Summary of the book for Clinical Psychology, Sintesi del corso di Psicologia Clinica

Scarica Summary of the book for Clinical Psychology e più Sintesi del corso in PDF di Psicologia Clinica solo su Docsity! CHAPTER 1: Abnormal Psychology: overview and research approaches Abnormal psychology is concerned with understanding the nature, causes, and treatment of mental disorders. If we are to understand mental disorders, we must learn to ask the kinds of questions that will enable us to help the patients and families who have mental disorders. Though not all people who are trained in abnormal psychology (this field is sometimes called psychopathology) conduct research, they still rely heavily on their scientific skills. The clinician will also rely on current research to choose the most effective treatment because Knowledge accumulates and advances are made. WHAT DO WE MEAN BY ABNORMALITY? There is still no universal agreement about what is meant by abnormality or disorder. However, the Indicators of Abnormality exist. No single indicator is sufficient in and of itself to define or determine abnormality. The more that someone has difficulties in the following areas, the more likely he or she is to have some form of mental disorder. 1. Subjective distress: It is the discomfort, pain, and general uncomfortable feelings a person is experiencing. Although subjective distress is an element of abnormality in many cases, it is neither a sufficient condition nor even a necessary condition. 2. Maladaptiveness: It interferes with our well-being and with our ability to enjoy our work and our relationships. But not all disorders involve maladaptive behavior. 3. Statistical deviance: In defining abnormality we make value judgments. If something is statistically rare and undesirable (as is severely diminished intellectual functioning), we are more likely to consider it abnormal than something that is statistically rare and highly desirable (such as genius) or something that is undesirable but statistically common (such as rudeness). 4. Violation of the standards of society: when people fail to follow the conventional social and moral rules of their cultural group, we may consider their behavior abnormal. Much depends on the magnitude of the violation and on how commonly the rule is violated by others. 5. Social discomfort: when someone violates an implicit or unwritten social rule, those around him or her may experience a sense of discomfort or unease. 6. Irrationality and unpredictability: there is a point at which we are likely to consider a given unorthodox behavior abnormal. Perhaps the most important factor, however, is our evaluation of whether the person can control his or her behavior. 7. Dangerousness: Just because we may be a danger to ourselves or to others does not mean we are mentally ill. Conversely, we cannot assume that someone diagnosed with a mental disorder must be dangerous. Decisions about abnormal behavior always involve social judgments and are based on the values and expectations of society at large. This means that culture plays a role in determining what is and is not abnormal. - What is the DSM and why was it revised? The Diagnostic and Statistical Manual of Mental Disorders (DSM) provides all the information necessary (descriptions, lists of symptoms) to diagnose mental disorders. Since DSM-I was first published in 1952, the DSM has been revised from time to time. Revisions are important because they allow new scientific developments to be incorporated The International Classification of Diseases (called ICD-10 because it is now in its 10th revision) is produced by the World Health Organization (WHO). Although the ICD-10 has much in common with DSM-5, it also has many differences. Within DSM-5, a mental disorder is defined as a syndrome that is present in an individual and that involves clinically significant disturbance in behavior, emotion regulation, or cognitive functioning. These disturbances are thought to reflect a dysfunction in biological, psychological, or developmental processes that are necessary for mental functioning. DSM-5 also recognizes that mental disorders are usually associated with significant distress or disability in key areas of functioning such as social, occupational, or other activities. CLASSIFICATION AND DIAGNOSIS Advantages - Most sciences rely on classification. Classification systems provide us with a nomenclature (a naming system). This gives clinicians and researchers both a common language and shorthand terms for complex clinical conditions. - they enable us to structure information in a more helpful manner. Classification systems shape the way information is organized. - Classification facilitates research, which gives us more information and facilitates greater understanding. - The classification of mental disorders has social and political implications. Establishes the range of problems that the mental health profession can address. Disadvantages Disadvantages are associated with the use of a discrete classification system. Classification, by its very nature, provides information in a shorthand form which leads to a loss of information. Although things are improving, there can still be some stigma (disgrace) associated with having a psychiatric diagnosis. Speaking candidly about having a psychological disorder will result in unwanted social or occupational consequences or frank discrimination. Stigma is a deterrent to seeking treatment for mental health problems. Related to stigma is the problem of stereotyping (e.g., New Yorkers are rude). Stigma can be perpetuated by the problem of labeling. Diagnostic labels can be hard to shake even if the person later makes a full recovery. It is important to keep in mind, however, that diagnostic classification systems do not classify people. Rather, they classify the disorders that people have. How can we reduce prejudicial attitudes toward people who are mentally ill? transportation injuries. The disorder that results in the biggest global burden is depression, which accounts for more than 40 percent of the disability adjusted years of life (DALYs) Treatment: Although they may not be available to everyone, many treatments for psychological disorders exist. These include medications as well as different forms of psychotherapy. It is important to emphasize that not all people with psychological disorders receive treatment. In some cases, people deny or minimize their suffering. Others try to cope on their own and may manage to recover without ever seeking aid from a mental health professional. Stigma is a factor that makes some people especially reluctant to seek help. Hospitalization and inpatient care are the preferred options for people who need more intensive treatment than can be provided on an outpatient basis. Various surveys indicate that admission to mental hospitals has decreased substantially during the past 45 years. The development of medications that control the symptoms of the most severe disorders is one reason for this change. RESEARCH APPROACHES IN ABNORMAL PSYCHOLOGY Through research we can learn about the symptoms of a disorder, its prevalence, whether it tends to be either acute (short in duration) or chronic (long in duration), and the problems and deficits that often accompany it. Research allows us to further understand the etiology (or causes) of disorders. One such error is that we often attend only to data that confirm our view of how things are. Abnormal psychology research can take place in clinics, hospitals, schools, prisons, and even highly unstructured contexts such as naturalistic observations of the homeless on the street. SOURCES OF INFORMATION 1. Case Studies: Much can be learned when skilled clinicians use the case study method. Still, the information presented in them is subject to bias because the writer of the case study selects what information to include and what information to omit. Besides, the conclusions of a case study have low generalizability—that is, they cannot be used to draw conclusions about other cases even when those cases involve people with a seemingly similar abnormality. However, case studies can be a valuable source of new ideas and serve as a stimulus for research. 2. Self report data: This might involve having our research participants complete questionnaires of various types. Another way of collecting self-report data is from interviews. Self-report data can sometimes be misleading. One problem is that people may not be very good reporters of their own subjective states or experiences. Besides, people will occasionally lie, misinterpret the question, or desire to present themselves in a particularly favorable (or unfavorable) light, self-report data cannot always be regarded as highly accurate and truthful. 3. Observational Approaches: When we collect information in a way that does not involve asking people directly (self-report), we are using some form of observational approach. Technology has advanced, and we are now developing methods to study behaviors, moods, and cognitions that have long been considered inaccessible. Observing behavior, in this context, refers to careful scrutiny of the conduct and manner of specific individuals. FORMING AND TESTING HYPOTHESES Why is a control (or comparison group) necessary to adequately test a hypothesis? To make sense of behavior, researchers generate hypotheses which are an effort to explain, predict, or explore something, scientists attempt to test their hypotheses. Hypotheses are vital because they frequently determine the therapeutic approaches used to treat a particular clinical problem. Sampling and Generalization We need to study a larger group of individuals with the same problem in order to discover which of our observations or hypotheses possess scientific credibility. The more people we study, the more confident we can be about our findings. Ideally, we would study everyone in the world who met our criteria. This, of course, is impossible to do, so instead we would try to get a representative sample of people. To do this, we would use a technique called sampling. What this means is that we would try to select people who are representative of the much larger group of individuals. We would like our smaller sample (our study group) to mirror the larger group (the underlying population) in all important ways. Finding research participants is not always easy, researchers sometimes use “samples of convenience” in their studies. This means that they study groups of people who are easily accessible to them and who are readily available. Internal and External validity The more representative our sample is, the better able we are to generalize. The extent to which we can generalize our findings beyond the study itself is called external validity. Internal validity reflects how confident we can be in the results of a particular given study. In other words, internal validity is the extent to which a study is methodologically sound, free of confounds, or other sources of error, and able to be used to draw valid conclusions. Criterion and comparison groups To test their hypotheses, researchers use a comparison group (sometimes called a control group) which is a group of people who do not exhibit the disorder being studied but who are comparable in all other major respects to the criterion group. By “comparable” we might mean that the two groups are similar in age, number of males and females, educational level, and similar demographic variables. The criterion group or the group of interest is the name of the group of people that presents the disorder. CORRELATIONAL RESEARCH DESIGNS Why correlational research designs are valuable? A correlational research design involves studying the world as it is. Any time we study differences between individuals who have a particular disorder and those who do not, we are utilizing this type of correlational research design. Measuring correlation: Correlational research takes things as they are and determines associations among observed phenomena. There are 2 kinds of correlation: Direct/ positive correlation or Inverse/ negative correlation. Besides, the variables could be uncorrelated. The strength of a correlation is measured by a correlation coefficient, which is denoted by the symbol r. A correlation runs from 0 to 1, with a number closer to 1 representing a stronger association between the two variables. The + sign or – sign indicates the direction of the association between the variables. Statistical significance: Next to the correlation you will almost certainly see a notation that reads p < .05. It means that the probability that the correlation would occur purely by chance is less than 5%. Researchers think that correlations that have a p < .05 to be statistically significant and worthy of attention. Statistical significance is influenced not only by the magnitude or size of the correlation between the two variables but also by the sample size. Correlations based on very large samples can be very small and yet still reach statistical significance. Conversely, correlations drawn from small samples need to be very large to reach statistical significance. Effect size: The fact that statistical significance is influenced by sample size creates a problem when we want to compare findings across studies. The effect size reflects the size of the association between two variables independent of the sample size. Because it is independent of sample size, the effect size can be used as a common metric and is very valuable when we want to compare the strength of findings across different studies. Meta-analysis: A meta-analysis is a statistical approach that calculates and then combines the effect sizes from all of the studies. Within a meta-analysis, each separate study can be thought of as being equivalent to an individual participant in a conventional research design. ● The nineteenth and early twentieth centuries witnessed a number of scientific and humanitarian advances. The work of Philippe Pinel in France, of William Tuke in England, and of Benjamin Rush and Dorothea Dix in the United States prepared the way for several important developments in contemporary abnormal psychology, such as moral management. Among these were the gradual acceptance of patients with mental illness as afflicted individuals who need and deserve professional attention; the successful application of biomedical methods to disorders; and the growth of scientific research into the biological, psychological, and sociocultural roots of abnormal behavior. ● The reform of mental hospitals continued into the twentieth century, but during the last four decades of the century, there was a strong movement to close mental hospitals and release people into the community. This movement remained controversial in the early part of the twenty-first century. THE EMERGENCE OF CONTEMPORARY VIEWS OF ABNORMAL BEHAVIOR ● In the nineteenth century, great technological discoveries and scientific advancements that were made in the biological sciences enhanced the understanding and treatment of individuals with mental illness. One major biomedical breakthrough came with the discovery of the organic factors underlying general paresis— syphilis of the brain—one of the most serious mental illnesses of the day. ● Beginning in the early part of the eighteenth century, knowledge of anatomy, physiology, neurology, chemistry, and general medicine increased rapidly. These advances led to the identification of the biological, or organic, pathology underlying many physical ailments. ● The development of a psychiatric classification system by Kraepelin played a dominant role in the early development of the biological viewpoint. Kraepelin’s work (a forerunner to the DSM system) helped to establish the importance of brain pathology in mental disorders and made several related contributions that helped establish this viewpoint. ● The first major steps toward understanding psychological factors in mental disorders occurred with mesmerism and the Nancy School, followed by the work of Sigmund Freud. During five decades of observation, treatment, and writing, he developed a theory of psychopathology, known as psychoanalysis, that emphasized the inner dynamics of unconscious motives. The beginning of psychoanalysis is hypnosis. During the past half-century, other clinicians have modified and revised Freud’s theory, which has thus evolved into new psychodynamic perspectives. ● Scientific investigation into psychological factors and human behavior began to make progress in the latter part of the nineteenth century. The end of the nineteenth century and the early twentieth century saw experimental psychology evolve into clinical psychology with the development of clinics to study, as well as intervene in abnormal behavior. ● Paralleling this development was the work of Pavlov in understanding learning and conditioning. Behaviorism emerged as an explanatory model in abnormal psychology. The behavioral perspective is organized around a central theme—that learning plays an important role in human behavior. Although this perspective was initially developed through research in the laboratory (unlike psychoanalysis, which emerged out of clinical practice with disturbed individuals), it has been shown to have important implications for explaining and treating maladaptive behavior. ● Understanding the history of psychopathology—its forward steps and missteps alike—helps us understand the emergence of modern concepts of abnormal behavior. CHAPTER 3: Causal factors and viewpoints RISK FACTORS AND CAUSES OF ABNORMAL BEHAVIOR Although understanding the causes of abnormal behavior is a desirable goal, it is enormously difficult to achieve because human behavior is so complex. In trying to understand what causes different kinds of psychopathology, an important first step is to observe what variables are associated with such outcomes. For example: If A variable (X) that is associated with an outcome of interest (Y) is considered to be a correlate of that outcome, then we can follow the next path from correlation to causation Necessary, sufficient, and contributory causes A necessary cause (X) is a characteristic that must exist for a disorder (Y) to occur. In other words, if Y occurs, then X must have preceded it. Most mental disorders have not been found to have necessary causes. - Biological perspective in which we try to understand how factors such as genetics, neurobiology, and hormonal responses can influence psychopathology - Psychological perspective and try to understand how dysfunctional thoughts, feelings, and behaviors can lead to psychopathology - sociocultural perspective in which we try to understand how social and cultural factors can influence the way that we think about abnormal behavior Many theorists recognize the need for a more integrative, biopsychosocial viewpoint that acknowledges that biological, psychological, and social factors all interact. THE BIOLOGICAL PERSPECTIVE The traditional biological viewpoint focuses on mental disorders as diseases. Mental disorders are thus viewed as disorders of the central nervous system, the autonomic nervous system, and/or the endocrine system that are either inherited or caused by some pathological process. At one time, people who adopted this viewpoint hoped to find simple biological explanations. Today, however, most people recognize that such explanations are rarely simple, and many also acknowledge that psychological and sociocultural causal factors play important roles as well. The disorders first recognized as having biological or organic components were those associated with gross destruction of brain tissue. These disorders are neurological diseases. However, most mental disorders are not caused by neurological damage per se. Four categories of biological factors that seem particularly relevant to the development of maladaptive behavior: (1) genetic vulnerabilities, (2) brain dysfunction and neural plasticity, (3) neurotransmitter and hormonal abnormalities in the brain or other parts of the central nervous system, and (4) temperament. 