whether this is a separate disorder. It may be more appropriate to label it as a psychotic disorder of an unspecified type until it is clarified which disorder it is • Delusional disorder consists of persistent delusions that do not have the same bizarre qualities as schizophrenia • Usually the paranoid type • See chart for types of delusions • Very uncommon, affecting 5-10 in 10,000 • This is distinguished from paranoid personality disorder in that it includes specific delusions in addition to general paranoia • Schizoaffective disorder consists of severe mood disturbance along with features associated with schizophrenia • Sometimes referred to as the “mixed bag” of symptoms • Tends to follow a chronic course • Schizoaffective disorder and schizophrenia appear to share a genetic link Chapter 13: Personality Disorders and Impulse Control Disorders Types of Personality Disorders (p. 435-454) • Personality disorders are excessively rigid behavior/cognitive patterns that ultimately become self-defeating • They become evident by adolescence or early adulthood and eventually become so deeply ingrained that they are resistant to change • Warning signs go back as early as preschool • Furthermore, people with personality disorders are often ego syntonic, and believe the disorders to be just a natural part of them • This is as opposed to mood and anxiety disorders which are acknowledged to be ego dystonic • There are also high comorbidity rates with these disorders • The DSM groups disorders into three clusters: • Cluster A: odd and eccentric • Paranoid • Schizoid • Schizotypal • Cluster B: overly dramatic, emotional, erratic or self-centered • Antisocial • Borderline • Histrionic • Narcissistic • Cluster C: anxious or fearful • Avoidant Dependent • • Obsessive-compulsive Cluster A • Paranoid personality disorder is characterized by undue suspicion of othersʼ motives, but not to the point of delusion • These people are excessively mistrustful of others • The can generally maintain employment • They are oversensitive to criticism, whether real or imagined • Hypervigilant • Clinicians need to be conscious of the fact that sometimes, the paranoia can be true ๏Schizoid Personality Disorder ๏DSM-IV-TR: A pervasive pattern of detachment from social relationships & a restricted range of expression of emotions in interpersonal settings ๏beginning by early adulthood & present in a variety of contexts, as indicated by 4+ symptoms neither desires nor enjoys close relationships, including being part of a family ๏almost always chooses solitary activities ๏has little, if any, interest in having sexual experiences w/ another person ๏takes pleasure in few, if any, activities ๏lacks close friends other than 1st-degree relatives ๏appears indifferent to the praise or criticism of others ๏shows emotional coldness, detachment, or flattened affect • Occurs in .5%-2.5% of the population, and more often in men than women • Schizoid personality disorder is characterized by a persistent lack of interest in social relationships, flat affect and social withdrawal • Not as strong as schizophrenia though g World, 7th Ed, International 52/77 • They rarely experience strong emotions • But while they present a flat affect, they do not necessarily have silent inner lives • Many connect with animals as emotional outlets • Schizotypal personality disorder is characterized by eccentricities of thought and behavior, without clearly psychotic features • They have social anxieties associated with paranoid thinking, as opposed to fear of negative evaluation • Affects about 3% of the population, with higher rates of the disorder among African Americans • Usually the eccentricity has a very wide range, including: • Unusual perceptions or illusions • Even if they know itʼs not real • Undue suspicion • Ideas of reference • Magical thinking • Attaching unusual meanings to words • Vague and unusually abstract language • Unusual mannerisms and behaviors • Poor hygiene • Flat affect This disorder may be more closely linked to • schizophrenia than the other disorders • Evidence of genetic links and similar brain abnormalities supports this • But at the same time, relatively few people diagnosed with schizotypal personality disorder go on to develop schizophrenia or other psychotic disorders Cluster B • Antisocial personality disorder is characterized by antisocial and irresponsible behavior and lack of remorse • Also a disregard for social convention • Tend to be impulsive and unreliable • Superficially charming • Show low levels of anxiety, so punishment has little effect • Must be at least 18 years old • Also called psychopath or sociopath • This is the most extensively studied disorder • Antisocial disorder cuts across all