Tuesday 10/6

http://courses.ucsd.edu/frose/ps163

Assessment and Classification

Assessing Psychological Disorders

Purposes of clinical assessment
○ Understanding
○ Predict
○ Treatment planning
○ Treatment outcome
No single treatment works for everybody in the same way
Analogous to a funnel
○ Start broad, get more narrow as you go along
 "Tell me what brought you in today" > > > > Diagnosis

Assessment concepts

Value of assessment depends on:

Reliability The degree to which a measurement is consistent
○ Validity The degree to which a technique measures what it is designed to measure
Standardization Application of certain standards to ensure consistency across different measurements
○ Reliability vs. validity - Consistent measurement, but measuring the wrong thing (it can happen)
○ Construct validity : Is our construct/concept accurately being measured?
○ A measure can be reliable but not valid. A measure cannot be valid unless it is reliable.
○ Rosenhan paper ("Being sane in insane places")
 Pseudopatients
□ Researcher and assistants went to mental health facilities with a made -up symptom and each were
diagnosed with schizophrenia, given medication (probably halidol - study done in 70s) and admitted to the
hospital for 13-62 days. Nobody caught on and they were dismissed with the label of schizophrenic.
 Patients caught on to ruse, but staff did not

The Clinical Interview and Physical Exam

• Clinical interview
○ Most common clinical assessment method
○ Structured or semi-structured
 Set # of questions asked in the same order to every potential patient.ion
□ Pitfalls: Too structured means that patient can't give a "richer" evaluation, and not structured enough
means it's harder to measure what you think you're measuring
□ Best compromise is probably having a set list of questions but letting the patient "take the lead" as needed

• Physical exam
○ Important because many physical ailments can cause or masquerade as psychological issues
 i.e. hypothyroidism causing same symptoms as depression

• The Clinical Interview

○ Purpose: Understanding
○ Mental Status Exam
 Appearance and behavior
□ Consistent with expected environment? Any early "red flags"? (Hygiene, etc.) Anxious or depressed -looking
behavior
□ Okay to take cultural background into consideration - actually it's important to
 Thought processes
□ What sorts of thoughts are they thinking and how are they being expressed? (Logical, disjointed, etc.)
 Mood and affect
□ Make sure they're consistent - what they say vs. what they're expressing
 Intellectual functioning
Ensure that they're at least baseline functional and try to assess i.e. vocabulary and education level

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 □ Ensure that they're at least baseline functional and try to assess i.e. vocabulary and education level
 Sensorium
□ A person's awareness of the "here and now" - are they in the moment?
 A&O x 3 (alert and oriented times three)
◊ Are they alert/Do they know where they are/what day it is/why they're there or who they are.
○ Psychological testing and projective tests
 Projective tests
□ i.e. Rorschach tests
 Subjective, easy to fake, easy to misdiagnose or extrapolate incorrectly, small standard set of slides
 Objective tests
□ Series of questions with set options (true/false, 1-5) that get counted/scored and lead to a result
 i.e. Myers-Briggs test
 Objective intelligence tests
 i.e. Weschler, Stanford-Binet

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Thursday 10/8
Thursday, October 08, 2009
3:38 PM
Neuropsychological Tests
Assess broad range of abilities
My Soup Lacks Many Hot Peas
○ Motor skills
 e.g. right hand vs left hand dexterity
○ Sensory functioning
 Ability to accurately sense various stimuli
○ Language
 Language output, ability to speak and name objects, grammar,
understanding language, repetition (connection between reception
and production)
○ Memory
 Both short term and long term
○ Higher brain functioning
 Reasoning, interpretation, e.g. understanding proverbs

Never ever ever base an outcome on the result of a single test

Classification and Diagnosis

○ Categorical approach
 If X, then Y; If not X, then not Y
○ Dimension approach
 How much of X?
○ Prototypical approach
 How much of X does it take for Y?

The Five DSM-IV Axes

○ Axis I - Most major disorders
○ Axis II - Stable, enduring problems
○ Axis III - Medical conditions
○ Axis IV - Psychosocial problems
- Axis V - Global assessment of functioning

Example:
- Axis I
 300.30 Obsessive-compulsive disorder
 296.22 Major depressive disorder
- Axis II
 301.7 Antisocial personality disorder
- Axis III
 None
- Etc.

DIFFERENCE BETWEEN: Reliable, valid, standardized

Reification
Stigmatization

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 Tuesday 10/13
Tuesday, October 13, 2009
3:32 PM

EXAM NEXT WEEK.

How to distinguish between disorders

Known causes
Treatment approaches

Nature of Anxiety and Fear

• Anxiety and fear: Moods (normal!), symptoms, and syndromes
○ In abnormal psych, where do you draw the line between normal/abnormal?
○ Short answer: When it begins to interfere with your life
○ Can be relative - one man's phobia is another man's hobby
• Fear
○ Fight or flight
 Biological readiness to deal with immediate threat
○ Sympathetic nervous system activation
○ Avoidance & escape
○ Present-oriented

WHOOPS BACKTRACK WRONG LECTURE

Somatoform disorders
• Preoccupation with health, physical appearance and function
○ With no identifiable medical cause
• DSM-IV somatoform disorders
○ Hypochondriasis
 Clinical description
□ Physical complaints; no clear cause
□ Severe anxiety over having a serious disease
□ Strong disease conviction
□ Not usually part of the pop culture display
□ Medical reassurance useless
 Statistics
□ 1-3% prevalence
□ Affects men and women equally
 Previously thought to be mostly female
□ Occurs across all age ranges
□ Onset can occur at any time
□ Chronic
 Physical evaluation
□ Rule out actual physical problem
 Diagnosis
□ Psychological evaluation
 Rule out actual physical problem
□ Determine nature of complaints
 Disease conviction
 Illness conviction
 Illness phobia
 Anxiety disorder
Cultural difference (Koro, dhat, etc.)