1. Genetic vulnerabilities Genes are very long molecules of DNA (deoxyribonucleic acid) that are present at various locations on chromosomes. Chromosomes are the chain-like structures within a cell nucleus that contain the genes. Genes are the carriers of the information that we inherit from our parents. Genes don’t fully determine whether a person develops a mental disorder; however, there is substantial evidence that most mental disorders show at least some genetic influence. For example, some children are just naturally more shy or anxious, whereas others are more outgoing. Some genetic sources of vulnerability do not manifest themselves until adolescence or adulthood, when most mental disorders appear for the first time. More typically, however, personality traits and mental disorders are not affected by chromosomal abnormalities per se. Instead they are more often influenced either by abnormalities in some of the genes on the chromosomes or by naturally occurring variations of genes known as Polymorphisms. In other words, a genetically vulnerable person has usually inherited a large number of genes, or polymorphisms of genes, that operate together in an additive or interactive fashion to increase vulnerability. In the field of abnormal psychology, genetic influences rarely express themselves in a simple and straightforward manner. This is because behavior, unlike some physical characteristics such as eye color, is not determined exclusively by genetic endowment; it is a product of the organism’s interaction with the environment. In other words, genes can affect behavior only indirectly. 2. Brain dysfunction and neural plasticity Specific brain lesions with observable defects in brain tissue are rarely a primary cause of psychiatric disorders. Research has revealed that genetic factors guide brain development. We also know that genetic programs for brain development are not so rigid and deterministic as was once believed. Instead, there is considerable neural plasticity—flexibility of the brain in making changes in organization and function in response to pre and postnatal experiences, stress, diet, disease, drugs, maturation, and so forth. Existing neural circuits can be modified, or new neural circuits can be generated. Research on neural and behavioral plasticity, in combination with the work described earlier on genotype - environment correlations, makes it clear why developmental psychopathologists have been devoting increasing attention to a developmental systems approach, which acknowledges that genetics influences neural activity, which in turn influences behavior, which in turn influences the environment, but also that these influences are bidirectional. 3. Imbalances of neurotransmitters and hormones In order for the brain to function adequately, neurons, or nerve cells, must communicate effectively with one another. This communication is done through the transmission of electrical nerve impulses. These interneuronal transmissions are accomplished by neurotransmitters—chemical substances that are released into the synapse by the presynaptic neuron when a nerve impulse occurs. There are many different kinds of neurotransmitters; some increase the likelihood that the postsynaptic neuron will “fire” (produce an impulse), and others inhibit the impulse. The belief that imbalances in neurotransmitters in the brain can result in abnormal behavior is one of the basic principles of the biological perspective today. Sometimes psychological stress can bring on neurotransmitter imbalances. These imbalances can be created in a variety of ways: - There may be excessive production and release of the neurotransmitter substance into the synapses, causing a functional excess. - There may be dysfunctions in the normal processes by which neurotransmitters, once released into the synapse, are deactivated. - Finally, there may be problems with the receptors in the postsynaptic neuron. Medications used to treat various disorders are often believed to operate by correcting these imbalances. Five different kinds of neurotransmitters have been most extensively studied in relationship to psychopathology: (1) norepinephrine, (2) dopamine, (3) serotonin, (4) glutamate, and (5) gamma aminobutyric acid. Some forms of psychopathology have also been linked to hormonal imbalances. Hormones are chemical messengers secreted by a set of endocrine glands in our bodies. Each of the endocrine glands produces and releases its own set of hormones directly into our bloodstream. Our central nervous system is linked to the endocrine system (in what is known as the neuroendocrine system) by the effects of the hypothalamus on the pituitary gland. One particularly important set of interactions occurs in the hypothalamic-pituitary-adrenal (HPA) axis. 4. Temperament Temperament refers to a child’s reactivity and characteristic ways of self-regulation, which is believed to be biologically programmed. Our early temperament is thought to be the basis from which our personality develops. Starting at about 2 to 3 months of age, approximately five dimensions of temperament can be identified: fearfulness, irritability/frustration, positive affect, activity level, and attentional persistence/ effortful control, although some of these emerge later than others. These seem to be related to the three important dimensions of adult personality: (1) neuroticism or negative emotionality, (2) extraversion or positive emotionality, and (3) constraint. The dimensions of fearfulness and irritability correspond to the adult dimension of neuroticism or negative emotionality. The positive affect and possibly activity level seem related to the adult dimension of extraversion, and the infant dimension of attentional persistence and effortful control seems related to the adult dimension of constraint or control. Not surprisingly, temperament may also set the stage for the development of various forms of psychopathology later in life. The impact of the biological viewpoint Biological discoveries have profoundly affected the way we think about human behavior. However, It is incorrect to think—as some prominent biological researchers have—that establishing biological differences between, for example, individuals with schizophrenia and those without schizophrenia in and of itself substantiates that schizophrenia is an illness. Thus, the decision about what constitutes a mental illness or disorder ultimately still rests on clinical judgment regarding the functional effects of the disordered behavior. Establishing the biological substrate does not bear on this issue because all behavior—normal and abnormal—has a biological substrate. We must remember that biology alone does not shape our thoughts, feelings, and behaviors; they instead occur via interaction with social events in our environment. THE PSYCHOLOGICAL PERSPECTIVE Three perspectives on human nature and behavior that have been particularly influential: 1. The psychodynamic perspective Generalization and Discrimination: When a response is conditioned to one stimulus or set of stimuli, it can be evoked by other, similar stimuli; this process is called generalization. A process complementary to generalization is discrimination, which occurs when a person learns to distinguish between similar stimuli and to respond differently to them based on which ones are followed by reinforcement. Observational Learning: Human and nonhuman primates are also capable of observational learning—that is, learning through observation alone, without directly experiencing an unconditioned stimulus (for classical conditioning) or a reinforcement (for instrumental conditioning). Impact of the Behavioral Perspective: Because there was so much resistance from well-entrenched supporters of psychoanalysis, behavior therapy did not become well established as a powerful way of viewing and treating abnormal behavior until the 1960s and 1970s. Maladaptive behavior is viewed as essentially the result of (1) a failure to learn necessary adaptive behaviors or competencies and/or (2) the learning of ineffective or maladaptive responses. For the behavior therapist, the focus of therapy is on changing specific behaviors and emotional responses— eliminating undesirable reactions and learning desirable ones. A behavior therapist specifies what behavior is to be changed and how it is to be changed. Later, the effectiveness of the therapy can be evaluated objectively by the degree to which the stated goals have been achieved. Nevertheless, the behavioral perspective has been criticized for several reasons. One early criticism was that behavior therapy was concerned only with symptoms, not underlying causes. Others have argued that the behavioral approach oversimplifies human behavior. 3. The cognitive - behavioral perspective Cognitive psychology involves the study of basic information-processing mechanisms such as attention and memory, as well as higher mental processes such as thinking, planning, and decision making. Albert Bandura, a learning theorist who developed an early cognitive-behavioral perspective, placed considerable emphasis on the cognitive aspects of learning. Bandura stressed that human beings regulate behavior by internal symbolic processes—thoughts. That is, we learn by internal reinforcement. We do not always require external reinforcement to alter our behavior patterns; our cognitive abilities allow us to solve many problems internally. Bandura later developed a theory of self-efficacy, the belief that one can achieve desired goals. He posited that cognitive-behavioral treatments work in large part by improving self-efficacy. Today the cognitive or cognitive-behavioral perspective on abnormal behavior generally focuses on how thoughts and information processing can become distorted and lead to maladaptive emotions and behavior. Schemas and Cognitive Distortions: Our schemas about the world around us and about ourselves (self-schemas) are our guides. We all have schemas about other people, schemas about social roles, and about events. However, schemas are also sources of psychological vulnerabilities because some of our schemas or certain aspects of our self-schemas may be distorted and inaccurate. We think that we are simply seeing things the way they are and often do not consider the fact that other views of the “real” world might be possible. These maladaptive schemas lead to the distortions in thinking that are characteristic of certain disorders such as anxiety, depression, and personality disorders. Another important feature of information processing is that a great deal of information is processed nonconsciously, mental processes that are occurring without our being aware of them. Attributions, Attributional Style, and Psychopathology: Attribution is simply the process of assigning causes to things that happen. For example: A student who fails a test may attribute the failure to a lack of intelligence (a personal trait) or to ambiguous test questions or unclear directions (environmental causes). Attributional style is a characteristic way in which an individual tends to assign causes to bad events or good events. For example, people with depression tend to attribute bad events to internal, stable, and global causes. Nondepressed people tend to have what is called a self-serving bias in which they are more likely to make internal, stable, and global attributions for positive rather than negative events, which means that they attribute the good things to their behavior. Cognitive Therapy: Beck, who is generally considered the founder of cognitive therapy, has been enormously influential in the development of cognitive-behavioral treatment. Fundamental to Beck’s perspective is the idea that the way we interpret events and experiences determines our emotional reactions to them. For example, cognitive-behavioral clinicians are concerned with their clients’ self-statements. People who interpret what happens in their lives as a negative reflection of their self-worth are likely to feel depressed. Cognitive-behavioral clinicians use a variety of techniques designed to alter whatever negative cognitive biases. The Impact of the Cognitive-Behavioral Perspective: Many researchers and clinicians have found support for the principle of altering human behavior through changing the way people think about themselves and others. However, Skinner reminded his audience that cognitions are not observable phenomena and, as such, cannot be relied on as solid empirical data. These criticisms have seemed to be decreasing in recent years as more and more evidence accumulates for the efficacy of cognitive-behavioral treatments for various disorders ranging from schizophrenia to anxiety, depression, and personality disorders. What the adoption of a perspective does and does not do None alone of the psychological perspectives can account for the complex variety of human maladaptive behaviors. Thus, which perspective we adopt has important consequences: It influences our perception of maladaptive behavior, the types of evidence we look for, and the way in which we are likely to interpret data. THE SOCIAL PERSPECTIVE Social factors are environmental influences (often unpredictable and uncontrollable negative events) that can negatively affect a person psychologically, making him or her less resourceful in coping with events. 1. Early deprivation or trauma The needed resources range from food and shelter to love and attention. Deprivation of such resources can occur in several forms: Institutionalization: there is likely to be significantly less warmth and physical contact; less intellectual, emotional, and social stimulation; and a lack of encouragement and help in positive learning. Many children institutionalized in infancy and early childhood show severe emotional, behavioral, and learning problems and are at risk for disturbed attachment relationships and psychopathology. Indeed, children raised in institutions from an early age show significant reductions in both gray and white matter volume. In general, early institutionalization is associated with long-lasting negative effects, and the earlier children are adopted out of orphanages the better they do. Neglect and Abuse in the Home: Most infants subjected to parental deprivation are not separated from their parents and placed in institutions; rather, they suffer from maltreatment in their own home. The majority (78 percent) of these cases are cases of neglect, with physical abuse (18 percent) and sexual abuse (9 percent) being less common. Among infants, gross neglect may be worse than having an abusive relationship. Abused children often have a tendency to be overly aggressive. There are also very long-lasting negative neurobiological effects that maltreatment has on the developing nervous system. Abused and maltreated infants and toddlers are also quite likely to develop atypical patterns of attachment (most often a disorganized and disoriented style of attachment). Childhood physical abuse predicts both familial and nonfamilial violence in adolescence and adulthood, especially in abused men. Maltreated children (whether the maltreatment comes from abuse or from deprivation) can improve to at least some extent when the caregiving environment improves. Separation: There are the short-term or acute effects of the separation, which can include significant despair during the separation as well as detachment from the parents upon reunion. 