ethnic groups, but lower SES is correlated with higher chances of antisocial behavior • This could be due to modeling, or survival strategy • Criminal behavior tends to decline with age and almost disappear at 40 • But the underlying traits, like egocentricity, manipulativeness, lack of empathy and lack of guilt remain • About half of prison inmates can be diagnosed with antisocial personality disorder • But only a minority of people with antisocial personalities break the law • The antisocial personality is composed of two dimensions • Personality dimension: these are just the personality traits, that do not turn into antisocial behavior • Behavioral dimension: these eventually show both antisocial personality traits and illegal behavior • Hervey Cleckley argued that many antisocial personality traits can be considered adaptive ones in a different context • Borderline Personality Disorder (BPD) is characterized by abrupt shifts in mood, lack of a coherent sense of self, and unpredictable, impulsive behavior • It is a pervasive pattern of instability in relationships, self-image and mood, along with general impulsivity • These people tend to be uncertain even about their personalities • They often need constant stimulation and cannot tolerate being alone • Also marked by fear of abandonment • Theyʼll often view people as all good or all bad, shifting between the two • Splitting is the abrupt shift • Itʼs diagnosed more often in women and Hispanics • Women tend to aim aggression inward, while men externalize it • But more severely impaired than people with neuroses, but not as bad as psychotics, and still maintain better contact with reality • BPD tends to “burn out” with age • Often self-mutilation is involved, to alleviate “numbness”, express anger or cry for help • They often have troubled family relationships • Histrionic Personality Disorder is characterized by an overwhelming demand for positive attention • Also involves excessive emotionality • Formerly called hysterical personality • Diagnosed more frequently in women • Self-centered and difficulty with delay of gratification • Drawn to fads • Flirtatious/seductive but are too self-centered to make intimate relationships • Lack self-esteem • Narcissistic Personality Disorder is characterized by an grandiose sense of self and an extreme need for admiration • Except for extreme cases, they are still able to maintain long-term relationships and successful careers • Regardless, they still feel envy • Seek the company of flatterers • The relationships are one-sided • Mostly diagnosed in men • Extremely sensitive to narcissistic injuries Cluster C • Avoidant Personality Disorder is characterized by avoidance of social relationships due to fears of rejection • Occur equally in men and women • Like those with social phobia, those with avoidant personality disorder want relationships, but are to afraid to initiate them • In fact, avoidant personality disorder rarely occurs without social phobia comorbidity (but it does happen the other way around) • Dependent Personality Disorder is characterized by difficulty making independent decisions and overly dependent behavior • While the person may be overly submissive and clinging, they could also tend to secretly resent the person who they rely on • Theyʼll avoid positions of responsibility • After marriage, people may turn to their spouses instead of their parents • Overly sensitive to criticism • Needs to be understood in terms of culture • Women are socialized to be more dependent • Sometimes, the dependent will turn to an abusive person to control them • High comorbidity with depression, bipolar disorder, social phobia, hypertension, cancer and gastrointestinal disorders • There is also a correlation between dependent personality disorder and psychodynamically “oral” behavior, like smoking, eating disorders and alcoholism • Obsessive-compulsive personality disorder is characterized by rigid ways of relating to others, perfectionist tendencies, lack of spontaneity and excessive attention to detail • Twice as common in men • Unlike regular OCD, people with OCPD do not necessarily experience outright obsessions or compulsions • If they did, theyʼd warrant both diagnoses • Preoccupation with perfection to the point that it becomes difficult to relax and enjoy pleasant activities Problems with the Classification of Personality Disorders • They may not be reliably differentiated from anxiety and mood disorders • There is a high degree of overlap among disorders • It can be difficult drawing the line at what point normal personality quirks turn abnormal • People often confuse the label attached to behavior as the cause of the behavior • There are noted sexist biases Theoretical