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 □ Cultural difference (Koro, dhat, etc.)
 Causes
□ Cognitive perceptual distortions
 Unpredictable and uncontrollable world
□ Overly attentive to physical sensations
□ Misinterpretation of sensations
□ Interpersonal influences
 Trigger event
 Family history of illness
 Rewards of sick role
 Integrative model of causes of hypochondriasis (graph)
□ Trigger (information, event, illness, image)
 Perceived threat
◊ Apprehension
► Increased focus on body
► Increased physiological arousal
► Checking behavior and reassurance seeking
 Preoccupation with perceived
alteration/abnormality of bodily
sensations/state
– Misinterpretation of body sensations
and/or signs as indicating severe illness
– BACK TO APPREHENSION
 Treatment
□ Challenge illness-related misinterpretations
 Collaborative empiricism to open dialogue
□ Substantial and sensitive reassurance
 Humanist approach
□ Stress management and coping strategies

○ Somatization disorder
 Clinical description
□ Extensive physical complaints before age 30
□ Marked impairment
□ Focus on symptoms, not illness
 Symptoms must come from multiple systems within the body
 i.e. be fairly unreasonable that someone could be suffering from
all of them legitimately
□ Symptoms become the person's identity
□ QUESTION FOR OFFICE HOURS: Someone internalizing symptoms
without having somatization disorder >30?
 Statistics
□ Rare
□ Onset usually in adolescence
□ Mostly affects unmarried, low SES women
 Not a lot of resources, most likely very stressed
 Having complaints enables one to feel entitled and possibly get
financial support due to supposed illness
□ Runs a chronic course
 Causes
□ Familial history of illness
□ Antisocial personality disorder
□ Weak behavioral inhibition system
Possible link to antisocial personality disorder?

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 □ Possible link to antisocial personality disorder?
 Some manipulative aspects involved
 Treatment
□ Often very treatment resistant
□ Limit visits to doctor unless there is a (definitive) emergency
□ Assign "gatekeeper" physician
□ Behavioral approaches
 Operant condition, etc.
 Removing rewards for sick role behavior
 Develop rewards for acting against symptoms
 "Fix your own sandwich"

○ Conversion disorder
 Clinical description
□ Physical malfunctioning without organic pathology
□ Typically sensory-motor areas
□ La belle indifference
 "Oh. I can't walk. Huh."
 In 1/3rd of patients
□ Retains most normal functions, but unaware
 Not faking
 e.g. "blindsight"
 Statistics
□ Rare condition, chronic intermittent course
□ Females, onset in adolescence
 Causes
□ Psychodynamic view
□ Trauma, conversion, and secondary gain
□ Detachment from the trauma and negative reinforcement
□ Trauma is too overwhelming, so is psychodynamically"converted" to
physical ailment
 Treatment
□ Similar to somatization disorder
□ Attend to the trauma
□ Behavioral approaches

○ Pain disorder
○ Body dysmorphic disorder
 Clinical description
□ Preoccupation with imagined defect
□ Fixation on or avoidance of mirrors
□ Suicidality
□ Ideas of reference
□ Paranoia
 Statistics
□ Lifelong, chronic course
□ More common than previously thought
□ Seen equally in males and females, with onset usually in early 20s
□ Most remain single, and many seek out plastic surgeons
 Causes
□ Unknown, tends to run in families
□ Related to OCD?
 Treatment
SSRIs provide some relief

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□ SSRIs provide some relief
□ CBT
 Cognitive Behavioral Therapy
□ Exposure and response prevention
□ Plastic surgery is often unhelpful

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Thursday 10/15
Thursday, October 15, 2009
3:34 PM

Video: Patient with Body Dismorphic Disorder

Dissociative Disorders

Compared to somatoform disorders; both involve possibilities for early trauma. What are the
similarities?

Two classes of disorders are thought to be maladaptive coping strategies for dealing with anxiety
One is pushing anxiety to a physical expression
The other is avoidance

○ Overview
 Involve severe alterations or detachments in identity, memory, or consciousness
 Depersonalization - Distortion in perception of reality
□ e.g. "out of body" experiences
 Derealization - Losing a sense of the external world
□ e.g. others appear to be moving in slow motion, buildings appear shaped oddly
 Variations of normal depersonalization and derealization experiences
□ Everyone experiences such things occasionally and mildly
 e.g. time dilation effects in times of extreme stress like car crashes
 "Highway hypnosis"
◊ COGS1: Also related to grouping of route information in brain?