2. Problems in parenting style There are the short-term or acute effects of the separation, which can include significant despair during the separation as well as detachment from the parents upon reunion. It is important to note that a parent–child relationship is always bidirectional: the behavior of each person affects the behavior of the other (children to parents and vice versa) Parental Psychopathology: Parents who have various forms of psychopathology (including schizophrenia, depression, antisocial personality disorder, and alcohol use problems) tend to have one or more children who are at heightened risk for a wide range of developmental difficulties. Not surprisingly, children of mothers with depression also are more likely than children of nondepressed mothers to live in environments with high levels of stress. Parenting Styles: Warmth and Control: Concern with how factors in peoples’ environment can influence the occurrence of mental disorders. Research in this area has led to programs designed to improve the social conditions that foster maladaptive behavior and mental disorder. THE CULTURAL PERSPECTIVE What is considered to be normal and abnormal differs in different places around the world. Relationship between various sociocultural conditions and mental disorders. The patterns of both physical and mental disorders within a given society could change over time as sociocultural conditions change. Cross cultural research can enhance our knowledge about the range of variation that is possible in human behavioral and emotional development and can generate ideas about what causes normal and abnormal behavior. Universal and culture-specific symptoms of disorders Research supports the view that many psychological disturbances (in both adults and children) are universal. Examining such issues is, of course, never easy. One example of such research has shown that when some tests are translated into the language of different cultures, they need to be adapted so that they are appropriate for the new cultural context. The Minnesota Multiphasic Personality Inventory (MMPI-2) is the best validated and most widely used test that has been adapted for use in many cultures. Although some universal symptoms and patterns of symptoms appear, sociocultural factors often influence which disorders develop, the forms they take, how prevalent they are, and their courses. Several international studies have found a more favorable course of schizophrenia in developing countries than in developed countries. In addition to the influence of culture on the symptoms experienced in different cultures, there are also entire patterns of symptoms in certain cultures that are unlike the patterns experienced in most other parts of the world. Culture and over - and undercontrolled behavior Cultural differences in psychopathology may also result from differences in what cultures consider to be the ideal kinds of parent–child attachment relationships. CHAPTER 4: Clinical assessment and diagnosis Psychological assessment refers to a procedure by which clinicians, using psychological tests, observation, and interviews, develop a summary of the client’s symptoms and problems. Clinical diagnosis is the process through which a clinician arrives at a general “summary classification” of the patient’s symptoms by following a clearly defined system such as DSM-5 or ICD-10. THE BASIC ELEMENTS IN ASSESSMENT The relationship between assessment and diagnosis Knowledge of a person’s type of disorder can help in planning and managing the appropriate treatment. Taking a social or behavioral history An adequate assessment includes much more than the diagnostic label. For example, it should include an objective description of the person’s behavior. Excesses, deficits, and appropriateness are key dimensions to be noted if the clinician is to understand the particular disorder that has brought the individual to the clinic or hospital. Personality Factors: Assessment should include a description of any relevant long-term personality characteristics. The Social Context: It is also important to assess the social context in which the individual functions. The clinician must then integrate them into a consistent and meaningful picture. Some clinicians refer to this picture as a “dynamic formulation” because it not only describes the current situation but also includes hypotheses about what is driving the person to behave in maladaptive ways. The formulation should allow the clinician to develop hypotheses about the client’s future behavior as well. Ensuring culturally sensitive assessment procedures In both clinical and court settings, for example, a psychologist might be referred to as a client who has limited English language skills and low exposure to American mores, values, and laws. It is critical for the psychologist to be informed of the issues involved in multicultural assessment (often referred to as cultural competence) and to use testing procedures that have been adapted and validated for culturally diverse clients. The challenges of understanding clients when performing multicultural assessments have been described and involve both test instrument characteristics and sociocultural factors such as the relationships among culture, behavior, and psychopathology. The influence of professional orientation How clinicians go about the assessment process often depends on their basic treatment orientations, both physical and psychosocial data can be extremely important to understanding a patient. Reliability, validity, and standardization Three measurement concepts that are important in understanding clinical assessment and the utility of psychological tests are: Reliability, validity, standardization. Reliability is a term describing the degree to which an assessment measure produces the same result each time it is used to evaluate the same thing. In the context of assessment or classification, reliability is an index of the extent to which a measurement instrument can agree that a person’s behavior fits a given diagnostic class. If the observations are different, it may mean that the classification criteria are not precise enough to determine whether the suspected disorder is present. Validity is the extent to which a measuring instrument actually measures what it is supposed to measure. If, for example, a person is predicted to have or is diagnosed as having schizophrenia, we should be able to infer the presence of some fairly precise characteristics that differentiate the person from individuals who are considered normal. Normally, the validity of a mental health measure or classification presupposes reliability. On the other hand, good reliability does not in itself guarantee validity. Standardization is a process by which a psychological test is administered, scored, and interpreted in a consistent or “standard” manner. Standardized tests are considered to be more fair than nonstandardized tests. Trust and rapport between the clinician and the client In a clinical assessment situation, this means that a client must feel that the testing will help the practitioner gain a clear understanding of her or his problems and must understand how the tests will be used and how the psychologist will incorporate them into the clinical evaluation. The clinician should explain what will happen during assessment and how the information gathered will help provide a clearer picture of the problems the client is facing. ASSESSMENT OF THE PHYSICAL ORGANISM The general physical examination In cases in which physical symptoms are part of the presenting clinical picture, a referral for a medical evaluation is recommended. A physical examination consists of the kinds of procedures most of us have experienced when getting a “medical checkup.” The neurological examination Because brain pathology is sometimes involved in some mental disorders (e.g., unusual memory deficits or motor impairments), a specialized neurological examination can be administered in addition to a general medical examination. For example, an EEG may reveal a dysrhythmia, or irregular pattern, in the brain’s electrical activity. Anatomical Brain Scans: Radiological technology, such as a computerized axial tomography (CAT) scan, is one of these specialized techniques, it provides rapid access, without surgery, to accurate information about the localization and extent of anomalies in the brain’s structural characteristics. CAT scans have been increasingly replaced by magnetic resonance imaging (MRI). The images of the interior of the brain are frequently sharper with MRI because of its superior ability to differentiate subtle variations in soft tissue. In addition, the MRI procedure is normally far less complicated to administer than a CAT scan and does not subject the patient to ionizing radiation. Still, the MRI can be problematic. For example, As assessment data are collected, their significance must be interpreted so that they can be integrated into a coherent working model for use in planning. Clinicians in individual private practice normally assume this complicated task on their own. In a clinic or hospital setting, assessment data are often evaluated in a staff conference attended by members of an interdisciplinary team. This integration of all the data gathered at the time of an original assessment may lead to agreement on a tentative diagnostic classification for a patient. The findings of each member of the team, as well as the recommendations for treatment, are entered into the case record. Ethical issues in assessment The decisions made on the basis of assessment data may have far-reaching implications for the people involved. Thus, a valid decision, based on accurate assessment data, is of far more than theoretical importance. It is important that those involved keep several factors in mind when evaluating test results: - Potential cultural bias of the instrument or the clinician - Theoretical orientation of the clinician - Underemphasis on the external situation - Insufficient validation - Inaccurate data or premature evaluation CLASSIFYING ABNORMAL BEHAVIOR In abnormal psychology, classification involves the attempt to delineate meaningful subvarieties of maladaptive behavior. Classification makes it possible to communicate about particular clusters of abnormal behavior. It is not unusual for a classification system to be an ongoing work in progress. Differing models of classification Three basic approaches are currently used to classify abnormal behavior: Categorical, Dimensional, Prototypal. The categorical approach considers illness as being either present or absent, and similarity with prototypical description of a disorder is taken as a marker for the disorder. The dimensional approach regards that symptoms of disorder exist on a continuum from normal to severely ill. The prototypical approach conceptualizes psychopathology into categories within the DSM. This approach allows for a high heterogeneity within categories as individuals must only meet a certain number of symptoms to fall within a category and therefore, may qualify under more than one as several disorders share similar symptoms (comorbidity). Prototypical approach opens the door for mis-diagnosis and co-existing disorders rather than a single unified diagnosis as the symptoms may be versatile among categories. Formal diagnostic classification of mental disorders Today, two major psychiatric classification systems are in use: the International Classification of Diseases (ICD-10) system, published by the WHO, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. The DSM specifies what subtypes of mental disorders are currently officially recognized and provides, for each, a set of defining criteria. The system purports to be a categorical one with sharp boundaries separating the various disorders from one another, but it is in fact a prototypal one with much fuzziness of boundaries and considerable interpenetration, or overlap, of the various “categories” of disorder it identifies. The term symptoms generally refers to the patient’s subjective description, the complaints she or he presents about what is wrong. Signs, on the other hand, are objective observations, which the doctor can see and test. The Evolution of the DSM: The first edition of the manual (DSM-I) appeared in 1952. Practitioners recognized a defect in both these early efforts: The various types of disorders identified were described in narrative that proved too vague for mental health professionals to agree. DSM-5 incorporated more theoretical shifts in diagnosis. Mental disorders have increased enormously from DSM-I to DSM-5 due both to the addition of new diagnoses and to the elaborate subdivision of older ones. Gender Differences in Diagnosis: Gender differences have long been noted for some disorders. Some disorders show a higher prevalence rate for male patients, others for females. Moreover, males and females who are diagnosed with the same disorder often show different symptom patterns. Appraisal of Cultural Background in DSM-5: The client’s ethnicity and cultural background, level of English language comprehension, religious background, and extent of their acclimation to the United States can result in incorrect appraisal of mental health symptoms. The DSM-5 provides a structured interview that focuses on the patient’s approach to problems. The Cultural Formulation Interview (CFI) contains 16 questions that the practitioner can use to obtain information during a mental health assessment about the potential impact the client’s culture can have on mental health care. The Problem of Labeling: A diagnostic label can make it hard to look at the person’s behavior objectively, without preconceptions about how he or she will act. Once an individual is labeled, he or she may accept a redefined identity and play out the expectations of that role. They can also have devastating effects on a person’s morale, self-esteem, and relationships with others. The person so labeled may decide that he or she “is” the diagnosis. Limited Usefulness of Diagnosis: Arriving at a diagnosis is usually required, at least in the form of a “diagnostic impression,” before the commencement of clinical services. This is necessitated, perhaps unwisely, by medical insurance requirements and longstanding clinical administrative tradition. Unstructured Diagnostic Interviews: The examiner follows no pre existing plan with respect to content and sequence of the probes introduced. Structured Diagnostic Interviews: The clinician using a structured interview typically seeks to discover whether the person’s symptoms and signs “fit” diagnostic criteria CHAPTER 5: Stress and physical and mental health WHAT IS STRESS? When we experience or perceive challenges to our physical or emotional well-being that exceed our coping resources and abilities, the psychological condition that results is typically referred to as stress. The external demands as stressors, to the effects they create within the organism as stress, and to efforts to deal with stress as coping strategies. Stress could occur not only in negative situations (such as taking an examination) but also in positive situations (such as a wedding). Both kinds of stress can tax a person’s resources and coping skills, although bad stress (distress) typically has the potential to do more damage. Stress and the DSM: Stress is recognized in diagnostic formulations. Nowhere is this more apparent than in the diagnosis of PTSD. Some other disorders in this new category are adjustment disorder and acute stress disorder. The key differences among them lie not only in the severity of the disturbances but also in the nature of the stressors and the time frame during which the disorders occur. Factors Predisposing a Person to Stress: Individual characteristics that have been identified as improving a person’s ability to handle life stress include higher levels of optimism, greater psychological control or mastery, increased self-esteem, and better social support. Also, differences in coping styles may be linked to underlying genetic differences, a particular gene (the 5 HTTLPR gene) was linked to how likely it was that people would become depressed in the face of life stress. The amount of stress we experience early in life may also make us more sensitive to stress later on. The term stress tolerance refers to a person’s ability to withstand stress without becoming seriously impaired. Stressful experiences may also create a self-perpetuating cycle by changing how we think about, or appraise, the things that happen to us. Characteristics of Stressors: The key factors involve (1) the severity of the stressor, (2) its chronicity (i.e., how long it lasts), (3) its timing, (4) how closely it affects our own lives, (5) how expected it is, and (6) how controllable it is. Stressors that involve the more important aspects of a person’s life tend to be highly stressful for most people. The longer a stressor operates the more severe its effects. Encountering a number of stressors at the same time also makes a difference. Events that are unpredictable and unanticipated are likely to place a person under severe stress. Most of us experience occasional periods of especially acute (sudden and intense) stress. The term crisis is used to refer to times when a stressful situation threatens to exceed or exceeds the adaptive capacities of a person or a group. and mistrust) that is most closely correlated with coronary artery deterioration. People with higher scores on the negative affectivity component of Type D personality are also at increased risk of having more problems after cardiac surgery. Depression: Like stress, depression is associated with disrupted immune function, the state of being depressed adds something beyond any negative effects of the stressors precipitating the depressed mood. People with heart disease are approximately three times more likely than healthy people to be depressed. Current thinking is that this is another example of the mind–body connection. Depression is an emotionally stressful condition that may have an impact on how much physical exhaustion can be detected in the body. Anxiety: Research has also demonstrated a relationship between phobic anxiety and increased risk for sudden cardiac death. Social Isolation and Lack of Social Support: Studies point to the strong link between social factors and the development of Coronary heart disease (CHD). Lonely people are also at increased risk of developing heart disease. Loneliness is a different construct from social support or depression, and it is not closely related to any objective measures of a person’s social network size. For people who already have CHD, there is similar evidence that feelings of being emotionally supported make a difference. Positive Emotions: An optimistic outlook on life, as well as an absence of negative emotions, may have some beneficial health consequences. Positive psychology is the school of psychology that focuses on human traits and resources such as humor, gratitude, and compassion that might have direct implications for our physical and mental well-being. Recent research shows that college-age adults who score high on a measure of forgivingness have fewer symptoms of both physical and mental health problems. The Importance of Emotion Regulation: If hostility, depression, and anxiety are all predictive of developing coronary heart disease, is it beneficial to be able to regulate one’s emotions? Research suggests that it is. Self-regulation skills may be very important, not only for our psychological well-being but for our physical health as well. TREATMENT OF STRESS-RELATED PHYSICAL DISORDERS Biological Interventions: For patients with CHD, such treatments might include surgical procedures as well as medications to lower cholesterol or reduce the risk of blood clots. However, in light of the strong associations between depression and risk for CHD, treating depression is also of the utmost importance. Psychological Interventions ➢ Emotional Disclosure: “Opening up” and writing expressively about life problems in a systematic way does seem to be an effective therapy for many people with illnesses. It may also speed up wound healing. It seems to provide some modest benefits for people who have been diagnosed with autoimmune illnesses. However, findings suggest that it does not seem to improve sleep problems, depression, or overall quality of life in people being treated for cancer. Emotional disclosure gives the patient an opportunity for emotional catharsis and to rethink their problems. However, it can also lead to rumination. ➢ Biofeedback: It aims to make patients more aware of such things as their heart rate, level of muscle tension, or blood pressure. This is done by connecting the patient to monitoring equipment and then providing a cue (for example, an audible tone) to the patient when he or she is successful at making a desired response (e.g., lowering blood pressure or decreasing tension in a facial muscle), these treatment effects tend to be stable over time. ➢ Relaxation and Meditation: Researchers have examined the effects of various behavioral relaxation techniques on selected stress-related illnesses. The results have been variable, though generally encouraging. ➢ Cognitive-Behavior Therapy: CBT has been shown to be an effective intervention for headache as well as for other types of pain. Some CBT techniques have also been used for patients with rheumatoid arthritis. STRESS AND MENTAL HEALTH In adjustment disorder, the stressor is something that is commonly experienced, and the nature of the psychological reaction is much less severe. In contrast, both acute stress disorder and PTSD involve exposure to a more traumatic stressor. This can lead to short term problems (acute stress disorder) or more long-term and intense difficulties that can be debilitating (PTSD). Adjustment Disorder: Psychological response to a common stressor (e.g., divorce, death of a loved one, loss of a job) that results in clinically significant behavioral or emotional symptoms. For the diagnosis to be given, symptoms must begin within 3 months of the onset of the stressor. The person’s symptoms disappear when the stressor ends or when the person learns to adapt to the stressor. In cases where the symptoms continue beyond 6 months, the diagnosis is usually changed. A typical example is Adjustment Disorder caused by Unemployment. Acute Stress Disorder: It is a diagnostic category that can be used when symptoms develop shortly after experiencing a traumatic event and last for at least 2 days, if symptoms persist beyond 4 weeks, the diagnosis can be changed from acute stress disorder to posttraumatic stress disorder. Post traumatic Stress Disorder: What becomes established, in PTSD, is a memory of the traumatic event that results in the traumatic event being re-experienced involuntarily and with the same full emotional force that characterized the original experience. The diagnosis of PTSD requires that symptoms must last for at least 1 month. - Changes to the Diagnostic Criteria for PTSD: When PTSD was first introduced into the DSM, the diagnostic criteria required exposure to a traumatic event that was “outside the range of usual human experience” and that would cause “significant symptoms of distress in almost anyone.” A major change occurred with DSM-IV. Not only was there a broadening of the range of experiences that could now be used to diagnose PTSD, but it was also required that the person’s response involve “intense fear, helplessness or horror.” Rather than conceptualizing PTSD as a normal response to an abnormal stressor, in DSM-IV, PTSD was viewed as a pathological response to an extreme form of stress. In DSM-5, the diagnostic criteria for PTSD have been tightened. The traumatic event must now be experienced by the person directly, either because the event happens to you or because you witness, in person, something traumatic happening to someone else. POSTTRAUMATIC STRESS DISORDER: CAUSES AND RISK FACTORS The clinical symptoms of PTSD are grouped into four main areas: 1. Intrusion: Recurrent re-experiencing of the traumatic event through nightmares, intrusive images, and physiological reactivity to reminders of the trauma. 