Perspectives (p. 454-463) Psychodynamic • Traditional Freudian theory focuses on Oedipus complex as the foundation of all abnormal behavior, including personality disorders • Recent psychodynamic theories have focused on the pre-Oedipal period of 18-36 months when identity is beginning to form • Links between parental abuse and personality disorder may point to the effects that early childhood have on a person • Hans Kohust • This theory was termed Self psychology because of its emphasis on a cohesive sense of self • He believed that people with narcissistic personalities mount a facade of self- importance to cover up feelings of inadequacy • In fact, everybody should have a degree of healthy narcissism, but lack of parental empathy and support leads to pathological narcissism • Otto Kernberg • He views borderline personality disorder in terms of early failure in creating a unified image of oneself and others • When the child cannot synthesize the contradictory elements of themselves and others into unified wholes, they instead shift between extremes of pure idealization and utter hatred • This process is called splitting • Margaret Mahler • In the first year, infants develop an interdependent, or symbiotic, relationship with their mothers • Eventually, they enter a separation-individualization stage where they see themselves as their own people • If they fail this developmental challenge, they can develop borderline personality disorder Learning Perspective • They focus of the maladaptive behaviors rather than disorders of personality • Theodore Milton suggests that histrionic personality disorder may be a result of inattentive parents that only reinforced dramatic expression, and even then, inconsistently • Social-cognitive theories like Ulmann and Krasner emphasize the role of reinforcement in explaining the origin of antisocial behaviors • They occur after a failure to respond to other people as potential reinforces • While this is true, it does not explain the “charismatic” type of antisocial behavior • Bandura emphasized modeling • People with antisocial personalities interpret social experiences differently • They have trouble reading othersʼ faces, especially fear • They have hostile cognitive biases • Problem-solving therapy helps in these cases • Unfortunately, learning theorists, like psychodynmicists, are more grounded in theory than reality Family Perspectives • Disturbances in family relationships underlie the development of personality disorders • People with borderline personality disorder remember parents who were more controlling and less caring • There is also a link to childhood physical or sexual abuse • Parental authoritarianism is connected with dependent personality traits • Antisocial personalities, however, are still up in the air Biological Perspectives • First-degree relatives of antisocial, schizotypal, narcissistic and borderline types are more likely to be diagnosed with the same • Certain psychopathic personality traits like callousness impulsivity and irresponsibility seem to be genetic as well • But it may not be generalizable to all personality disorders • A variant on a particular gene is associated with antisocial behavior in adult men, but only in those maltreated in childhood • There seems to be an interaction between genetic factors and life experiences • Hervey Cleckley found that people with antisocial personalities can maintain composure much better than the average person • In other words, the autonomic nervous system (ANS) is not activated, and the galvanic skin response (GSR) does not give any stress behavior • This may help explain why punishment fails • Other investigators point to the craving for attention model, where antisocial people require a much higher threshold of arousal to feel stimulated • There is a link between borderline and antisocial personality disorders with dysfunction in the brain, especially the prefrontal cortex Sociocultural Perspectives • Antisocial personality is reported most often among lower socioconomic classes • This could be a result of anything including alcohol, drug abuse, teenage pregnancy, disintegrated families, child abuse, neglect and anything else • Cognitively, there could be low self-esteem, anger and resentment • There could be worse role models and school environment • There is little information regarding the prevalence of personality disorders in other cultures • The International Personality Disorder Examination (IPDE) is a semistructured interview protocol for diagnosing personality disorders which is being pilot-tested in 11 countries • Borderline and aviodant types are most frequently diagnosed Treatment of Personality Disorders (p. 463-465) • Both psychodynamic and CBT