Depersonalization Disorder
○ Overview and Defining Features
 Severe and frightening feelings of unreality and detachment
 Such feelings and experience dominate and interfere with life functioning
 Primary problem involves depersonalization and derealization
○ Facts and Statistics
 Comorbidity with anxiety and mood disorders is extremely high
 Onset is typically around age 16
 Usually runs a lifelong chronic course
○ Causes
 Show cognitive deficits in attention, short-term memory, and spatial reasoning
 Such persons are easily distracted
 Cognitive deficits correspond with reports of tunnel vision and mind emptiness

Dissociative Amnesia & Dissociative Fugue

○ Overview
 Dissociative Amnesia
□ Includes several forms of psychogenic memory loss
□ Generalized type - Inability to recall anything, including their identity
□ Localized or selective type - Failure to recall specific (usually traumatic) events
 Dissociative Fugue
□ Related to dissociative amnesia
□ Such persons take off and find themselves in a new place
□ Lose ability to remember the past and relocation
□ Such persons often assume a new identity
As person gets distances from the trauma, often memories of their old life and

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 □ As person gets distances from the trauma, often memories of their old life and
eventually their old identity resolve on their own and both the amnesia and fugue
recede (often within hours or days).

○ Fugue: Causes and Treatments

 Statistics
□ Dissociative amnesia and fugue usually begin in adulthood
□ Both conditions show rapid onset and dissipation
□ Both conditions occur most often in females
 Causes
□ Little is known, but trauma and stress seem heavily involved
□ Not well known about difference between simple amnesia and fugue; fugue
considered more extreme trauma
 Treatment
□ Persons with dissociative amnesia and fugue usually get better without treatment
□ Most remember what they have forgotten

 Often an incident of adaptive amnesia to block out a traumatic event (e.g. rape) will usually
not repeat if a similar event occurs, but could if a dissimilar event does

QUESTION FOR OFFICE HOURS: What is the biological basis for amnesia?

Dissociative Trance Disorder

○ Clinical Description
 Symptoms resemble those of other dissociative disorders
 The clinical presentation varies across cultures
 Involves dissociative symptoms and sudden changes in personality
 Symptoms and personality changes are often attributed to possession by a spirit
 Symptoms must be considered undesirable/pathological by the culture
□ e.g. not holy rollers, speaking in tongues, etc.

Dissociative Identity Disorder (DID)

○ Clinical Description
 Adoption of several new identities
□ Not truly new personalities in the sense that we understand it
 Identities display unique behaviors, voice, and posture
□ Definitely an obvious change, not just a role change
 Formerly known as multiple personality disorder
□ Fringe reports of needing different eyeglass prescriptions, switches in handedness,
reactions to different medications
□ Definitely needs more study before it can be considered true
 Dissociation of certain aspects of personality
○ Unique aspects of DID
 Alters - Refers to the different identities or personalities in DID
 Host - The identity that seeks treatment and tries to keep identity fragments together
□ Dominant most often
□ May not necessarily be the core personality - who the person was before the disorder
 Switch - Often instantaneous transition from one personality to another
 Goal of therapy is not to get rid of all alters but the host or core, but to integrate all the
personalities together into one gestalt
□ Kind of like group therapy with an individual - get everyone aware of each other and
okay with each other
□ Alters often fight for dominance, don't like to be in the background
Book: First Person Plural, by Cameron West

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 Alters often fight for dominance, don't like to be in the background
□ Book: First Person Plural, by Cameron West
 Semiautobiographical
□ Sometimes alters are used for general life issues
 e.g. an alter for eating and swallowing, one for dealing with anger, etc.
□ Often a difficult diagnosis to come to
 "When you hear hooves you think of horses, not zebras"
 Controversial diagnosis
 Don't want to throw the label around, as some people can suddenly start to
"develop" alters when given the diagnosis
 Often mistaken for something else at first
○ Statistics
 Average number of identities is close to 15
 Ratio of females to males is high (9:1)
 Onset is almost always in childhood
 High comorbidity rates, with a lifelong chronic course

○ Mapping the Inner House

 Sherry
 Mary, Baby & Birdie, Seraphim, Little Sherry, Candy, Twin 1, Twin 2, etc.

○ Causes
 Almost all patients have histories of horrible, unspeakable, child abuse
 Closely related to PTSD
 Most are also highly suggestible
 DID is viewed as a mechanism to escape from the impact of trauma
○ Treatment
 Focus is on reintegration of identities
 Aim is to identify and neutralize cues/triggers that provoke memories of trauma

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Tuesday 10/27
Tuesday, October 27, 2009
3:33 PM
Panic Disorder: Treatment
○ Psychological and Combined Treatments
 Cognitive-behavior therapies are highly effective (PCT)
 Combined treatments do well in the short term
□ SSRIs in particular, not so much the benzodiazepines
 Best long-term outcome is with cognitive-behavior therapy alone

Specific Phobias: An Overview

○ Extreme irrational fear of a specific object or situation
○ Markedly interferes with one's ability to function
○ Avoidance of feared object
○ Knows that the fear and avoidance are unreasonable
Associated Features and Subtypes
○ Blood-injury-injection phobia
 Vasovagal response to blood, injury or injection
○ All other subtypes are less meaningful
Facts and Statistics
○ Females are again over-represented
○ About 11% of the general population
○ Chronic course, with onset beginning between 15 and 20 years of age
Causes
○ Biological and evolutionary vulnerability
 Prepared learning: If we can preserve some genetic sensitivity to things that are a threat, then we're more likely to survive
○ Direct conditioning
○ Observational learning
○ Information transmission
Psychological treatments
○ CBTs are highly effective
○ Systematic desensitization
 Highly effective
○ Flooding
 "Trial by fire"