2. Avoidance: Efforts to avoid thoughts, feelings, or reminders of the trauma. 3. Negative alterations in cognitions and mood: This includes such symptoms as feelings of detachment as well as negative emotional states such as shame or anger, or distorted blame of oneself or others. 4. Arousal and reactivity: Hypervigilance, excessive response when startled, aggression, and reckless behavior. - DSM-5 Criteria for Posttraumatic Stress Disorder The following criteria apply to adults, adolescents, and children older than 6 years a. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. b. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 2. Recurrent distressing dreams in which the content and/or affect of the 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or ➔ Biological Factors: Under conditions of imposed experimental stress (trauma reminders, cognitive challenges), people with PTSD do seem to show an exaggerated cortisol response. However, baseline levels of cortisol are often very similar in people with PTSD when they are compared to those of healthy controls. Gender may be an important factor here: Women with PTSD do seem to have higher levels of baseline cortisol than women without PTSD. This is not so for men with and without PTSD. Also, the type of trauma may be an important factor. Studies show that a brain area called the hippocampus (which involves memory and is responsive to stress) seems to be reduced in size in people with PTSD. However, depressed people show the same. ➔ Sociocultural Factors: Being a member of a minority group seems to place people at higher risk for developing PTSD. After 9/11, compared with whites, African American and Hispanic survivors were more likely to have PTSD, maybe because they are more educated and have a higher annual income. Returning to a negative and unsupportive social environment can also increase vulnerability to posttraumatic stress. Sociocultural variables also appear to play a role in determining a person’s adjustment to combat. Identification with the combat unit and the quality of leadership also make a difference Long-term Effects of Post traumatic Stress: As we have already noted, soldiers who have experienced combat exhaustion may show symptoms of posttraumatic stress for sustained periods of time. If it develops, PTSD can be a severe and chronic condition. The delayed version of PTSD is less well defined and more difficult to diagnose than disorders that emerge shortly after the precipitating incident, these delayed cases are rare and some even question if it should be classified as PTSD. PREVENTION AND TREATMENT OF STRESS DISORDERS Prevention of PTSD: One way to prevent PTSD is to reduce the frequency of traumatic events. It is also worth considering whether it is possible to prevent maladaptive responses to stress by preparing people in advance and providing them with information and coping skills. The use of cognitive-behavioral techniques to help people manage potentially stressful situations or difficult events has been widely explored. This preventive strategy, often referred to as “stress inoculation” training, prepares people to tolerate an anticipated threat by changing the things they say to themselves before or during a stressful event. Treatment for PTSD ➢ Telephone Hotlines: National and local telephone hotlines provide help for people under severe stress and for people who are suicidal, there are specific hotlines for victims of rape and sexual assault and for runaways who need help. ➢ Crisis Intervention: It has emerged in response to especially stressful situations, be they disasters or family situations. Therapy is focused only on helping the person through the immediate crisis, not on “remaking” her or his personality. The therapist is usually very active, helping to clarify the problem, suggesting plans of action, providing reassurance. ➢ Psychological Debriefing: It helps and speeds up the healing process in people who have experienced disasters or been exposed to other traumatic situations. Traumatized victims are provided with emotional support and encouraged to talk about their experiences. One form of psychological debriefing is Critical Incident Stress Debriefing (CISD), one single session lasts between 3 and 4 hours and is conducted in a group format, usually 2 to 10 days after a “critical incident” or trauma. It is controversial because reviews of the literature have generally failed to support the clinical effectiveness of the approach but those who experience the debriefing sessions often report satisfaction. ➢ Medication: persons experiencing traumatic situations usually report intense feelings of anxiety or depression, numbing, intrusive thoughts, and sleep disturbance. To help with these problems, patients are often treated with medication, such as antipsychotic (evidence for effectiveness is slim) and antidepressants (some evidence of significant benefits). ➢ Cognitive-Behavioral Treatments: One behaviorally oriented treatment strategy that is now being used for PTSD is prolonged exposure. The patient is asked to vividly recount the traumatic event over and over until there is a decrease in his or her emotional responses. The client has to trust in the therapist enough to engage in the exposure treatment. One problem with prolonged exposure therapy is that it tends to have a higher dropout rate than other approaches. Another current issue of concern is how long the treatment effects last. Another strategy was made by Ehlers and colleagues (2005), who have developed a treatment for PTSD that is based on a cognitive model of the disorder. More specifically, it is thought that PTSD becomes persistent when people who have experienced trauma make excessively negative and idiosyncratic appraisals of what has happened to them in a way that creates a sense of a serious, current threat. Evidence suggests that this treatment approach is very effective. The drop-out rate was also very low. Trauma and Physical Health: Traumatic events are not only bad for the mind, they also damage the body. Although the mechanisms for this are still being explored. CHAPTER 6: Panic, anxiety, obsessions, and their disorders THE FEAR AND ANXIETY RESPONSE PATTERNS Anxiety involves a general feeling of apprehension about possible future danger, whereas fear is an alarm reaction that occurs in response to immediate danger. Fear: (or panic) It is a basic emotion (shared by many animals) that involves activation of the “fight-or-flight” response of the autonomic nervous system. This is an almost instantaneous reaction to any imminent threat such as a dangerous predator or someone pointing a loaded gun. When the fear response occurs in the absence of any obvious external danger, we say the person has had a spontaneous or uncued panic attack. Three components of fear: Cognitive/ subjective (“I’m going to die”), physiological (increased heart rate), and behavioral (strong urge to escape). Anxiety: It is more oriented to the future and much more diffuse than fear. It also has 3 components: Cognitive/ subjective (negative mood, worry, self-preoccupation), physiological (state of tension and chronic overarousal, no flight-or-fight), and behavioral (avoidance of situations). In mild to moderate degrees, anxiety actually enhances learning and performance. However, it is maladaptive when it becomes chronic and severe. Many of our sources of fear and anxiety are learned. OVERVIEW OF THE ANXIETY DISORDERS AND THEIR COMMONALITIES Anxiety disorders are characterized by unrealistic, irrational fears or anxieties that cause significant distress and/or impairments in functioning. Among the disorders recognized in DSM-5 are: Specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder. People with these varied disorders differ from one another both in terms of the amount of fear or panic versus anxiety symptoms that they experience and in the kinds of objects or situations that most concern them. Many people with one anxiety disorder will experience at least one more anxiety disorder and/or depression either concurrently or at a different point in their lives Biological causal factors: personality trait called neuroticism (disposition to experience negative mood states, it is a common risk factor for both anxiety and mood disorders). The brain structures: limbic system (often known as the “emotional brain”) and certain parts of the cortex, and the neurotransmitter GABA, norepinephrine, and serotonin. Psychological causal factors: Classical conditioning of fear, panic, or anxiety. People who have perceptions of a lack of control over either their environments or emotions (or both) seem more vulnerable. The sociocultural environment in which people are raised also has prominent effects on the kinds of objects and experiences people become anxious about or come to fear. 1. SPECIFIC PHOBIAS A specific phobia is said to be present if a person shows strong and persistent fear that is triggered by the presence of a specific object or situation and leads to significant distress and/or impairment in a person’s ability to function. Generally, people with specific phobias recognize that their fear is somewhat excessive or unreasonable although occasionally they may not have this insight. The 5 subtypes of Specific Phobias: Animal, natural environment, blood-injection-injury, situational, other. Phobic behavior tends to be reinforced because every time the person with a phobia avoids a feared situation, his or her anxiety decreases. Blood-injection-injury phobia occurs in approximately 3 to 4 percent of the population, these people show an initial acceleration, followed by a dramatic drop in both heart rate and blood pressure. This is very frequently accompanied by nausea, dizziness, or fainting, which does not occur with other specific phobias. This type of phobia appears to be highly heritable - DSM-5 Criteria for Specific Phobia g. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. h. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. i. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. j. If another medical condition (e.g. Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. Prevalence, age of onset, and gender differences: Approximately 12 percent of the population meets the diagnostic criteria for social phobia at some point in their lives. More common among women (about 60 percent of sufferers are women), and it typically begins during adolescence or early adulthood. ⅔ suffer from one or more additional anxiety disorders, ½ suffer from a depressive disorder, ⅓ abuse alcohol to face the fear. Lower employment rates and lower socioeconomic status, ⅓ have severe impairment in one or more domains in their lives. The disorder is really persistent, only ⅓ get better. Psychological causal factors Social Phobia as Learned Behavior: Originate from simple instances of direct or vicarious classical conditioning such as experiencing or witnessing a perceived social defeat or humiliation, or being or witnessing the target of anger or criticism Social fears and phobia in an evolutionary context: Social fears and phobia evolved as a by-product of dominance hierarchies that are a common social arrangement among animals. Dominance hierarchies are established through aggressive encounters between members of a social group, and a defeated individual typically displays fear and submissive behavior but only rarely attempts to escape the situation completely. Perceptions of Uncontrollability and Unpredictability: They often lead to submissive and unassertive behavior, which is a characteristic of people who are socially anxious or phobic. Cognitive Biases: People with social phobia tend to expect that other people will reject or negatively evaluate them. They argued that this leads to a sense of vulnerability when they are around people who might pose a threat. Another cognitive bias seen in social phobia is a tendency to interpret ambiguous social information in a negative rather than a benign manner Biological causal factors: The most important temperamental variable is behavioral inhibition, which shares characteristics with both neuroticism and introversion. Kids who are shy and avoidant are more likely to become fearful during childhood and, by adolescence, to show increased risk of developing social phobia. Treatments: - Cognitive and behavioral therapies: Prolonged and graduated exposure to the feared situation (in this case, social situations), has proven to be a very effective treatment. Cognitive restructuring techniques (identify their underlying negative, automatic thoughts) have been added to the behavioral techniques, generating a form of cognitive-behavioral therapy. - Medications: Unlike specific phobias, social phobia can sometimes be effectively treated with medications. The most effective are antidepressants (including the monoamine oxidase inhibitors and the selective serotonin reuptake inhibitors). The medications must be taken over a long period of time to help ensure that relapse does not occur. Therapy produces more long-lasting improvement with very low rates of relapse. 3. PANIC DISORDER Panic disorder is defined and characterized by the occurrence of panic attacks that often seem to come “out of the blue.” Panic attacks are fairly brief but intense, with symptoms developing abruptly and usually reaching peak intensity within 10 minutes; the attacks often subside in 20 to 30 minutes and rarely last more than an hour. Panic attacks often are “unexpected” or “uncued” in the sense that they do not appear to be provoked by identifiable aspects of the immediate situation. Patients with heart problems have almost twice the risk of developing panic disorder. Panic disorder causes as much impairment in social and occupational functioning as that caused by major depressive disorder. - DSM-5 Criteria for Panic Disorder a. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath 5. Feelings of choking 6. Chest pain or discomfort 7. Nausea 8. Feeling dizzy, or faint 9. Chills or heat sensations 10. Paresthesias (numbness) 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12. feelings of “going crazy” 13. Fear of dying The abrupt surge can occur from a calm state or an anxious state. Culture-specific symptoms may be seen. Such symptoms should not count as one of the four required symptoms. b. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). 2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). c. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). d. The disturbance is not better explained by another mental disorder. 4. Agoraphobia In agoraphobia the most commonly feared and avoided situations include streets and crowded places such as shopping malls, movie theaters, and stores. Standing in line can be particularly difficult. Sometimes, agoraphobia develops as a complication of having panic attacks in one or more such situations. People with agoraphobia are anxious about being in places or situations from which escape would be difficult. Typically people with agoraphobia are also frightened by their own bodily sensations (exercising, watching scary movies, drinking caffeine, and even engaging in sexual activity). First, they tend to avoid situations in which the attacks have occurred, but then it escalates. In moderate cases, they are afraid to leave the house alone. In severe cases, they can’t go outside the house or even in certain places of the house. Agoraphobia is a frequent complication of panic disorder. However, many patients with agoraphobia do not experience panic. - DSM-5 Criteria for Agoraphobia a. Marked fear or anxiety about two (or more) of the following five situations: 1.Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. b. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence). c. The agoraphobic situations almost always provoke fear or anxiety. d. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. e. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. f. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. g. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. h. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive. i. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder. diagnosed. They live in a constant, future-oriented mood of anxious apprehension, chronic tension, worry, and diffuse uneasiness that they cannot control. It leaves them continually upset and discouraged. The most common areas of worry tend to be family, work, finances, and personal illness. They also struggled with making decisions and consequences. - DSM-5 Criteria for Generalized Anxiety Disorder a. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). b. The individual finds it difficult to control the worry. c. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required for children. 1. Restlessness or feeling keyed up or on edge. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). d. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. e. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). f. The disturbance is not better explained by another mental disorder Prevalence, age of onset, and gender differences: Approximately 3 percent of the population suffers from GAD in any 1-year period and 5.7 percent at some point in their lives. It also tends to be chronic but after 50, it's replaced by a somatic symptom disorder. GAD is approximately twice as common in women as in men. Most people with this disorder manage to function despite the constant worry. Comorbidity with other disorders: especially other anxiety and mood disorders such as panic disorder, social phobia, specific phobia, PTSD, and major depressive disorder. They can experience panic attacks but don’t meet the criteria for panic disorder. Psychological causal factors The psychoanalytic viewpoint: Free-floating anxiety results from an unconscious conflict between ego and id impulses that is not adequately dealt with because the person’s defense mechanisms have either broken down or have never developed. In specific phobias the defense mechanisms of repression and displacement of an external object or situation actually work, in the other don’t. Perceptions of Uncontrollability and Unpredictability: some evidence indicates that people with GAD may be more likely to have had a history of trauma in childhood than individuals with several other anxiety disorders. People with GAD have far less tolerance for uncertainty than non anxious controls and even people with panic disorder A Sense of Mastery: The possibility of immunizing against anxiety: A person’s history of control over important aspects of his or her environment is another significant experiential variable strongly affecting reactions to anxiety-provoking situations. The Reinforcing Properties of Worry: The worry process is now considered the central feature of GAD. Why do people keep worrying? Superstitious avoidance of catastrophe, Avoidance of deeper emotional topics, Coping and preparation. The Negative Consequences of Worry: worry itself is certainly not an enjoyable activity and can actually lead to a greater sense of danger and anxiety, people who worry about something tend subsequently to have more negative intrusive thoughts than people who do not worry and attempts to control thoughts and worry may paradoxically lead to increased experience of intrusive thoughts. Cognitive Biases for threatening information: They process threatening information in a biased way, perhaps because they have prominent danger schemas. Anxious people are also more likely than non anxious people to think that bad things are likely to happen in the future. Biological causal factors Genetic Factors: Evidence for genetic factors in GAD is mixed, but there does seem to be a modest heritability, although perhaps smaller than that for most other anxiety disorders except phobias. GAD and major depressive disorder have a common underlying genetic predisposition. Neurotransmitters and Neurohormonal abnormalities: It appears that highly anxious people have a kind of functional deficiency in GABA, which ordinarily plays an important role in the way our brain inhibits anxiety in stressful situations. More recently, researchers have discovered serotonin is also involved in modulating generalized anxiety. Neurobiological differences between anxiety and panic: Fear and panic involve activation of the fight-or-flight response, and the important brain areas are the amygdala (and locus coeruleus) and the neurotransmitters norepinephrine and serotonin. Generalized anxiety is a more diffuse emotional state than acute fear or phobia, and the limbic system (especially the bed nucleus of the stria terminalis, an extension of the amygdala), GABA, and CRH are implicated. Perhaps they share the serotonin. Treatments - Medications: Their effects on worry and other psychological symptoms are not as great, they can create physiological and psychological dependence and withdrawal - Cognitive-Behavioral Treatment: has become increasingly effective. It usually involves a combination of behavioral techniques, such as training in applied muscle relaxation, and cognitive restructuring techniques. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS This new category includes not only OCD but also body dysmorphic disorder, hoarding disorder, excoriation (skin-picking) disorder, and trichotillomania (compulsive hair pulling). Obsessive-Compulsive Disorder The occurrence of both obsessive thoughts and compulsive behaviors performed in an attempt to neutralize such thoughts Obsessions are persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing, inappropriate, and uncontrollable. People who have such obsessions actively try to resist or suppress them or to neutralize them with some other thought or action Compulsions involve overt repetitive behaviors that are performed as rituals.There are five primary types of compulsive rituals: cleaning (hand washing and showering), checking, repeating, ordering or arranging, and counting. The compulsive behaviors are performed with the goal of preventing or reducing distress or preventing some dreaded event or situation. It brings a feeling of reduced tension and satisfaction, as well as a sense of control, although this anxiety relief is typically short. OCD is often one of the most disabling mental disorders in that it leads to a lower quality of life and a great deal of functional impairment. The person must recognize that the obsession is the product of his or her own mind, not like schizophrenia. Besides, diagnosis requires that obsessions and compulsions take at least 1 hour per day, and in severe cases they may take most of the person’s waking hours. Many obsessive thoughts involve contamination fears, fears of harming oneself or others, and pathological doubt. Other fairly common themes are concerns about or need for symmetry sexual obsessions, and obsessions concerning religion or aggression - Why is OCD no longer considered to be an anxiety disorder? Because anxiety is not generally used as an indicator of OCD severity. Also, the presence of some anxiety is not a valid reason to regard OCD as an anxiety disorder. Yet another reason is that the neurobiological underpinnings of OCD appear to be rather different from those of other anxiety disorders. - DSM-5 Criteria for Obsessive-Compulsive Disorder a. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): cases if they use antipsychotic medications they get better. However, when medication is discontinued, relapse rate is super high. Studies in adults have generally not found that combining medication with exposure and response prevention is much more effective than behavior therapy alone. Besides, for severe cases of OCD (at least 5 yrs and not responding to therapy or medication) there are neurosurgical techniques designed to destroy brain tissue. Body Dysmorphic Disorder People with BDD are obsessed with some perceived or imagined flaw or flaws in their appearance to the point they firmly believe they are disfigured or ugly. Another symptom is avoidance of usual activities because of fear that other people will see the imaginary defect and be repulsed. In severe cases, they may become too isolated, 50% are unemployed. People with BDD may focus on almost any body part, the most common are: skin, hair, nose, etc. This is leading in many cases to complete preoccupation and significant emotional pain. Nobody else sees the defects. They frequently engage in excessive grooming behavior - DSM-5 Criteria for Body Dysmorphic Disorder a. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. b. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. c. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. d. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. ● Prevalence, Age of Onset, and Gender differences: 1 to 2 percent of the general population and up to 8 percent of people with depression, equal in men and women. Men are more likely to obsess about their genitals, body build, and balding, whereas women tend to obsess more about their skin, stomach, breasts, buttocks, hips, and legs. Onset is adolescence. BDD commonly has depression and it can lead to suicide attempts and death. Sufferers of BDD commonly make their way into the office of a dermatologist or plastic surgeon. ● Relationship to OCD and Eating Disorders: People with BDD, like those with OCD, have prominent obsessions, and they engage in a variety of ritualistic behaviors such as reassurance seeking, mirror checking, comparing themselves to others, and camouflage. The same neurotransmitter (serotonin) and the same sets of brain structures are implicated in the two disorders. BDD is related to anorexia nervosa. People with BDD look normal and hate it, people with anorexia look bad and like it. ● Why now?: First, its prevalence may actually have increased in recent years as contemporary Western culture has become increasingly focused on “looks as everything,”. Second, people with BDD suffer silently or go to dermatologists or plastic surgeons but now they are looking for help thanks to the media attention. ● Causal Factors: A Biopsychosocial approach to BDD: First, overconcern with a perceived or slight defect in physical appearance is a moderately heritable trait. Second, sociocultural context that places great value on attractiveness and beauty, maybe as kids they were teached that looks is everything or they were physically bullied. People with BDD tend to interpret ambiguous facial expressions as contemptuous or angry more than others. Patients with BDD showed fundamental differences in visually processing other people’s faces relative. ● Treatment of Body Dysmorphic Disorder: Treatments that are effective for BDD are closely related to those used in the effective treatment of OCD. For BDD, you need a higher dose than for OCD. A form of cognitive-behavioral treatment emphasizing exposure and response prevention has been shown to produce marked improvement. Hoarding Disorder Compulsive hoarding (as a symptom) occurs in approximately 3 to 5 percent of the adult population, and in 10 to 40 percent of people diagnosed with OCD. People with hoarding disorder both acquire and fail to discard many possessions that seem useless or of very limited value, in part because of the emotional attachment they develop to their possessions. Their living spaces are extremely cluttered and disorganized to the point of interfering with normal activities. People with compulsive hoarding may be neurologically distinct from people with OCD. Compulsive hoarders are significantly more disabled (both occupationally and socially) than people with OCD but without compulsive hoarding symptoms. Most effective treatment is home visits. Trichotillomania Trichotillomania (also known as compulsive hair pulling) has as its primary symptom the urge to pull out one’s hair from anywhere on the body (most often the scalp, eyebrows, or arms). It usually occurs when the person is alone (or with immediate family members) and the person often examines the hair root, twirls it off, and sometimes pulls the strand between their teeth and/or eats it. The onset can be in childhood or later, with onset post-puberty being associated with a more severe course. CULTURAL PERSPECTIVES Cross-cultural research suggests that although anxiety is a universal emotion, and anxiety disorders probably exist in all human societies, there are some differences. Examples: Lifetime risk for social phobia, generalized anxiety disorder, and panic disorder is somewhat lower among ethnic minority groups than among the non-Hispanic whites. Latin Americans from the Caribbean (especially those from Puerto Rico), and other people from the Caribbean, do show higher rates of a variant of panic disorder called ataque de nervios. In Nigeria, sources of worry center on creating and maintaining a large family, being bewitched in one’s dreams, and having problems with one’s brain (such as experiencing insects or worms crawling in the brain). In China and other Southeast Asian countries that have cultural concerns about male sexual potency, a common source of worry is the penis retracting into the body. CHAPTER 7: Mood disorders and suicide MOOD DISORDERS: AN OVERVIEW Nevertheless, in all mood disorders (formerly called affective disorders), extremes of emotion or affect dominate the clinical picture. Other symptoms are also present, but abnormal mood is the defining feature. The two key moods involved in mood disorders are depression, which usually involves feelings of extraordinary sadness and dejection, and mania, often characterized by intense and unrealistic feelings of excitement and euphoria. - DSM-5 Criteria for Major Depressive Disorder a. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, it can be an irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. UNIPOLAR DEPRESSIVE DISORDERS Major Depressive Disorder Also known as “Major Depression” (or MDD). The person must be in a major depressive episode and never have had a manic, hypomanic, or mixed episode. People with MDD lacks energy and the ability to carry out activities of daily life, physical symptoms include loss of appetite and sleep disturbance, cognitive symptoms of worthlessness and thoughts of death and suicide. There are very high levels of comorbidity between depressive and anxiety disorders. ● Depression as a Recurrent Disorder: When a diagnosis of MDD is made, it is usually also specified whether this is a first, and therefore single (initial), episode or a recurrent episode (preceded by one or more previous episodes). Depressive episodes typically last about 6 to 9 months if untreated. The return of symptoms is one of 2 types: relapse and recurrence. The first one is thought to be a return of symptoms of an ongoing episode that was symptomatically suppressed, whereas a recurrence represents an entirely new episode. ● Depression throughout the Life Cycle: The onset of depression is usually late adolescence up to middle adulthood, however, school age kids can have it. As in adults, recurrence rates are high in children. ● Specifiers for Major Depressive Episodes: People with MDD can have additional patterns, called “specifiers”: Specifier Characteristic Symptoms With Melancholic Features Three of the following: early morning awakening, depression worse in the morning, marked psychomotor agitation or retardation, loss of appetite or weight, excessive guilt, qualitatively different depressed mood. This subtype of depression is more heritable than most other forms of depression and is more often associated with a history of childhood trauma. With Psychotic Features Delusions (false beliefs) or hallucinations (false sensory perceptions). Those are usually mood congruent, the content is like depression, sad/negative). Also, they have feelings of guilt and worthlessness. With Atypical Features Mood reactivity, the person brightens to potential positive events; two of the four following symptoms: weight gain or increase in appetite, hypersomnia, leaden paralysis (arms and legs feel as heavy as lead), being acutely sensitive to interpersonal rejection. Much more common in females, more likely to have suicidal thoughts. Linked to a mild form of bipolar disorder, associated with hypomanic. With Catatonic Features A range of psychomotor symptoms from motoric immobility (catalepsy) to extensive psychomotor activity, as well as mutism and rigidity. Catatonia is known as a subtype of schizophrenia, but is more related to depression. With Seasonal Pattern Commonly known as “Seasonal affective disorder”. At least two or more episodes in the past 2 years that have occurred at the same time (usually fall or winter), and full remission at the same time (usually spring). No other nonseasonal episodes in the same 2-year period. Persistent Depressive Disorder Formerly called dysthymic disorder or dysthymia, it is a disorder characterized by persistently depressed mood most of the day, for more days than not, for at least 2 years (1 year for children and adolescents). Periods of normal mood may occur briefly, but they usually last for only a few days to a few weeks (and for a maximum of 2 months). People with PDD have worse outcomes than MDD. When both occur it is called “double depression”, which is classified as a form of PDD. PDD is quite common, with a lifetime prevalence estimated at between 2.5 and 6 percent. The average duration of persistent depressive disorder is 4 to 5 years, but it can last for 20 years or more. Chronic stress increases the severity of symptoms. Difference between PDD and MDD: The first one is a form of depression that lasts for 2 years or more. MDD, on the other hand, is characterized by episodes of major depression that are separated by at least 2 months. - DSM-5 Criteria for Persistent Depressive Disorder a. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. b. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or difficulty making decisions. 6. Feelings of hopelessness. c. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. d. Criteria for a major depressive disorder may be continuously present for 2 years. e. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder f. The disturbance is not better explained by a persistent schizo affective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. g. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism). h. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted Other Forms of Depression ● Loss and the Grieving Process: A major depressive disorder usually should not be diagnosed for the first 2 months following the loss, even if all the symptom criteria are met. However, in a controversial move, this 2-month grief exclusion was dropped. It is important to note that not all loss is followed by depression ● Postpartum “Blues”: Postpartum depression sometimes occurs in new mothers (and occasionally fathers) and it is known to have adverse effects on child outcomes. It is a very common disorder. Symptoms: changeable mood, crying easily, sadness, and irritability, often liberally intermixed with happy feelings. Postpartum women do not have a higher risk of developing MDD. CAUSAL FACTORS IN UNIPOLAR MOOD DISORDERS Biological Causal Factors Genetic Influences: Taken together, the results from family and twin studies make a strong case for a moderate genetic contribution to the causal patterns of MDD, although not as large a genetic contribution as for bipolar disorder. Neurochemical Factors: The monoamine theory of depression (norepinephrine and serotonin) stated that depression was at least sometimes due to an absolute or relative decrease of one or both of these neurotransmitters. However, it was proved that it was not that simple, sadly there is no other alternative yet. Abnormalities of Hormonal regulatory and Immune Systems: Hypothalamic pituitary- adrenal (HPA), in particular in the hormone Cortisol. The human stress response is associated with elevated activity of the HPA axis, in recent years many studies have shown that depression is also accompanied by dysregulation of the immune system Neurophysiological and Neuroanatomical Influences: Damage (for example, from a stroke) to the left, but not the right, anterior prefrontal cortex often leads to depression. People that had no damage showed low activity in that area (researchers used EEG and PET). - The Orbital prefrontal cortex (responsivity to reward) shows decreased volume, dorsolateral prefrontal cortex (cognitive control) decreased activity. - The Hopelessness Theory of Depression states that the combination of a pessimistic attributional style and negative life events is not sufficient to cause depression, but rather an individual must first experience a state of hopelessness (characterized by a perceived lack of control over future outcomes and the absolute certainty that an important bad outcome will occur) - The Ruminative Response Styles Theory of Depression highlights the role of rumination in the development and maintenance of depression. Rumination is a process of repetitive and passive thinking about one's negative thoughts and feelings, which can exacerbate and prolong depressive symptoms. In contrast, problem-solving or distracting responses may help alleviate depressive symptoms. Women are more likely to ruminate when they become depressed, while men engage in distracting activities or consume alcohol. - Comorbidity of Anxiety and Mood Disorders: There is significant overlap between anxiety and mood disorders The personality trait of neuroticism is a major risk factor for all of these disorders. Depressed individuals tend to have low levels of positive affect, while anxious individuals do not, except those with social phobia. 5. Interpersonal Effects of Mood Disorders: Interpersonal problems and social-skills deficits may well play a causal role in at least some cases of depression - Lack of Social Support and Social-Skills Deficits: individuals with depression may also have negative views of themselves and others, leading to difficulty in forming and maintaining social relationships. This negative cognitive bias can also impact their ability to interpret and respond to social cues accurately, which may contribute to their social-skills deficits. - The Effects of Depression on Others: depression can also have negative effects on the family members and close friends of the person who is depressed. Family members often experience high levels of distress and burden, especially kids. - Marriage and Family Life: couples experiencing marital distress have at least one partner with clinical depression, and there is a strong correlation between marital dissatisfaction and depression for both women and men. Children of parents with depression who become depressed themselves tend to become depressed earlier and to show a more severe and persistent course. BIPOLAR AND RELATED DISORDERS Cyclothymic Disorder This is a less serious version of bipolar disorder because it lacks the extreme mood and behavior changes, psychotic features, and marked impairment seen in bipolar disorder. The person may become especially creative and productive because of increased physical and mental energy. For a diagnosis of cyclothymia, there must be at least a 2-year span during which there are numerous periods with hypomanic (less severe and shorter than BD II) and depressed (similar to PDD) symptoms (1 year for adolescents and children). These individuals are at risk for bipolar disorder. Bipolar Disorders (I and II) Bipolar Disorder I Bipolar Disorder II Person has full-blown mania. Person experiences periods of hypomania, but his or her symptoms are below the threshold for full-blown mania. Person experiences episodes of mania and periods of depression. Even if the periods of depression do not reach the threshold for a major depressive episode, the diagnosis of bipolar I disorder is still given. Person experiences periods of depressed mood that meet the criteria for major depression. In Bipolar Disorder I, if a person shows only manic symptoms, it is nevertheless assumed that a bipolar disorder exists and that a depressive episode will eventually occur. Bipolar II disorder is equally or somewhat more common than bipolar I disorder. Bipolar disorder occurs equally in males and females (although depressive episodes are more common in women than men) and usually starts in adolescence and young adulthood, with an average age of onset of 18 to 22 years (BD II is 5yrs more than BD I). There is also bipolar disorder with a seasonal pattern. Features of Bipolar Disorder: Three times as many days spent depressed than manic or hypomanic. Difference between Unipolar depressive episode and Bipolar depressive episode is that the latter show more mood lability, more psychotic features, more psychomotor retardation, and more substance abuse. While individuals with unipolar depression, on average, show more anxiety, agitation, insomnia, physical complaints, and weight loss. People with bipolar disorder (4 episodes per year) suffer from more episodes during their lifetimes than do persons with unipolar disorder. People with rapid cycling have more episodes. The probabilities of “full recovery” from bipolar disorder are discouraging even with the widespread use of mood-stabilizing medications such as lithium. CAUSAL FACTORS IN BIPOLAR DISORDERS Biological Causal Factors Genetic Influences: There is a strong genetic contribution to bipolar disorder, specifically bipolar I disorder. Different disorders, such as schizophrenia and depression, may share some genetic etiology with bipolar disorder. There is no consistent support yet for any specific mode of genetic transmission of bipolar disorder. Neurochemical Factors: Norepinephrine, serotonin, and dopamine, in regulating mood and their connection to bipolar disorder. It suggests that mania may be caused by excesses of norepinephrine or serotonin, while depression may be caused by deficiencies in these neurotransmitters. Increased dopaminergic activity is also related to manic symptoms, while drugs like lithium reduce dopaminergic activity and are antimanic. Abnormalities of Hormonal Regulatory Systems: Abnormalities in the hormonal regulatory systems, such as the hypothalamic-pituitary-adrenal (HPA) axis and the hypothalamic-pituitary-thyroid axis, may play a role in bipolar disorder. Elevated cortisol levels, as well as abnormalities on the dexamethasone suppression test, have been observed in bipolar depression, but not typically during manic episodes. Abnormalities in thyroid function are also common in bipolar patients, and administration of thyroid hormone may improve the efficacy of antidepressant drugs, but can also precipitate manic episodes in some patients. Neurophysiological and Neuroanatomical Influences: - Studies have shown that blood flow to the left prefrontal cortex is reduced during depression but increased in certain other parts of the prefrontal cortex during mania. - Structural imaging studies suggest that certain subcortical structures, including the basal ganglia and amygdala, are enlarged in bipolar disorder but reduced in size in unipolar depression. - The decreases in hippocampal volume that are often observed in unipolar depression are generally not found in bipolar depression. - Dysregulation in frontal-limbic activation in individuals with bipolar disorder compared to others. Sleep and Other Biological Rhythms: There is evidence of disturbances in biological rhythms, such as circadian rhythms, in bipolar disorder. During manic episodes, patients tend to sleep very little, while during depressive episodes, they tend towards hypersomnia. Bipolar disorder also sometimes shows a seasonal pattern, suggesting disturbances of seasonal biological rhythms, which may be due to circadian abnormalities. Patients with bipolar disorder are sensitive to changes in their daily cycles that require a resetting of their biological clocks. Psychological Causal Factors Stressful Life Events as Causal Factors: Stressful life events appear to be as important in precipitating bipolar depressive episodes as they are in triggering unipolar depressive episodes. - Cognitive-Behavioral Therapy: It is effective in treating unipolar depression. The therapy focuses on teaching patients to evaluate their dysfunctional beliefs, negative automatic thoughts, biases, and distortions in information processing. CBT relies on an empirical approach in which patients treat their beliefs as hypotheses that can be tested through behavioral experiments. Studies have shown that CBT is at least as effective as pharmacotherapy when delivered by well-trained therapists, and it has a special advantage in preventing relapse. Recent brain-imaging studies have shown that the biological changes that occur following effective treatment with CBT versus medications are somewhat different, suggesting that the mechanisms through which they work are also different. A variant of CBT, called mindfulness-based cognitive therapy, has been developed to be used with people with highly recurrent depression. This group treatment involves training in mindfulness meditation techniques aimed at developing patients' awareness of their unwanted thoughts, feelings, and bodily sensations. Recently, there have been indications that a modified form of CBT may be quite useful, in combination with medication, in the treatment of bipolar disorder as well. - Behavioral Activation Treatment: New approach to treating unipolar depression that focuses on increasing patients' activity levels and engagement with their environment and relationships. BAT involves scheduling daily activities, rating pleasure and mastery while engaging in them, exploring alternative behaviors to reach goals, and role-playing to address specific deficits. BAT does not focus on implementing cognitive changes directly but rather on changing behavior, with the goals of increasing levels of positive reinforcement and reducing avoidance and withdrawal. BAT has several advantages over traditional cognitive therapy. For example, it is easier to train therapists to administer BAT than cognitive therapy. However, cognitive therapy may be slightly superior at follow-up. - Interpersonal Therapy: It is a treatment approach that focuses on current relationship issues to help individuals with depression understand and change maladaptive interaction patterns. It has not been evaluated as extensively as CBT, studies suggest that it is effective for treating unipolar depression and is about as effective as medications or CBT. IPT has also been adapted for the treatment of bipolar disorder by adding a focus on stabilizing daily social rhythms that, if they become destabilized, may play a role in precipitating bipolar episodes. This new treatment is called interpersonal and social rhythm therapy. - Family and Marital Therapy: It is important to note that addressing life stressors and interpersonal problems should not be viewed as an alternative to effective treatments for depression such as medication and psychotherapy, but rather as an essential adjunct to them. - Conclusions: It is important to note that despite the effectiveness of modern treatment methods, many individuals with depression and bipolar disorder do not receive adequate treatment. Additionally, individuals with depression and bipolar disorder have higher mortality rates than the general population. Suicide is a significant cause of death for those with depression, and individuals with bipolar disorder have a higher risk of death from accidents and neglect of proper health precautions. SUICIDE: THE CLINICAL PICTURE AND THE CAUSAL PATTERN The risk of suicide is increased in individuals with psychological disorders, particularly depression. Suicide is currently the 15th leading cause of death worldwide and is more common than deaths caused by wars, genocide, and interpersonal violence combined. However, many self-inflicted deaths are attributed to other causes, so the actual number of suicides may be even higher. Additionally, approximately 5 percent of Americans have made a nonlethal suicide attempt, and 15 percent have experienced suicidal thoughts. The risk of transitioning from suicidal thoughts to an attempt is highest in the first year after onset. NSSI (nonsuicidal self-injury) is also a significant concern and has been reported in many cultures, with 15 to 20 percent of adolescents and young adults reporting engaging in it. Although there is a clear distinction between suicidal and nonsuicidal self-injury, most people who die by suicide or make nonlethal attempts are ambivalent about taking their own lives. Who attempts and dies by suicide? There are several patterns and risk factors associated with suicidal behavior that have been consistently observed across different countries and populations. Women are more likely to think about suicide and make nonlethal suicide attempts, while men are more likely to die by suicide due to their use of more lethal means. Suicidal thoughts and behaviors increase in prevalence starting around age 12 and continue to increase into the early to mid-20s, followed by a peaking in middle age (45-55 years) and a slight decrease for the remainder of the lifespan. However, the suicide rate for white men in the United States shows another dramatic increase beginning at age 75. There has been a surge in suicide attempts and completed suicides in adolescence, which may be due to increasing prevalence of depression, anxiety, alcohol and drug use, and conduct disorder problems, as well as increased availability of firearms and exposure to suicides through the media. Many college students also seem vulnerable to the development of suicidal ideation and plans due to academic demands, social interaction problems, and career choices. Suicide rates vary dramatically around the world and even within countries, with the highest rates seen in the Western United States and the lowest rates in the Mid-Atlantic states. Racial and ethnic differences are also observed, with the majority of suicides in the United States being classified as people who are white. Psychological Disorders The association between different psychological disorders and suicidal behavior is likely due to a combination of several factors. - One possibility is that some disorders may directly increase the risk of suicidal behavior by affecting a person's mood, thoughts, and behavior. - Another possibility is that certain disorders may increase the likelihood of experiencing life stressors and adversities, which in turn can trigger suicidal behavior. - It's also possible that the association between multiple disorders and suicidal behavior reflects the cumulative impact of multiple risk factors. People with multiple disorders may experience a combination of mood disturbances, impulsivity, substance use, and interpersonal difficulties, all of which can contribute to suicidal behavior. Overall, the association between psychological disorders and suicidal behavior is complex and likely involves a combination of genetic, environmental, and psychological factors. Other Psychosocial Factors associated with Suicide While most people with psychological disorders do not become suicidal, suicide is strongly associated with intense psychological pain or "psychache." This pain is often caused by a combination of factors, including childhood experiences of family psychopathology, child maltreatment, and family instability, as well as biological vulnerabilities that may increase the risk of personality traits such as hopelessness, impulsiveness, aggression, pessimism, and negative affectivity. Other symptoms that may predict suicide in the short term include severe anxiety, panic attacks, severe anhedonia, global insomnia, delusions, and alcohol abuse. Additionally, research suggests that people who have a strong implicit association between the self and death or suicide may be at elevated risk of future suicide attempts. Biological Factors It is well-established that genetic factors play a strong role in the risk for suicide. This vulnerability seems to be independent of the genetic vulnerability for major depression, which suggests that it may be a distinct genetic factor that contributes to suicide risk. - Research has also found that alterations in serotonin (decreased activity) functioning are associated with increased suicide risk, particularly for violent suicide. - Studies have also investigated the association between suicide and the short allele serotonin transporter gene, which controls the uptake of serotonin from the synapse and has been implicated in the vulnerability to depression, people with one or two copies of the short allele are at heightened risk for suicide following stressful life events. Theoretical Models of Suicidal Behavior There is strong evidence that genetic factors and alterations in serotonin functioning play a role in the risk for suicide. - Suicidal behavior is often conceptualized using diathesis-stress models, in which underlying vulnerabilities interact with stressful life events to produce suicidal thoughts and behaviors. - Joiner's interpersonal-psychological model of suicide proposes that suicidal thoughts and desires stem from a combination of feeling like a burden on others and a lack of social belonging. This model also suggests that the ability to carry out a lethal suicide attempt is acquired over time. However, no existing models have completely explained suicidal behavior. SUICIDE PREVENTION AND INTERVENTION Crisis intervention involves immediate, short-term care for people who are in the midst of a suicidal crisis. This can include suicide hotlines, emergency departments, and mobile crisis teams. The goal is to stabilize the person and ensure their safety until they can receive more comprehensive treatment. somatic symptom disorder can be viewed as a disorder of both perception and cognition, for example, “noticing benign sensations such as one’s heart skipping a beat” and “Does this mean I have a serious heart problem?” People with somatic symptom disorders tend to be hypervigilant, have an increased awareness of bodily changes, and see bodily sensations as somatic symptoms. They tend to worry excessively about what the symptoms mean and have catastrophizing cognitions. An individual’s past experiences with illnesses, negative affect, absorption, and alexithymia may also contribute to the development of somatic symptom disorders. Research also shows that when people who report many physical problems are put into a negative mood, their reporting of physical symptoms increases. Treatment of Somatic Symptom Disorder Cognitive-behavioral therapy (CBT) as a treatment for somatic symptom disorders. CBT can be used to assess and modify patients' beliefs about illness and bodily sensations, and also involves behavioral techniques such as response prevention and inducing innocuous symptoms. CBT can also help reduce anxiety and depression more generally. The duration of CBT is relatively brief and sessions can be delivered in a group format. Additionally, medical management can provide further benefits, including educating general practitioners on how to better manage and treat patients with these disorders and identifying one physician to integrate the patient's care. CBT is also widely used in the treatment of somatic symptom disorder involving pain, which involves relaxation training, cognitive restructuring, scheduling of daily activities, and reinforcement of "no-pain" behaviors. Antidepressant medications can also reduce pain intensity. 