therapies have been found to be effective • Psychodynamic • Itʼs focused on making people aware of the roots of their self-defeating behavior patterns and learning more adaptive ways to relate to others • Those with borderline and narcissistic disorders often present particular challenges to the therapist • Behavioral • They aim to change behavior rather than personality structures • Through extinction, modeling and reinforcement, they aim to replace maladaptive behaviors with adaptive ones • Aaron Beck focuses on identifying and correcting distorted thinking • Marsha Linehan uses dialectical behavior therapy to treat specifically borderline personality disorder • The therapist provides continuing acceptance and support, even when clients become overly demanding • Sometimes antisocial behaviors are retrained through a token economy, but this has limited effects • Biological • Drug therapy does not directly effect personality disorders • But they can be used to treat the comorbid disorders, like mood and anxiety • SSRIs help temper anger in borderline personalities • Similarly, impuslive and aggressive behavior may be linked to serotonin deficiencies • Atypical antipsychotics have been used for borderline personality disorder as well Impulse Control Disorders (p. 465-469) • We donʼt have to know this for the final Chapter 14: Abnormal Behavior in Childhood and Adolescence Normal and Abnormal Behavior in Childhood and Adolescence (p. 475-478) • In addition to the criteria outlined in chapter 1, we also consider the childʼs age and cultural background • For example, Thai-Buddhist beliefs accept much further extremes, and expect change to come about naturally • Furthermore, new methods of treatment must be used because of many childrenʼs limited verbal abilities • Play therapy is a popular one • 1 in 10 children suffers from a mental disorder severe enough to impair development • The most common is learning disability, followed by ADHD • See Table 14.1 for full statistics • Risk factors include: • Genetic susceptibility • Environmental stressors, like poverty • Major life changes • Family factors • Neglect and abuse specifically can lead to difficulty forming healthy relationships • Possibly due to modeling • Other effects include lowered self-esteem, depression, immature behaviors, suicidal tendencies, poor performance, behavioral problems and fear of the outside world • 1.5 million children in the US are victims of child abuse or neglect • And most cases arenʼt publicly identified, especially verbal or emotional abuse/neglect • Gender affects rates as well • Boys are at greater risk for all childhood disorders • But by adolescence, normal rates take over as girls become more susceptible to mood and anxiety disorders Pervasive Developmental Disorders (p. 478-485) • Children with pervasive developmental disorders (PDDs) show markedly impaired functioning in many areas of development • Usually becomes evident in the first few years of life, and is associated with mental retardation • Originally viewed as extensions of schizophrenia, now itʼs acknowledged as a distinct disorder • Many call these autism spectrum disorders because they follow a similar pattern, but range from less to more severe • 1 in 150 children are affected • Autism is a PDD characterized by failure to relate to others, disturbed motor behaviors, lack of speech, intellectual impairment and extreme demand for sameness in an environment • Asbergerʼs disorder a PDD characterized by social deficits and stereotyped behavior, but without the significant language and cognitive delays associated with autism • Also associated with poor social interaction and development of narrow, obsessive and/ or repetitive behavior • Rettʼs disorder is a PDD characterized by a range of physical, behavioral, motor and cognitive abnormalities that begin after a few months of apparently normal development • Reported only in females • Childhood disintegrative disorder is a PDD characterized by loss of previously acquired skills and abnormal functioning following a period of apparently normal development during the first 2 years of life • More common among males Autism • The word autism comes from the Greek word autos, meaning “self” • Originally, it was a symptom of schizophrenia, its self-centeredness • Similarly, Leo Kramer labeled autism as a tendency to view oneself as the center of the universe • And they see others as a threat • It is unclear why there is a near tenfold increase in reported autism • It may be due to increased cases, or possibly due to improved diagnostic practices and greater awareness • Nobody knows the cause • Not vaccinations • Four times as common in boys • Becomes evident at 18-30 months, but diagnosis