Post-Traumatic Stress Disorder (PTSD)

○ Overview
 REQUIRES (according to DSM) exposure to an event resulting in extreme fear, helplessness, or horror
 Re-experiencing
 Avoidance of cues
 Emotional numbing and/or arousal
 Markedly interferes with one's ability to function
 Symptoms > 1 month
○ Statistics
 Combat and sexual assault are the most common traumas
 About 7.8% of the general population meet criteria for PTSD
□ "Not terrible uncommon"
 Most commonly associated with Vietnam, but we've seen symptoms in veterans from Korea and WW2 but it was called war fatigue,
war neurosis or shell shock
○ Subtypes
 Acute PTSD
□ 1-3 months post trauma
 Chronic PTSD
□ >3 months post trauma
 Delayed onset PTSD
□ Onset >6 months post trauma
 Acute stress disorder
□ Immediately post-trauma
○ Causes
 Intensity of the trauma and one's reaction to it
□ With more severe traumas, virtually anyone will be susceptible
 e.g. during 9/11
 Uncontrollability and unpredictability
 Direct conditioning and observational learning
 Moderator: Social support
○ Treatment
 Psychological treatment
 CBTs are effective to an extent
□ Trying to help them cope rather than eliminate effects entirely
 Can't erase memories, don't want to
Graduated or massed (e.g., flooding) imaginal exposure

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 □ Graduated or massed (e.g., flooding) imaginal exposure
 e.g. violent video games?
□ Some try to recreate or alter the memories via hypnosis
 Medical treatments
□ SSRIs are helpful

Obsessive Compulsive Disorder

○ Overview
 Obsessions - Intrusive and nonsensical thoughts, images, or urges that one tries to resist or eliminate
□ Contamination
 Germaphobes don't realize - we need our immunity! We're running around with our bottles of Purel and creating more
resistant bugs. We're going to wipe out the human race because we're overly concerned with sanitization.
□ Aggression
□ Symmetry
 Compulsions - Thoughts or actions to suppress the obsessions
□ Overt: Cleaning and washing, checking rituals
□ Covert: Sequencing, repetition
 More like mental exercises; counting
◊ Threes and sevens are highly common for some reason
 Obsessions
□ Doubts (74%)
 Did I lock the door? (M, 28)
□ Thinking (34%)
 Fear that he had cancer (M, 46)
 Image that he had knocked someone down in his car (M, 26)
□ Fears (26%)
□ Impulses (17%)
 Impulse to shout obscenities in church (F, 19)
 Impulse to drink from inkpot and strangle son (M, 41)
□ Images (17%)
 Of corpse rotting away (F, 27)
□ Other (2%)
○ Statistics
 About 2.6% lifetime adult prevalence rate
 Mostly female
 Onset in early adolescence or young adulthood
□ Possibility for children to have?
 Tends to be chronic
○ Causes
 Parallel the other anxiety disorders (biopsychosocial interactions)
 Early life experiences and learning
□ Some thoughts are dangerous but controllable
 Thought-action fusion
□ Moral vs. likelihood
 "Thinking about swearing in church is just as bad as actually doing it"
◊ Believe themselves to be bad people, adds to anxiety
○ Multisite OCD study - Foa and Liebowitz (1997)
 Primary aim
□ Compare independent and combined effects of clomipramine and exposure-response prevention (ERP)
 Treatment conditions
□ Clomipranine (CMI) alone
□ ERP alone
□ Clomipranine + ERP
□ Pill placebo alone
 Sample
□ 99 patients meeting DSM-III-R criteria for obsessive compulsive disorder
 2 phases of the study
□ Acute phase (12 weeks)
□ No treatment follow-up (6 months)
 Study slides for graph
□ Using ERP was the most effective and with zero relapse

Wrapup
• Anxiety disorders represent some of the msot common forms of psychopathology
• From a normal to a disordered experience of anxiety and fear
○ Fear and anxiety persist to bodily or environmental non -dangerous cues
○ Symptoms and avoidance cause distress and impairment
○ Consideration of biological, psychological, experimental and social factors
• Psychological treatments are generally superior in the long-term
○ Most treatments involve exposure
○ Suggests that anxiety-related disorders share common processes

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Thursday 10/29
Thursday, October 29, 2009
3:34 PM
Post-Traumatic Stress Disorder
○ Requires exposure to an event resulting in extreme fear, helplessness, or horror
○ Re-experiencing that trauma
○ Avoidance of cues
○ Emotional numbing and/or arousal
○ Markedly interferes with one's ability to function
○ Symptoms > 1 month

Video on PTSD

Mood Disorders
○ Extremes in normal mood
 Nature of depression
 Nature of mania and hypomania
○ DSM-IV Depressive Disorders
 Major depressive disorder
 Dysthymic disorder
 Double depression
○ DSM-IV Bipolar Disorders
○ Major Depressive Eposide
 Depressed mood
 Anhedonia
□ Inability to experience pleasure
 Cognitive symptoms
 Vegetative symptoms
□ Changes in eating; usually weight loss
□ Sometimes insomnia or hypersomnia
○ Major Depressive Disorder
 Single episode
□ Major depressive episode that lasts for >= 2 weeks and interferes with normal functioning
 Recurrent episodes
○ Dysthymia
 Overview
□ Depressed mood for at least 2 years
□ Mild
□ Chronic
 Statistics
□ Late onset - early 20s
□ Early onset - Before age 21, poorer prognosis
○ Double Depression
 Overview
□ Major depressive episodes AND dysthymic disorder
□ Dysthymic disorder typically first
 Statistics
□ Severe psychopathology
□ Poor outcome
□ Most difficult to treat
○ Bipolar I Disorder
 Overview
□ Full manic episodes and major depression
 Statistics
□ Average age on onset is 18 years
□ Chronic
Suicide is common