2. ILLNESS ANXIETY DISORDER Illness Anxiety Disorder (IAD) involves high anxiety about having or developing a serious illness, even when there are very few or no physical symptoms present. Somatic Symptom Disorder (SSD) involves distressing or disruptive physical symptoms that may or may not have an underlying medical cause. It is estimated that around 25 percent of people previously diagnosed with hypochondriasis in DSM-IV will now be diagnosed with illness anxiety disorder, while the remaining 75 percent will be diagnosed with somatic symptom disorder. - DSM-5 Criteria for Illness Anxiety Disorder a. Preoccupation with having or acquiring a serious illness. b. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. c. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. d. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). e. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time. f. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type. 3. CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER) Conversion disorder is a neurological disorder in which a patient experiences symptoms or deficits that suggest a medical or neurological condition, but they are not consistent with any medical or neurological problem. Symptoms may include partial paralysis, blindness, deafness, and seizures. Psychological factors are thought to play an important role in the development or exacerbation of the disorder, often related to emotional or interpersonal conflicts or stressors. "La belle indifférence," or a lack of concern about symptoms, was once considered an important diagnostic criterion, but only occurs in 20% of the patients. - DSM-5 Criteria for Conversion Disorder a. One or more symptoms of altered voluntary motor or sensory function. b. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. c. The symptom or deficit is not better explained by another medical or mental disorder. d. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Range of Conversion Disorder Symptoms: There are four categories of symptoms: Sensory, motor, seizures, mixed - Sensory Symptoms or Deficits: Conversion disorder is a condition where individuals exhibit neurological symptoms that do not have any neurological diagnosis. The symptoms can affect any sensory modality and are inconsistent with known anatomical pathways. Common examples include blindness, deafness, and glove anesthesia. Individuals with conversion blindness and deafness may be able to navigate about a room without difficulty and orient appropriately on hearing their name. While it is unclear whether sensory information is registered but screened from consciousness or not, evidence suggests that it is somehow screened from explicit conscious recognition. - Motor Symptoms or Deficits: The symptoms of motor conversion reactions are diverse, ranging from selective paralysis of a single limb to the sensation of a lump in the throat. Conversion paralysis usually affects a specific function, and a person may be able to use the same muscles for other tasks. Speech-related conversion disturbance is often aphonia, where the person can speak only in a whisper, but can cough normally. Another common motor symptom is globus, which involves the sensation of a lump in the throat. These symptoms are not consistent with known anatomical pathways, and the person may have normal function in some situations and impaired function in others. - Seizures: Resemble epileptic seizures but are not true seizures. Patients do not show any EEG abnormalities or confusion and loss of memory afterward as patients with true epileptic seizures do. Patients who experience conversion seizures tend to exhibit more vigorous and uncontrolled movements compared to those with true seizures. However, unlike true seizures, they are less likely to suffer injuries due to falling or lose control of their bowel or bladder. Important Issues in Diagnosing Conversion Disorder: Conversion disorder can be difficult to diagnose accurately because the symptoms can mimic various medical conditions. Patients with suspected conversion symptoms should receive a comprehensive medical and neurological examination. Misdiagnoses can still occur, but with the advancement of medical tests, the rate of misdiagnoses has declined substantially. Other criteria are also commonly used to diagnose Conversion Disorder: - The symptoms of conversion disorder often do not precisely correspond to those of the medical condition they are imitating - The nature of the dysfunction is highly selective - Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can usually be removed. Prevalence and Demographic Characteristics: Conversion disorder used to be commonly diagnosed in soldiers during World War I and World War II, as it enabled them to avoid combat situations. Currently, it is found in about 5% of people referred to neurology clinics, with unknown prevalence in the general population, and occurs more frequently in medically unsophisticated individuals. It occurs two to three times more often in women than in men, commonly between early adolescence and early adulthood. Conversion disorder has a rapid onset after a significant stressor, often resolves within two weeks if the stressor is removed, but commonly recurs. It is often accompanied by other disorders, such as major depression, anxiety disorders, and other forms of somatic symptoms or dissociative conditions. Causes of Conversion Disorder: It is thought to develop due to stress or internal conflicts. Freud believed that symptoms were an expression of repressed sexual energy that was converted into bodily disturbances. However, this theory is not widely accepted, and primary (reduction in anxiety and intrapsychic conflict that is maintained by the physical symptoms) and secondary gains (attention and sympathy received from others because of the symptoms) are seen as a way of escaping stressful situations. The role of stressful life events in the onset of conversion disorder is not well understood. Neuroimaging studies of conversion disorder are rare, but they are showing promising findings. Two types of amnesia: retrograde amnesia and anterograde amnesia, with the first being the partial or total inability to recall previously acquired information or past experiences, and the latter being the partial or total inability to retain new information. Dissociative amnesia is usually limited to a failure to recall previously stored personal information, typically following intolerably stressful circumstances. Personal information is still there beneath the level of consciousness, and it sometimes becomes apparent in interviews conducted under hypnosis or narcosis. Dissociative fugue is a subtype of dissociative amnesia, where a person not only forgets some or all aspects of their past but also departs from their home/work environment and travels away, even creating a new persona with a new name and background story. It can end as suddenly as they began. The exact causes of dissociative fugue are not fully understood, but they are thought to be linked to severe stress, trauma, or abuse. Treatment for dissociative fugue may involve therapy, medications, and other supportive care to help the person recover their lost memories. The pattern in dissociative amnesia is similar to conversion symptoms, except that people unconsciously avoid thoughts about the situation or leave the scene to avoid unpleasant situations. - DSM-5 Criteria for Dissociative Amnesia a. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history. b. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. c. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition). d. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder. - Where does Conversion Disorder belong? Conversion disorder, previously classified with dissociative disorders as subtypes of hysteria, is now classified as a somatic symptom disorder due to its physical symptoms with no medical basis. However, the symptoms of conversion disorder closely resemble neurological problems, unlike other somatoform disorders. Therefore, there is a proposal to reclassify conversion disorder as dissociative disorders, as both involve disruptions in the normally integrated functions of consciousness. 3. DISSOCIATIVE IDENTITY DISORDER Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder. In DSM-IV, a person had to display two or more distinct personalities with recurrent episodes of amnesia, while in DSM-5, it is required that there is a disruption of identity characterized by two or more distinct personalities as well as recurrent episodes of amnesia, which can be either self-reported or observed by others. Another change in DSM-5 is the inclusion of pathological possession in the diagnostic criteria for DID. Alter identities may differ in various ways and often take control at different points in time, and the switches typically occur quickly, although more gradual switches can also occur. DID is a condition in which normally integrated aspects of memory, identity, and consciousness are no longer integrated, and additional symptoms include depression, self-injurious behavior, frequent suicidal ideation, and attempts, erratic behavior, headaches, hallucinations, posttraumatic symptoms, and other amnesic and fugue symptoms. Comorbid diagnoses, such as PTSD, depressive disorders, substance-use disorders, and borderline personality disorder, are common. - DSM-5 Criteria for Dissociative Identity Disorder a. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory motor functioning. These signs and symptoms may be observed by others or reported by the individual. b. Recurrent gaps in the recall of everyday events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting. c. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. d. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. e. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Causal factors and Controversies about DID: There are four controversies surrounding DID: - Firstly, whether DID is a real disorder or can be faked: It has become critical in cases where defendants use it as a defense for their crimes. In the case of the Hillside Strangler, Kenneth Bianchi, he denied committing the crimes and under hypnosis, a second personality named Steve emerged and confessed to the crimes, but it was later determined that Bianchi was faking the disorder. While factitious and malingering cases of DID may occur, they are relatively rare, and most researchers believe that DID is a real disorder. - Secondly, how DID develops, whether it is caused by childhood trauma or social enactment of different roles encouraged by careless clinicians: Two theories of how DID develops and is maintained. The first theory is the posttraumatic theory, DID as a coping mechanism for a child's overwhelming sense of powerlessness in the face of severe childhood abuse. The social cognitive theory, DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities, mostly because clinicians have inadvertently suggested, legitimized, and reinforced them. - Thirdly, the controversy surrounding the memories of early abuse reported by most individuals with DID, whether they are real or false: Reports may be the result of false memories created by suggestive techniques used by psychotherapists. While some cases of false memory have had tragic consequences, it is also true that abuse can occur and have negative effects on development. One way to verify the memories would be through independent verification of the abuse, but some studies have been criticized for their loose criteria and inconclusive results. The development of a reliable physiological test to distinguish between real and false memories is currently being researched. - Finally, if abuse has occurred, whether it was the cause or if something else correlated with the abuse was the cause: Childhood abuse often occurs in family environments with many sources of adversity, making it difficult to determine which factor has the causal effect. Additionally, individuals with symptoms of DID and child abuse are more likely to seek treatment, which may not be representative of all individuals with DID. Finally, childhood abuse has been linked to various other mental disorders, making it difficult to say whether it plays a specific role in the development of DID. Current Perspectives: Studies comparing people diagnosed with dissociative identity disorder (DID) and those trained to simulate it suggest that patients with DID have more symptoms and cognitive processing problems. However, cognitive deficits are common in many disorders and may not be specific to DID. One key feature of DID is interidentity amnesia, where different identities are unaware of each other's experiences. Studies suggest that information can transfer across identities, which challenges the idea of complete amnesia. The controversies surrounding DID are often dichotomized, but theorists are acknowledging that multiple causal pathways are likely involved, and new methods are needed to distinguish between real and false memories. Both advocates of posttraumatic and sociocognitive theories are softening their positions and acknowledging the complexity of the disorder. CULTURAL FACTORS, TREATMENTS, AND OUTCOMES IN DISSOCIATIVE DISORDERS Cultural Factors in Dissociative Disorders: The prevalence of dissociative disorders, particularly DID, is influenced by cultural acceptance and tolerance. In some cultures, related phenomena like spirit possession and dissociative trances are accepted as a normal part of religious or spiritual practices, while in others, they are considered pathological. Pathological possession and DID have similar features, but in the former, the other identity is not experienced as an internal personality state. The inclusion of pathological possession in the diagnostic criteria for DID in DSM-5 acknowledges that DID can present in two different forms: a possession form and a nonpossession form. Treatments by indigenous healers and therapists have similarities, but culturally sanctioned attempts to remove the alternate identity often lead to poor outcomes. Amok is a cross-cultural variant of dissociative disorders characterized by rage episodes that often lead to violent or homicidal behavior. Treatment and Outcomes in Dissociative Disorders: The absence of randomized controlled trials has resulted in little knowledge of how to treat depersonalization/ derealization disorder and dissociative amnesia effectively. The effectiveness of treatments 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). b. The binge-eating episodes are associated with three (or more) of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 1. Eating large amounts of food when not feeling physically hungry. 2. Eating alone because of feeling embarrassed by how much one is eating. 3. Feeling disgusted with oneself, depressed, or very guilty afterward. c. Marked distress regarding binge eating is present. d. Binge eating occurs, on average, at least once a week for 3 months. e. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Age of onset and gender differences: Anorexia nervosa and bulimia nervosa typically develop during adolescence, with anorexia nervosa being most likely to develop between 16 to 20, and bulimia nervosa being most prevalent among women aged 21 to 24. Binge eating disorder is most common in those aged 30 to 50. Eating disorders were traditionally believed to be more prevalent in women, but recent studies suggest that there is a ratio of three females to every one male with an eating disorder. This may be due to past underdiagnosis of eating disorders in men, as the DSM criteria are biased towards women, emphasizing weight and shape concerns typically associated with women. Homosexual and bisexual men and those in specific professions, such as wrestling and jockeying, are also at higher risk of developing eating disorders. - Other forms of eating disorders: The DSM-5 has renamed the category of eating disorders to feeding and eating disorders to include several other types of eating and feeding problems. One of these is purging disorder, which involves purging for normal weight people who have not eaten large amounts of food. Prevalence of Eating Disorders: The prevalence of binge-eating disorder is around 2-3.5% in the general population, with higher rates in obese individuals. Bulimia nervosa has a prevalence of around 1%, while anorexia nervosa is less common but has increased in prevalence since the 1940s. Despite a decrease in the prevalence of bulimia nervosa, many adolescents and young adults still exhibit disordered eating behaviors or distorted self-perceptions about their bodies. Non-diagnosable disordered eating behaviors are also concerning, as they may worsen over time. Medical Complications of Eating Disorders: Anorexia nervosa is a life-threatening disorder with a mortality rate more than five times higher than young females in the general US population. Patients with anorexia nervosa experience malnutrition, which can lead to hair loss, dry skin, and yellowish skin. They also have difficulty coping with cold temperatures, low blood pressure, and potential vitamin B1 deficiency. People with Anorexia could die from the consequences of starvation. Bulimia nervosa, although less lethal, is still associated with a mortality rate twice as high as the general population. Purging can lead to electrolyte imbalances and low potassium, which puts patients at risk of heart abnormalities. Patients can damage their teeth, develop small red dots around the eyes, and have swollen parotid glands caused by repeatedly vomiting. Course and Outcome: Anorexia nervosa is the second most common cause of death, and suicide is the leading cause of death for those who suffer from it. Patients who have lost the ability to maintain an "emotionally protective" low body weight are at particularly high risk of suicide. The age at which patients receive clinical attention for their disorder is a factor that affects their prognosis. Recovery from anorexia nervosa is possible over the long term, with 51% of patients fully recovering in a 21-year follow-up study. Patients with bulimia nervosa tend to have a good prognosis, with