usually doesnʼt happen until about 6 • They start as undemanding babies, who often become intolerant of physical affection • They appear to have failed to develop a differentiated self-concept • They also have trouble with symbols and reading emotions • Testing is especially difficult because it is very difficult to get autistic children to cooperate • An outdated etiology is that autism is caused by parents who are “emotional refrigerators” • O. Ivar Lovaas suggested that children with autism canʼt process multiple stimuli, which interferes with symbolic understanding and conditioning • While normal children grow close to their parents through association with primary reinforcers (e.g. food, affection, etc.), autistic children make no such connection • This deficit may explain why sometimes, autistic children are over-sensitive to other stimuli, while at other times, they ignore them entirely, as if they do not exist • Brain scanning show brain abnormalities like malfunctioning circuitry and loss of brain tissue • While itʼs not clear what the sources are, theyʼre probably biological • Early, intensive treatment programs that apply learning principles can significantly improve learning and communication skills, and reduce disturbed behaviors • Painstaking operant conditioning teaches these skills • Theyʼre highly intensive and structured, with a great deal of one-to-one instruction • Results vary • Psychiatric drugs help limit disruptive behavior, but do little to improve the cognitive deficits • Based on the severity of the disorder, and reaction to treatment, people with autism can have a range of adulthood functionality Mental Retardation (p. 485-489) • About 1% of the population is affected by mental retardation, a generalized impairment in the development of intellectual and adaptive abilities • With proper support, guidance and educational enrichment, these handicaps may be mitigated • Mental retardation is diagnosed by three criteria: 1. Low scores on formal intelligence tests (IQ below 70) 2. Impaired functionality compared to those of the same age 3. Development of the disorder before 18 • See chart for how the DSM classifies severity of retardation • Mental retardation seems to come from: • Biological factors • Psychosocial factors • Some combination of the two • Biological: • Chromosomal and genetic disorders • For this reason, females are protected since they have two sets of X chromosomes • Maternal alcohol use during pregnancy • Disease • Psychosocial: • Impoverished home environment • Lack of intellectual stimulation as a child • Prenatal factors: • Rubella • Syphilis • Cytomegalovirus • Genital herpes • Contracted when the infant comes in contact with the motherʼs birth canal, and can be prevented with a caesarean section • Alcohol • Leads to fetal alcohol syndrome • Insufficient oxygen during birth • Toxins ingested during childhood, like lead paint chips • Down syndrome is the most frequently diagnosed disorder, which is caused by an extra chromosome on the 21st pair, leading to 47 chromosomes instead of 46 • It occurs in 1 out of 800 births • Chromosome abnormalities become more common as parents age • In about 95% of cases, the extra chromosome can be traced back to the mother • Physical characteristics: • Round face • Broad, flat nose • Small, downward-sloping folds of skin at the inside corners of the eyes • Protruding tongue • Small, squarish hands with short fingers • Curved fifth finger • Disproportionately small extremities • Deficits include: • Severe mental retardation (see table below) • Malformations of the heart • Respiratory difficulties • 49 year life expectancy • Early senility, like memory loss and childlike emotions • Lack of coordination • Lack of muscle tone • Difficulty following instructions • But that said, most can learn to read, write and perform simple arithmetic • Kleinfelterʼs syndrome is a similar disorder which occurs only with males, who have an XXY chromosome • 1 in 500-1000 births • They fail to develop secondary sex characteristics: • Small testes • Low sperm count • Enlarged breasts • Poor muscular development • Infertility • Also, mild retardation or learning disabilities are common • But men can often not know they have Kleinfelterʼs until they get fertility tested • Turnerʼs syndrome is characterized by only one X chromosome • Ovaries remain underdeveloped • Reduced amounts of estrogen • Women tend to be shorter and infertile • Mild retardation, especially regarding math and science • Fragile X syndrome is an inherited form of mental retardation caused by a mutated gene on the X chromosome • Itʼs the second most common form of retardation overall • 1 out of 1000-1500 men and 1 out of 2000-2500 women • Effects