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 □ Suicide is common
 Bipolar I has the highest suicide risk
○ Bipolar II Disorder
 Overview
□ Hypomanic episodes and major depression
 Statistics
□ Average age on onset is 22 years
□ Only 10 to 13% of cases progress to bipolar I
 Bipolar II is not as serious as bipolar I
 Not considered to be a "bipolar I waiting to happen"; separate disorders
□ Chronic
○ Cyclothymic
 Overview
□ Milder mania and depression
□ Pattern must last for at least 2 years
 Statistics
□ High risk for developing bipolar I or II
□ Most are female
□ Average age on onset is early adolescence
○ The Bipolar Spectrum
 The disorders cycle back and forth every few days, from normal > cyclothymic > bipolar II > bipolar I

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Tue. 11/03
Tuesday, November 03, 2009
3:33 PM
The Bipolar Spectrum

Major Depressive Mnemonic

SIGECAPS
Sleep
○ Disturbance
○ Insomnia (typical)
○ Hypersomnia (atypical)
○ Early-morning wakening
Interest
○ Anhedonia
Guilt
Energy

Concentration
Appetite
○ Disturbance, sometimes anorexia or overeating
Psychomotor
○ How much effort someone subjectively feels it takes to do things
Suicide
○ Not just considered it, actually planned it out - i.e. not just calls for help
○ Important to try and build a contract - the client will call the doctor if they feel they're considering suicide too strongly

Mood Disorders: Characteristics

Characteristic Major Dep'n Dysthymia Bipolar I Bipolar II Cyclothymia
Onset 25-29 20-25 18 22 12-14
Pattern Stable Stable Variable Variable Variable
Duration 2 weeks 2 years Varies Varies 2 years
Chronicity 6-9 months Chronic Chronic Chronic Chronic
Lows Severe Mild Severe Severe Mild
Highs No No Manic Hypomanic Hypomanic
Suicide Risk 12% Low 24% 17% Low

Bipolar disorders have a higher risk of suicide than the unipolar disorders. Why?
○ Research is mixed. Some think the suicide rate for bipolar II is higher than bipolar I.

Mood Disorders: Subtypes

Major Depressive Disorder

Dysthymic Disorder
 With melancholic features
 With atypical features
 With psychotic features
 With catatonic features
 With postpartumfeatures
 With seasonal onset (SAD)

Bipolar Disorders
Cyclothymic Disorder
Depression Mania
Melancholic Psychotic
 Atypical Catatonic
Postpartum
Seasonal onset

Additional Facts and Statistics

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Additional Facts and Statistics
Lifetime Prevalence
 About 7.8% of the US population
Sex Differences
 MDD: 2:1 Women to Men
 Bipolar disorders: 1:1
○ Most depressed persons are anxious, not all anxious persons are depressed

Genetic Influences
○ Strong familial inheritance patterns for both major depression and bipolar
○ Serotonin transporter gene (5-HTT) is ONE candidate
○ Depression in MDD and bipolar have same genetics
○ Mania has a separate genetic influence

Genetic Influences
Identical twins much more likely to also develop depression/bipolar than just fraternal twins

Neurobiological Influences
○ Neurotransmitter systems
 Serotonin
□ Some people are questioning if serotonin actually plays as much a part as previously thought
 Permissive hypothesis
○ The Endocrine System
 Cortisol and Dexamethasone suppression test (DST)
○ Sleep and Circadian Rhythms
 Sleep disturbance = hallmark

Learned Helplessness
○ Animal Research (Seligman and Maier, 1967)
○ Dogs learn to avoid shock by jumping a barrier.
○ Dogs who previously cannot control shock do not subsequently learn to avoid shock.
○ Instead, these dogs become "helpless".

Psychological Dimensions (Learned Helplessness)

○ The Learned Helplessness Theory of Depression
 Related to lack of perceived control over life events
○ Depressive Attributional Style
 Internal attributions - Negative outcomes are one's own fault
 Stable attributions - Believing future negative outcomes will be one's own fault; pessimism
 Global attribution - Believing negative events will disrupt many life activities
○ All three domains contribute to a sense of hopelessness

Beck's Cognitive Triad

○ Aaron Beck
 Psychiatrist in the 60s doing classic psychotherapy, noticed patients would make strange logical leaps when talking
□ Negative view of themselves
□ Negative view of the world
□ Negative view of the future
 Mirrors Seligman's attributional styles
○ Beck's Cognitive Model (1967)
 Early Experience >
□ Formation of Depressogenic Schemas
 Critical Incidents
◊ Schemas Activated
► Negative Automatic Thoughts (NATs)
 Symptoms
– Behavioural
– Cognitive
– Motivational
– Somatic
– Affective
 Depressive Cognitions
□ Negative Cognitive Triad
 (Pessimistic views of the self, the world and the future)
□ Depressogenic (negative) Schema
 Triggered by negative life events. (e.g. "I must be the best at everything")