around 70% being in remission at the end of an 11- to 12-year follow-up. Patients with binge eating disorder also have high rates of remission. Even when well, many individuals who recover from anorexia nervosa and bulimia nervosa still have residual food issues. Diagnostic Crossover: There is a lot of diagnostic crossover in eating disorders. Bidirectional transitions between the two subtypes of anorexia nervosa were especially common. Shifts from anorexia nervosa to bulimia nervosa also occurred in about a third of patients. The main difference between patients with the binge-eating/purging subtype of anorexia nervosa and bulimia nervosa is weight, and even after crossing over into bulimia nervosa, women remain vulnerable to relapsing back into anorexia nervosa. Binge-eating disorder and anorexia nervosa appear to be quite distinct disorders, and there is no diagnostic crossover between these diagnoses, but around 10 percent of patients who previously had binge-eating disorder transitioned into bulimia nervosa Association of Eating Disorders with other forms of Psychopathology: The presence of other psychiatric conditions alongside eating disorders is common, with comorbidity being the rule rather than the exception. For example, depression is frequently diagnosed alongside anorexia nervosa, bulimia nervosa, and binge-eating disorder. Obsessive-compulsive disorder is also often found in patients with anorexia nervosa and bulimia nervosa, while substance abuse disorders are commonly associated with the binge-eating/purging subtype of anorexia nervosa and bulimia nervosa. Additionally, personality disorders, particularly in the anxious-avoidant and dramatic, emotional, or erratic clusters, are frequently diagnosed in people with eating disorders. However, it is important to be cautious in conclusions drawn from personality disturbances found in eating disorder patients, as some may be a result of malnourishment while others may predate the onset of the disorder. Eating Disorders across Cultures: The prevalence of eating disorders is not limited to Western countries, as cases have been documented in India, Africa, Japan, Hong Kong, Taiwan, Singapore, and Korea. Although Caucasian individuals exhibit subclinical problems that place them at a higher risk for developing eating disorders, African Americans are less susceptible to these problems than Caucasians. However, as minorities become more integrated into Western society, eating disorders rates may increase among them. Anorexia nervosa is not a culture-bound syndrome, but culture can influence the disorder’s clinical manifestation. Conversely, bulimia nervosa seems to be a culture-bound syndrome as it is more prevalent in Western cultures. RISK AND CAUSAL FACTORS IN EATING DISORDERS Biological Factors - Genetics: The tendency to develop eating disorders is shown to be heritable. The risk is 11.4 times greater when you have a family member with anorexia, and for bulimia nervosa is 3.7. The relatives of patients with eating disorders are also more likely to suffer from other disorders, such as major depressive disorder. The contribution of genetic factors may be as strong as that of bipolar disorder and schizophrenia. - Brain Abnormalities: The hypothalamus is an important brain area in eating, with the ventromedial hypothalamus (VMH) acting as a "satiety center" and the lateral hypothalamus serving as an "appetite center." Lesions in the VMH cause animals to overeat and become obese, while stimulating the VMH inhibits food intake and promotes weight loss. In contrast, stimulating the lateral hypothalamus triggers eating, and animals with lesions to this area will stop eating. Damage to the frontal and temporal cortex seems to be linked to the development of anorexia nervosa and bulimia nervosa. - Set Points: The body tries to maintain a biologically determined set point or weight, and it resists significant variations from this set point. This is shown by physiological opposition, such as an increase in hunger when weight is lost, which encourages weight gain and a return to equilibrium. Patients with anorexia nervosa experience an increase in hunger but suppress it, while chronic dieting may lead to irresistible impulses to eat large amounts of high-calorie food. Patients with bulimia nervosa may experience uncontrollable binge eating due to these impulses. - Serotonin: This neurotransmitter modulates appetite and feeding behavior, and some researchers believe that eating disorders involve a disruption in the serotonergic system. People with anorexia nervosa have low levels of 5-HIAA, a major metabolite of serotonin, which may be due to their limited food intake. In contrast, people with bulimia nervosa have normal levels of 5-HIAA. Interestingly, recovered patients from both groups have higher levels of 5-HIAA than control subjects. Sociocultural Factors: The ideal body shape for women in Western culture emphasizes thinness (1960s) in the fashion industry, which features thinner models, influencing young unlikely to happen later. Antidepressants reduce the frequency of binge eating, improve patients' mood and their preoccupation with shape and weight. - Cognitive-behavior Therapy: It is the leading treatment for bulimia nervosa, it consists of normalizing eating patterns and a cognitive component targeting dysfunctional thought patterns. CBT reduces the severity of symptoms and eliminates binging and purging in 30-50% of cases, patients may still have weight and shape concerns after treatment. New approaches like dialectical behavior therapy and individualized CBT are being explored. The transdiagnostic approach, called enhanced cognitive-behavior therapy (CBT-E), aims to address eating disorders regardless of the specific diagnosis. Treatment of Binge-eating Disorder: Due to the comorbidity between BED and depression, antidepressant medications have been used in treatment. Other medication categories, such as appetite suppressants and anticonvulsants, have also been explored. There are findings that suggest that interpersonal psychotherapy may be a particularly suitable treatment approach for racial and ethnic minorities with BED. THE PROBLEM OF OBESITY Storing fat historically has served as a survival advantage during periods of food shortage. However, in the modern world, access to food is no longer a problem for many people, leading to an abundance of energy-dense foods and a rise in obesity. Obesity is described as a state of excessive and chronic fat storage, which is a major public health issue. Medical Issues: These include high cholesterol, hypertension, heart disease, arthritis, diabetes, and cancer. People who are obese have a reduced life expectancy of 5 to 20 years Definition and Prevalence: Obesity is defined on the basis of a statistic called the body mass index (BMI). This is a measure of a person’s weight relative to height. Obesity is BMI 30 - 40, more than 40 is morbid obesity. Weight Stigma: Obese people have to face harsh judgment, ridicule, discrimination, and stigmatization. The media plays a significant role in that. Obese are more likely to be shown eating, less likely to be in romantic relationships. Male participants were more likely to rate an obese female defendant as guilty and a repeat offender. Healthcare professionals blame obese patients for their weight-related health problems. Being obese is not necessarily a personal choice, as genetics, biological factors, and environmental influences play significant roles. Obesity and the DSM: Obesity is not an eating disorder, and it is not included in DSM-5. However, some argue that obesity is a “food addiction”, the idea that obesity is a brain disorder is very controversial. RISK AND CAUSAL FACTORS IN OBESITY The role of genes: Our genetic makeup influences our ability to gain weight in an environment with abundant food availability. Population groups that historically experienced starvation are more prone to obesity in modern sedentary lifestyles and Western diets. Genes contribute to both obesity development and binge-eating tendencies Hormones involved in Appetite and Weight regulation: The hormone leptin is produced by fat cells. Decreased leptin production stimulates food intake, while rare genetic mutations that prevent leptin production lead to insatiable appetite and morbid obesity. However, overweight individuals often have high levels of leptin but are resistant to its effects. Another hormone called ghrelin, produced by the stomach, is a powerful appetite stimulator, with levels rising before a meal and falling after eating. High levels of ghrelin are seen in people with Prader-Willi syndrome, a genetic disorder associated with extreme obesity and uncontrollable food cravings. Sociocultural Influences: Factors such as easy access and affordability to high-fat, high-sugar foods, encouragement of overconsumption, and sedentary lifestyles contribute to weight-related issues. Ultra Processed foods high in sugar, fat, and salt may trigger addictive processes, leading to overconsumption. Family Influences: In some families, a high-fat, high-calorie diet or an overemphasis on food can contribute to obesity among family members. Emotional distress or expressing love through eating may lead to habitual overeating. Children whose mothers smoked during pregnancy or gained a significant amount of weight during pregnancy have a higher risk of being overweight at a young age. Stress and “Comfort Food”: When feeling stressed or unhappy, individuals tend to crave foods high in fat or carbohydrates as a form of consolation. Overeating may serve as a coping mechanism for reducing distress or depression. Pathways to Obesity: Binge eating emerges as a crucial factor in the development of obesity. Sociocultural pressures, particularly related to the thin ideal, can contribute to binge eating behaviors. Additionally, depression, low self-esteem, and lack of peer support increase the risk of binge eating. Children who are overweight may face rejection from peers, leading a cycle of binge eating. TREATMENT OF OBESITY 1. Lifestyle Modifications: The first step includes a low-calorie diet, exercise, and behavioral intervention. Research trials have shown that lifestyle modifications can lead to modest weight loss, typically around 7 pounds. Extreme approaches and crash diets are ineffective and lead to weight regain in the long term. 2. Medications: Orlistat reduces the absorption of dietary fat in the gut, while drugs like lorcaserin and Contrave target neurotransmitters to promote weight loss. Sibutramine, a previously widely used medication, has been withdrawn due to safety concerns. 3. Bariatric Surgery: It is considered the most effective long-term treatment for individuals with severe obesity. Various techniques are used to reduce the stomach's capacity and, in some cases, shorten the intestine to limit food absorption. The surgery significantly restricts the amount of food the stomach can hold, making binge eating difficult. However, some patients may still find ways to overeat and regain weight over time. The importance of Prevention: Parental education is crucial since childhood obesity predicts adult obesity. Simple strategies include eating three fewer bites per meal (around 100 calories), incorporating more walking into daily activities, and prioritizing sufficient sleep. CHAPTER 10: Personality disorders CLINICAL FEATURES OF PERSONALITY DISORDERS Most adults have a personality that aligns with societal expectations and allows them to function effectively. However, some individuals have traits that are inflexible and maladaptive, hindering their ability to meet societal demands. To diagnose a personality disorder, the person's enduring pattern of behavior must be pervasive, inflexible, stable, and long-lasting. It should also cause significant distress or impairment in functioning, evident in at least two areas such as cognition, affectivity, interpersonal functioning, or impulse control. People with personality disorders often cause difficulties for others, and their behavior can be confusing, exasperating, and unacceptable. Cluster A has people who seem odd or eccentric, with unusual behavior ranging from distrust and suspiciousness to social detachment. Cluster B are individuals that share a tendency to be dramatic, emotional, and erratic. Cluster C often shows anxiety and fearfulness. PD Characteristics Point Prevalence Gender Ratio 5 Factor Model Paranoid Suspiciousness and mistrust of others; tendency to see self as blameless; on guard for perceived attacks by others. 1.5% M = F Agree (low) Neu (high) Schizoid Impaired social relationships; inability and lack of desire to form attachments to others 1.2% M > F Ext (low) Open (low) Schizotypal* Peculiar thought patterns; oddities of perception and speech that interfere with communication and social interaction 1.1% M > F Ext (low) Neu (high) Histrionic Self-dramatization; over concerned with attractiveness; tendency to irritability and temper outbursts if attention seeking is frustrated 1.2% M < F Ext (high) Neu (high) Narcissistic Grandiosity; preoccupation with receiving attention; self-promoting; lack of empathy. Two types: Grandiose have Neu (low) and Ext (high). Vulnerable have Neu (high) <1% M > F Agree (low) b. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition. Schizoid Personality Disorder: They tend not to have good friends, with the possible exception of a close relative, their feelings and are seen by others as cold and distant. They rarely marry. They have high levels of introversion (especially low on warmth, gregariousness, and positive emotions) and low on openness to feelings (one facet of openness to experience) and on achievement striving. Not much studies because Schizoid PD people don’t volunteer for research. This PD has high heritability of around 55 percent. In some cases, schizoid personality disorder precedes psychotic illness. There is a link between this PD and autism. Cognitive theorists proposed that Schizoid PD people see themselves as self-sufficient loners and to view others as intrusive (“relationships are messy”). - DSM-5 Criteria for Schizoid Personality Disorder a. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with another person. 4. Takes pleasure in few, if any, activities. 5. Lacks close friends or confidants other than first-degree relatives. 6. Appears indifferent to the praise or criticism of others. 7. Shows emotional coldness, detachment, or flattened affectivity. b. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition Schizotypal Personality Disorder: Excessively introverted, just like Schizoid PD but, in addition, they have cognitive and perceptual distortions, and oddities/eccentricities. Contact with reality is usually maintained but they often believe that they have magical powers. They believe that conversations or gestures of others have special meaning (ideas of reference). Schizotypal PD is considered (by some) as an attenuated form of schizophrenia. Using the five-factor model, this PD has introversion and neuroticism, but some symptoms are explained by psychoticism, which is not in the 5FM. There has been significant research on schizotypal personality disorder, it was the only categorical disorder retained from Cluster A in the DSM-5 proposal. It has a moderate heritability and is genetically linked to schizophrenia. Teenagers with schizotypal PD are at high risk of developing schizophrenia. However, it is proposed that there is a subtype of schizotypal PD unrelated to schizophrenia, linked to a history of childhood abuse and early trauma. - DSM-5 Criteria for Schizotypal Personality Disorder a. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations). 3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect. 7. Behavior or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or confidants other than first-degree relatives. 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. b. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder. CLUSTER B PERSONALITY DISORDERS Histrionic Personality Disorder: Characterized by excessive attention-seeking behavior and emotionality. They have lively, dramatic, and extraverted styles that can charm others into paying attention to them. However, their relationships tend to be unstable and unsatisfying because others tire of constantly providing attention. They often display seductive behavior and emotional manipulation. They are dependent and self-centered, with a strong desire for approval from others. It is highly comorbid with other personality disorders such as borderline, antisocial, narcissistic, and dependent personality disorders. There is some evidence of a genetic link between histrionic personality disorder and antisocial personality disorder. Extraversion and neuroticism is found in Histrionic PD, the diagnosis is questionable. Cognitive theorists emphasize the need for attention to validate self-worth, but research on the development of these beliefs is lacking. - DSM-5 Criteria for Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention. 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. 3. Displays rapidly shifting and shallow expression of emotions. 4. Consistently uses physical appearance to draw attention to self. 5. Has a style of speech that is excessively impressionistic and lacking in detail. 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion. 7. Is suggestible (i.e., easily influenced by others or circumstances). 8. Consider relationships to be more intimate than they actually are. Narcissistic Personality Disorder: It is characterized by an exaggerated sense of self-importance, a desire for admiration, and a lack of empathy. There are two subtypes of narcissism: grandiose and vulnerable. Grandiose narcissists have a strong belief in their superiority, display arrogance, and seek constant attention and recognition. They underestimate others' abilities and accomplishments and have a sense of entitlement. Vulnerable narcissists have low self-esteem, experience shame and hypersensitivity to rejection, and may avoid relationships. Both exhibit interpersonal antagonism, low agreeableness, and lack of empathy. Grandiose narcissists have low neuroticism and high extraversion, while vulnerable narcissists have high levels of negative affectivity/neuroticism. They can be hypercritical and retaliatory. Grandiose narcissism is associated with parental overvaluation, while vulnerable narcissism is linked to childhood abuse and intrusive parenting. - DSM-5 Criteria for Narcissistic Personality Disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). 4. Requires excessive admiration 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviors or attitudes. Antisocial Personality Disorder: They consistently disregard and violate the rights of others through deceitful, aggressive, and antisocial behaviors. Irresponsible behavior with little concern for safety, leading to high risk for incarceration. ASPD is highly common among incarcerated individuals, with approximately 47% of incarcerated men and 21% of