range from mild learning disabilities to profound retardation • Phenylketonuria (PKU) is a genetic disorder that prevents the metabolication of phenylpyruvic acid, leading to mental retardation unless the diet is strictly controlled • 1 in 10,000 births • The acid accumulates in the body, causing damage to the nervous system • Protein supplements compensate for the nutritional loss incurred when these foods are removed from the diet • Prenatal tests detect chromosomal abnormalities and genetic disorders • Amniocentesis draws amniotic fluid at 14-15 weeks, and detects the condition of the fetus • Cultural-familial retardation is a mild form of mental retardation that is influenced by impoverishment of the home environment • These children respond incredibly well to intervention, even more so the earlier itʼs done • This is one of the goals of the Head Start program Intervention • With appropriate training, children with mild retardation can reach sixth-grade levels of competence along with vocational skills and may even be mainstreamed to regular classes • This is a controversial decision • Sometimes, however, in cases of destructive behavior, the child will need to be institutionalized • But not due to mental impairment • The Developmentally Disabled Assistance and Bill of Rights Act of 1975 provided that persons with mental retardation have the right to receive appropriate treatment in the least-restrictive treatment setting • This led to huge and generally successful deinstitutionalization for people with mental retardation • However, people with mental retardation stand at a high risk of developing other disorders, like anxiety, depression and behavioral problems Learning Disorders (p. 489-492) • A learning disorder is a deficiency in a specific learning ability in the context of normal intelligence and exposure • Theyʼre typically chronic • Usually have other psychological problems, like low self-esteem • High comorbidity with ADHD • There are three types of learning disorders: • Mathematics Disorder • Disorder of Written Expression • Reading Disorder (dyslexia) • Dyslexia is the most common, accounting for 80% of learning disabilities, and is characterized by impaired reading ability • Affects 4% of school-age children • Much more commonly diagnosed in boys, possibly because they tend to be more disruptive when they donʼt understand • Comorbidity with depression • Higher rates in harder languages, like English and French, as opposed to simpler ones like Italian • Dyslexia may be caused by a less active left hemisphere, and may be genetic • It takes two general forms - genetic and environmental • The genetic is caused by defective mental circuitry • Children need compensate by relying on other brain capacities • It takes time, but is effective • In environmental deficiencies, they rely on remembering words, as opposed to developing skills necessary to read them • This is associated with low SES • More difficult to deal with • Good therapists need to tailor to each childʼs particular type of disability Communication Disorders (p. 492-493) • Communication disorders are persistent difficulties in understanding or using language • Expressive language disorder - impairment in the use of spoken language: • Slow vocabulary development • Errors in tense • Difficulties recalling words • Problems producing sentences of appropriate length and complexity • Mixed receptive/expressive language disorder - difficulties both understanding and producing speech • Ex. Word types (large, huge, big) • Ex. Spatial terms (near, far, close) • Ex. Sentence types (words that start with the word “unlike”) • Ex. General difficulty understanding • Phonological disorder - persistent difficulty articulating the sounds of speech in the absence of defects in the oral speech mechanism or neurological impairment • Often resolves itself by 8 • Children with disorder will omit words that have the sound, or replace it with another • Stuttering - disturbance in the ability to speak fluently with appropriate timing • Affects about 1 in 100 before puberty • Characterized by: • Repetitions of sounds and syllables • Prolongations of certain sounds • Interjections of inappropriate sounds • Broken words • Blocking of speech • Circumlocutions • Displaying an excess of physical tension when emitting words • Affects 3 times as many males • About 80% overcome it by 16 • Genetic and environmental influences interact, along with emotional component Attention-Deficit and Disruptive Behavior Disorders (p. 493-499) Attention Deficit Hyperactivity Disorder • ADHD is a behavior disorder characterized by excessive motor activity and inability to focus oneʼs attention • Hyperactivity is an abnormal behavior pattern characterized