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 Triggered by negative life events. (e.g. "I must be the best at everything")
□ Cognitive Biases (Systematic Logical Errors)
 Arbitrary Inference - The professor must think I'm stupid because I got a D.
 Selective abstraction - I did poorly because I'm stupid.
 Overgeneralization - I got a D. I'm going to flunk out of school.
 Magnification & Minimization - That A was a fluke.
 Personalization - The professor didn't call on me; he must think I'm dumb.
 Absolutist Dichotomous Thinking - If I don't get an A, I'm a loser.
 Should & Must Statements - I have to get the highest grade.
◊ Result: Depression

An Integrative Theory
○ Shared Biological Vulnerability
 Overactive neurobiological response to stress
○ Exposure to Stress
 Stress activates hormones that affect neurotransmitter systems
 Stress turns on certain genes, affects circadian rhythms, awakens dormant psychological vulnerabilities (i.e., negative
thinking), contributes to sense of uncontrollability (i.e. helplessness), fosters a sense of helplessness and hopelessness
 Social and Interpersonal Support are Moderators

Gene-Environment Interactions
○ Murphy et al. (2001)
 Mice with altered 5-HTT susceptible to stress
○ Sumoi and colleagues, Bennet et al. (2002)
 Macaques with 5-HTTs gene susceptible to stress AND show lower serotonin levels
○ Hariri et al. (2002)
 Humans with 5-HTTs show INCREASED amygdala activation to fearful stimuli
○ Caspi et al. (2003)

Mood Disorders
Treatment: Tricyclic Medication
○ Widely used (e.g. Tofranil, Elavil)
○ Block Reuptake of Norephinephrine and Other Neurotransmitters
○ Takes 2 to 8 weeks for the therapuetic effects to be known
○ Negative side effects are common
○ May be lethal in excessive doses

Monoamine Oxidate Inhibitors (MAO-I)

○ Blocks Monoamine Oxidase
 Monoamine oxidate (MAO) is an enzyme that breaks down serotonin/norephinephrine
○ MAO inhibitors are slightly more effective that tricyclics
○ Must avoid foods containing tyramine (e.g. beer, red wine, cheese)
 Tyramine can be fatal if you're on MAOIs
○ It is a serotonin agonist

Selective Serotonin Reuptake Inhibitors (SSRIs)

○ Specifically blocks reuptake of serotonin
 Fluoxetine (Prozac) is the most popular SSRI
○ SSRIs pose no unique risk of suicide or violence
○ Negative side effects are common but temporary (3-4 weeks)
 Decreased sexual arousal/functioning
 "Jitteriness"
 Sleep disturbance

Lithium
○ Lithium is a common salt
 Primary drug of choice for bipolar disorders
○ Side effects may be severe
 Dosage must be carefully monitored
○ Why lithium works remains unclear
 Treats mania more than depressive symptoms
○ Common alternative: Depakote

Electroconvulsive Therapy (ECT)

○ ECT is Effective for Cases of Severe Depression
 The nature of ECT
□ Involves applying brief electrical current to the brain

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 □ Results in temporary seizures
□ Usually 6 to 10 outpatient treatments are required
○ Side effects are few and include temporary short-term memory loss
 Also formerly brain damage.
○ Uncertain why ECT works and relapse is common

Psychosocial Treatments
○ Cognitive Therapy
 Overwhelmingly shown to have the best talking-therapy response for depression
 Addresses cognitive errors in thinking
 Also includes behavioral components
○ Interpersonal Psychotherapy
 Focuses on problematic interpersonal relationships
□ e.g. changing how you ask someone out to actually get results
○ Outcomes with psychological treatments are comparable to medications

Suicide Facts and Statistics

○ Eight leading cause of death in the United States
○ Overwhelmingly a white and Native American phenomenon
○ Suicide rates are increasing, particularly in the young
○ Gender differences
 Males are more successful at committing suicide than females
 Females attempt suicide more often than males

Suicide: Risk Factors

○ Suicide in the family increases risk
○ Low serotonin levels increase risk
○ A psychological disorder increases risk
○ Alcohol use and abuse
○ Past suicidal behavior increases subsequent risk
○ Experience of a shameful/humiliating stressor increases risk
○ Publicity about suicide and media coverage increases risk

Suicide: What to Do
○ Research shows that threats should be taken seriously
○ Do not be afraid to discuss the topic
○ Get assistance - don't accept responsibility
○ Consider hospitalization

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Thursday 10/05
Thursday, November 05, 2009
3:37 PM

Suicide: Risk Factors

○ Suicide in the family increases risk
○ Low serotonin levels increase risk
○ A psychological disorder increases risk
○ Alcohol use and abuse
 Lowers inhibitations; decreases judgment
 "Self-medicating" behavior indicative of stress
○ Past suicidal behavior increases subsequent risk
○ Experience of a shameful/humiliating stressor increases risk
○ Publicity about suicide and media coverage increase risk

Suicide: What to Do
○ Research shows that threats should be taken seriously
○ Do not be afraid to discuss the topic
○ Get assistance - don't accept responsibility
○ Consider hospitalization