by difficulty maintaining attention and extreme restlessness • Affects 3% to 7% of children • 2-9 times more often in boys • More often in whites • Associated problems include inability to sit still, bullying, temper tantrums, stubbornness and failure to respond to punishment (see chart) • ADHD breaks down into three subtypes: • Prediminantly inattentive type • Predominantly hyperactive or impulsive type • A combination of the two • While they tend to have average to above-average intelligence, they also tend to be: • Underachievers • Disruptive • Aggressive (especially boys) • Bad with instructions • Have learning disabilities Taken from Abnormal Psychology in a Changing World, 7th Ed, International 65/77 • Have mood and anxiety disorders • Lack empathy (especially boys) • ADHD symptoms tend to decline with age, but never disappear • 4.4% of adults have had it at some point • Genetics play a key role • Probably after interacting with the environment ADHD Treatment: • Stimulants like Ritalin, Concerta are used • Because Concerta is a once-a-day drug, itʼs the most commonly prescribed drug • They activate the prefrontal cortex • Stimulants not only reduce disruptive, hyperactive behavior, but also improve attention spans • There is a high rate of relapse after the medication is stopped, and range of effectiveness is limited • Short-term side effects include: • Loss of appetite • Insomnia • Slowdown of physical growth • Strattera was the first nonstimulant drug used • Itʼs a selective norepinephrine reuptake inhibitor (SNRI) • Drugs cannot teach new skills • Behavioral interventions, like behavioral modification programs have demonstrated therapeutic benefits Conduct Problems • Conduct Disorder (CD) is a psychological disorder in childhood and adolescence characterized by disruptive, antisocial behavior • Unlike with ADHD, these children are capable of controlling their behavior; they just choose not to • It affects about 12% of males, 7% of females (9.5% overall) • In boys, conduct disorder is focused more on aggression, stealing, vandalism and disciplinary problems • In girls, itʼs more likely to involve lying, truancy, running away, substance abuse and prostitution • Median age is 11.6 years • But even before and after the median age, boys are more commonly diagnosed • High comorbidity rate with ADHD, social withdrawal and major depression • Itʼs closely linked to antisocial behavior, callousness and relating unemotionally • Oppositional defiant disorder (ODD) is a psychological disorder in childhood and adolescence characterized by excessive oppositionality or tendencies to refuse requests from parents and others • ODD is more closely related to non-delinquent conduct disturbance • Typically develops earlier than CD and may lead to it or antisocial behavior • Negativistic or oppositional • One of the most common diagnoses among children • 6-12% of school-age children and over 15% of adolescents • Among 12 or younger, itʼs more common with boys, but over 12, itʼs more common with girls • Etiology: • Some believe itʼs due to an underlying temperament described as the “difficult child” type • Others say itʼs due to unresolved parent-child conflicts • Overly strict parental control • Psychodynamic: Anal fixation which occurs during toilet training conflicts • Learning: parental use of inappropriate reinforcement strategies • Family factors, like ineffective and overly negative parenting styles, marital conflict • Parents often have antisocial personalities and substance abuse issues • Cognitive biases • Some genetic contribution • Treatment: • Parent-training programs • Better behavioral training • Problem solving techniques • Reinforcement • Frequency of positive interactions • Children with CD are sometimes placed in residential treatment programs • Training in how to manage conflict without resorting to aggressive behavior Childhood Anxiety and Depression (p. 499-506) • Five types of relevant anxiety disorders: • Specific phobias • Social phobias • Generalized anxiety disorder • PTSD • OCD • Separation anxiety disorder Separation anxiety (and most anxiety disorders) • Separation anxiety disorder is diagnosed when separation produces anxiety and is persistent and excessive or inappropriate for the childʼs developmental level • Mary Ainsworth did a lot of work on this, relating it to parenting styles • Marked by too much concern with death and dying, irrational fear that something will happen to them or their parents if they separate • Occurs in 4% to 5% of children, most often girls, and associated with school refusal and social anxiety • This is why it used to be called school phobia • In the worst cases it persists to adulthood • Often follows a stressful life event • Etiology: • Psychoanalytic: itʼs about unconscious conflicts, just like with adults • Cognitive: cognitive biases, like adults. Interpreting ambiguous situations as threatening, and expecting bad things to happen • Learning: fears of rejection and failure which carry across situations • Biological: genetic • CBT is often used • Gradual exposure • Relaxation training • Fluvoxamine (Fluvox) is a SSRI which is often assigned • It shows effects with anxiety Childhood Depression • Includes major depression and bipolar disorder • An estimated 3 million adolescents in the US suffer from major depression • Even rarely among preschoolers • During childhood, thereʼs no discernible gender difference, but after adolescence, girls follow the normal pattern of being twice as depressed • Childhood depression mostly follows the same path, but has a few distinctive features • Refusal to attend school • Fear of parents dying • Clinging to parents • Conduct disorder • Academic problems • Physical complaints • Among adolescents, sexual acting out and aggression come into play as well • Often, children donʼt even report feeling sad • This may be a cognitive issue, because children usually have trouble recognizing internal feeling states until 7 • About 20-40% of depressed adolescents later develop bipolar disorder Etiology and Treatment: • Children exposed to stressful life events stand an increased risk of depression • Like adults, their cognitive style characterized by negative attitudes towards themselves and others, and pessimistic attributional style • This means problems are internal, stable and global • Distorted cognitions of depressed children include: • Expecting the worst (pessimism) • Catastrophizing • Assuming personal responsibility for negative outcomes • Minimizing accomplishments • Focusing on negative aspects of events • Like with adults, unclear whether depression or attribution errors come first • CBT has shown modest success • Lithium has been used for bipolar disorder • SSRIs like Prozac (fluoxetine), Zoloft (sertraline), and Celexa (citalopram) are showing promise for depression Suicide • Among college students, suicide is the second leading cause of death after motor accidents • Among 15-24, itʼs the third most common, after homicide and accident • .01% rate • Teenage suicide was big in the 1990ʼs but has since subsided • Risk factors for adolescent suicide include: • Gender • Age • Geography • Less populated areas carry a higher likelihood of suicide • Race • Native Americans are highest, followed by Whites • Depression/hopelessness • Past suicidal behavior • Prior sexual abuse • Increases risk tenfold • Strained family relationships • Stressful/traumatic life events • Substance abuse • Social contagion Elimination Disorders (p. 506-509) • Enuresis - Failure to control urination (daytime +/or nighttime) after one has reached the expectable age for attaining such control (5+) • Must be frequent (2+/week for 3+ months) &/or distressing/impairing • Not due to medical condition • 7% of boys, 3% of girls by 5 • In about 1%, it continues to adulthood • Bed-wetting usually occurs during the deepest stage of sleep and may reflect the immaturity of the nervous system • Theoretical perspectives: • Psychodynamic: expression of hostility toward parents because of harsh toilet training • Regression in response to a stressor • Learning: parents attempted to train too early, associating bladder control with anxiety • Primary enuresis is the most common, when children never learned how to establish urinary control in the first place • In this case, it is most likely that genetic, environmental and behavioral factors come into play • Secondary enuresis is when children learn how to control, but then forget • This, on the other hand, isnʼt genetically influenced • Treatment: • Usually resolves itself • O. Hobart Mowrer invented the urine alarm method in the 1930ʼs, using classical conditioning technique • Certain drugs help, like Luvox (fluvoxamine), an SSRI • But urine alarm has highest success rate, and lowest relapse • Encopresis is lack of control over bowel movements, not caused by an organic problem, for children over 4 • Caused by inconsistent/incomplete toilet training • More likely to happen during the day, and therefore very embarrassing • As such, there are more emotional and behavioral problems associated • Often involuntary, and associated with constipation, impaction or retention that results in overflow • May be related to psychological factors Appendix Anxiety Disorders • See slides for more summary Mood Disorders Eating Disorders Schizophrenia Personality Disorders Childhood and Adolescence [Show More]

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