Summary of Mood Disorders

○ All mood disorders share:
 Gross deviations in mood
 Common biological and psychological vulnerability
○ Stress and social support seem critical in onset, maintenance, and treatment
○ Suicide is an increasing problem not unique to mood disorders
○ Medications and psychotherapy produce comparable results

Nature of Schizophrenia and Psychosis: An Overview

○ Schizophrenia vs. Psychosis
 Psychosis - Cluster of disorders; hallucinations andor loss of contact with reality
 Schizophrenia - A type of psychosis, out of several
○ Affects 1 in 100 persons, $65 billion annually
○ Historical background
 Emil Kraeplin - 1896; used the term dementia praecox, focused on onset and outcomes
 Eugene Bleuler - 1911 he introduced the term schizophrenia" or "splitting of the mind"

Prevalence of Shizophrenia
○ Prevalence of 1% worldwide
 2x Alzheimer's
 5 x Multiple Sclerosis
 6 x Insulin-dependent (Type I) Diabetes
 60 x Muscular Dystrophy
○ Schizophrenia is generally chronic
 Moderate-to-severe lifelong impairment
 Life expectancy is slightly less than average
 Equal gender distribution
□ Women - better long-term prognosis
□ Onset differs between men and women

Gender differences in onset of schizophrenia in a sample of 470 patients

Diagnosis: DSM IV
○ Symptoms (2 or more):
 Delusions (content)
 Hallucinations
 Disorganized speech (form)
 Disorganized or catatonic behavior
 Negative symptoms (flat affect, etc.)
○ Social/occupational dysfunction
○ Duration: 6 months (1 month of symptoms)
○ Not caused by substances
○ Not schizoaffective/Mood disorder

The "Positive" Symptoms

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The "Positive" Symptoms
○ Active manifestations of abnormal behavior or distortions of normal behavior
○ Delusions - 90%
 Somatic: "Snake living inside my abdomen"
 Grandeur "Chosen by God"
 Persecution: "'They' are monitoring me"
 Manifestations: Thought broadcasting, ideas of reference, thought withdrawal

The "Positive" Symptom Cluster

○ Hallucinations
 Sensory events without environmental input
 Auditory are the most common (can be any sensory modality)
 Normal volume, known, external, negative
 Speech vs. auditory processing studies

The "Negative" Symptom Cluster

○ Absence or insufficiency of normal behavior
○ Spectrum of negative symptoms
 Avolition (or apathy) - Inability to initiate and persist in activities
 Alogia - A relative absence of speech
 Anhedonia - Inability to experience pleasure or engage in pleasurable activities
 Flat affect - Show little expressed emotion, but may still feel emotion

Mood Disorder + Psychosis

Mood disorder

Schizophrenic symptoms

Mood Disorders with Psychotic Features

Schizoaffective Disorder

"Disorganized" Symptoms
○ Severe and excessive disruptions in:
 Speech
□ Cognitive slippage - Illogical and incoherent speech
□ Tangentiality - "Going off on a tangent" and not answering a question directly
□ Loose associations or derailment - Taking conversation in unrelated directions
 Affect
□ Inappropriate affect (e.g., crying when one should be laughing)
 Behavior
□ Disruption in goal-directed behavior
□ Decline in routine daily functioning
□ Catatonia - Spectrum from wild agitation, waxy flexibility, to complete immobility

Disorganized Speech
"I have also killed my ex-wife, [name], in a 2.5 to 3.0 hours sex bout in Devon Pennsylvania in 1976, while two Pitcairns were
residing in my next room closet, hearing the event. Enclosed, please find my urology report, indicating that my male genitals ,
specifically my penis, are within normal size and that I'm capable of normal intercourse with any women, signed by Dr.
[name], a urologist and surgeon who performed a circumcision on me in 1982. Conclusions: I cannot be a nincompoop in a
physical sense (unless Society would feed me chemicals for my picture in the nincompoop book)."

Symptoms of Schizophrenia
Positive (Type I) Negative (Type II) Disorganized
Thematic Delusions Avolition (Apathy) Grossly Bizarre Behavior
Thematic Hallucinations Alogia (Povert of Speech/Content) Incoherent hallucinations or delusions

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Bizarre Behavior Anhedonia Disorganized Affect
"Good" intellect Flat Affect Disorganized Speech
Asociality
Better Prognosis Poor Prognosis Poor Prognosis
Lenzenweger, Dworkin & Wethington (1991)

Subtypes of Schizophrenia
○ Paranoid Type
 Intact cognitive skills and affect, and do not show disorganized behavior
 Hallucinations and delusions thematic (e.g., grandeur or persecution)
 Probably matches up to Type I
 Means more thematic hallucinations rather than just paranoia
○ Disorganized Type
 Marked disruptions in speech, behavior, affect
 Fragmented hallucinations and delusions
 Develops early, tends to be chronic, lacks periods of remissions
○ Catatonic Type
 Unusual motor responses and odd mannerisms (e.g. echolalia, echopraxia)
 ? Need for consistency
 Tends to be severe and quite rare
○ Undifferentiated Type
 Symptoms, but don't meet criteria for another type
○ Residual Type
 One past episode of schizophrenia
 Continue to display less extreme residual symptoms (e.g., odd beliefs)

Problems with Diagnosis

○ "Schizophrenia appears to be a disorder with no particular symptoms, no particular course, no particular outcome and which
responds to not particular treatment" (Bentall, 1990)
○ Heterogeneity of symptoms
 Symptoms change as the disorder develops
 Schizophrenics 'slip back into reality'
○ Treatment response varies
○ Is it a unitary disorder?
○ Is it distinct from normal experience?

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Tue. 11/10
Tuesday, November 10, 2009
3:31 PM

Subtypes of Schizophrenia

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Tue. 11/17
Tuesday, November 17, 2009
3:31 PM

Sexual & Gender Identity Disorders

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Thu. 11/19
Thursday, November 19, 2009
3:39 PM

Overview of Sexual Dysfunctions

○ Pain may be associated with sexual functioning
○ Males & females experience parallel versions of most disorders
○ May be lifelong or acquired
○ May be generalized or specific

Sexual Dysfunction - Females

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Thu. 12/03
Thursday, December 03, 2009
3:40 PM

Cluster B: Borderline PD
○ Clinical Features
 Unstable moods and relationships
 Very poor boundaries
□ Egocentric and impulsive
□ Acts as if world revolves around them
 Impulsivity, fear of abandonment, coupled with a very poor self-image
 Self-mutilation and suicidal gestures
 Most common personality disorder in psychiatric settings
 High comorbidity
○ The Causes
 Runs in families - genetics?
 Early trauma and abuse

○ Treatment Options
 Many doctors shy away from borderline patients due to aforementioned boundary issues
 Few good treatment outcome studies
 Antidepressant medications provide some short-term relief
 Dialectical behavior therapy is the most promising psychosocial approach
□ Developed by Marshall Lyneham out of sexual abuse literature
□ Form of CBT designed to address interpersonal skills

Cluster B: Histrionic PD
○ Clinical features
 Overly dramatic, sensational, and sexually provocative
 Need to be the center of attention
 Perceived as shallow
○ The causes
 Unknown
 Female variant of antisocial personality disorder?
○ Treatment options
 Few good treatment outcome studies
 Treatment focuses on attention seeking and long-term negative consequences
 Targets may also include problematic interpersonal behaviors
 Little evidence that treatment is effective

Cluster B: Narcissistic PD
○ Clinical Features
 Exaggerated and unreasonable sense of self-importance
□ Differences with histrionics
 Histrionics try to run out and "grab" attention
 Narcissist just naturally expects it
 Preoccupation with receiving attention
 Lack of empathy
 Highly sensitive to criticism
 Envious and arrogant
□ Envious because they feel that they're naturally more deserving than all others
○ The Causes
Early failure to learn empathy as a child

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  Early failure to learn empathy as a child
 Sociological view - a product of the "me" generation?
○ Treatment Options
 Extremely limited treatment research
 Treatment focuses on grandiosity, lack of empathy, unrealistic thinking
 Treatment may also address co-occurring depression
 Little evidence that treatment is effective

Cluster C: Avoidant PD
○ Overview and clinical features
 Extreme sensitivity to the opinions of others
 Highly avoidant of most interpersonal relationships
 Are interpersonally anxious and fearful of rejection
○ The causes
 Numerous factors have been proposed
 Early development - A difficult temperament produces early rejection
○ Treatment options
 Several well-controlled treatment outcome studies exist
 Treatment is similar to that used for social phobia
 Treatment targets include social skills and anxiety

Cluster C: Dependent PD
○ Clinical features
 Excessive reliance on others to make major and minor life decisions
 Fear of abandonment
 Clingy and submissive
○ The causes
 Still largely unclear
 Early disruptions in learning independence
○ Treatment options
 Research on treatment efficacy is lacking
 Therapy typically progresses gradually
 Treatment targets include skills that foster independence

Cluster C: Obsessive-Compulsive PD
○ Clinical features
 Excessive and rigid fixation on doing things the right way
 Highly perfectionistic, orderly, and emotionally shallow
 Obsessions and compulsions are rare
○ The causes
 Are largely unknown
○ Treatment options
 Data supporting treatment are limited
 Treatment may address fears related to the need for orderliness
 Other targets include rumination, procrastination, and feelings of inadequacy

Summary of Personality Disorders

○ Personality Disorders
 Long-standing, ingrained ways of thinking, feeling and behaving
○ Disagreement exists over how to categorize personality disorders
 Categorical vs. dimensional, or some combination of both

FINAL MONDAY AT 3PM

100Q, 50 COMPREHENSIVE 50 NOT

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100Q, 50 COMPREHENSIVE 50 NOT
BRING SCANTRON

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Study notes
Monday, December 07, 2009
12:52 PM Chapter 11 Personality Disorders
Chapter 10
Check p.398 for benzo + addiction (anxiety) Schizoid PD p.439

Psychoactive drugs p.410 Narcissistic PD p.459

Anxiolytic effect - p.412 Treating narcissistic PD p.458

Chapter 4 Anxiety Disorders Chapter 6 mood disorders

Stress + biology p.125 Major depressive disorder p.210

Stress + limbic system p.127 Dysthymia p.212

Panic attacks + conditioned stimulus p.142 Bipolar meds p.220

History of PTSD p.157 SAD p.220

Learned alarms p.165

Chapter 12 Schizophrenia

Broca's area hallucinations p.476

Paranoid vs. delusional disorder delusions p.481

Neuroleptics p.488
Essentials of Abnormal Psych
4th Edition
V. Mark Durand

FINAL HAS QUESTIONS FROM ONLINE PRACTICE TESTS

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