507- General Psychopathology

Question 1

ADHD

Answer 1

Attention-deficit/hyperactivity disorder: a neurodevelopmental brain-based disorder marked by inattention, hyperactivity, and impulsivity, or both. ADHD is commonly diagnosed in children, but symptoms must be age-inappropriate for diagnosis.

• Occurs in males 4x more than females.
• Commonly comorbid with learning disorders and ODD/CD; also greater risk for substance abuse.
• Strong genetic component; 30% chance if 1st-degree family member carries it
• ADHD is treated with stimulants like Ritalin and/or CBT (operant conditioning and token economies).

Clinical example: 7-yr-old Sophie disrupts her classroom instruction often by getting up and walking over to the window when she is distracted by something she sees outside or blurting out thoughts and questions. When she is stuck at her desk, she fidgets constantly and is unable to sit still. Based on Sophies inability to focus and impulsivity, Sophie’s pediatrician screens her for ADHD.

Question 2

Anxiety Disorders

Answer 2

Part of: Psychopathology

What: Anxiety disorders occur when feelings of anxiety interfere with everyday life, include multiple physical characteristics, and are irrational, uncontrollable, and disruptive. Anxiety is distinct from fear in that it is the central nervous system’s physiological and emotional response to a vague sense of threat or danger rather than a response to an immediate threat. Worry, physical arousal, panic attacks, feelings of tension, and apprehension are common in anxiety disorders.

• more frequent in females (2:1)
• most common of mental disorders (29% of adults in a lifetime).
• Include Social Anxiety Disorder, Generalized Anxiety Disorder, Panic Disorder, Phobias, and Agoraphobia

They are often maintained through avoidance. Treatments include cognitive-behavioral therapy, mindfulness, and relaxation techniques, along with exposure (if applicable) and anti-anxiety medications.

Clinical example: Mark is afraid he will be judged or rejected in social settings. Even imagining a meal out with coworkers can elicit a physiological anxiety response in him. He avoids such situations as a way to manage his anxiety. Mark’s symptoms of physiological arousal, avoidance of stimuli that provoke discomfort, and negative emotions in imagined social interactions indicate he may have an anxiety disorder.

Question 3

Anxiety sensitivity

Answer 3

Part of: psychopathology

What: A tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful. “Fear of fear.” Bodily sensations such as increased heart rate or nausea are mistaken as harmful and intensify anxiety.

Who: Term Anxiety Sensitivity originally coined by Reiss who created Anxiety Sensitivity Index (ASI) which has spurred additional research.

Clinical example: Brenda notices her heart rate increases as she climbs the stairs in her apartment building. She interprets her increased heart rate as a sign of physical danger and presents at the ER a short time later saying she thinks she is having a heart attack.

Question 4

Assessment interview

Answer 4

Part of: clinical practice

What: Primary technique for clinical assessment; an initial interview in which the counselor gathers information about the patient and begins to conceptualize their case and presenting problem(s) to aid in developing a treatment plan and/or making the diagnosis.

• Counselor should examine all spheres of influence & use multiple sources of info if possible
• A structured interview would include a clinician-administered formal assessment, while a semi-structured interview is more guided by clinical judgment.
• May be used in conjunction with other assessment techniques (e.g. psychological tests or screening tools like the BDI)

Clinical example: Bill schedules a consultation because he is having trouble concentrating at work and his wife says he is withdrawn at home. In his assessment interview, the therapist will gather family history information, ask specifics about his current problems, and use a screening measure like the BDI to get a better idea Bill’s psychological picture.

Question 5

Bipolar I vs. Bipolar II

Answer 5

Part of: psychopathology

What: Both are mood disorders in which patients experience major depressive episodes, manic episodes, hypomanic episodes, and/or mixed episodes.

• Bipolar I is marked by full manic and major depressive episodes while bipolar II is marked by mildly manic episodes (hypomanic) and major depressive episodes. Bipolar II has later onset (around 20s). Bipolar II can be harder to detect as people do not notice the hypomanic episodes and rarely come into treatment. When they do it is for depression. Bipolar II is capable of turning into Bipolar I.
• Manic episodes typically last a week (hypomanic 3-4 days) & depressive episodes much longer
• Bipolar I and II can include psychotic features either mood-congruent (i.e. thinking you are god during manic episode) or mood incongruent

Who: Equally common in men and women. Onset between 15-30 yrs old.

• Etiology ~ 50% heritability - strong genetic component
• Treatment usually includes medication to prevent mania and reduce kindling effect (Antipsychotics, mood stabilizers, lithium) and psychotherapy (focus on medication management and social skills; used in conjunction to meds). Therapy shown to help reduce hospitalization.

Clinical example: Drake has been unable to get out of bed most days for the past week. He finds pleasure in nothing, and had neglected his personal hygiene. A short time after this depressive episode, he finds himself staying up all night absorbed in a new project. He charges expensive items to his credit card and impulsively decides to go out with friends and get intoxicated. This episode continues for a week. Drake is suffering from Bipolar I.

Question 6

Case study

Answer 6

A type of research that includes a detailed description of a specific individual and treatment of that individual. Useful to document 1. success of a specific treatment, 2.
to describe a new treatment, or 3. to demonstrate novel application of existing treatment (such as using anti-seizure medications for stabilizing mood) and can show the feasibility of implanting treatment with a specific population. Cannot generalize its results or determine causality.

Clinical example: A therapist working with a child with autism has a novel behavioral intervention. She decides to write a detailed case study of her treatment implementation to document the results of this new treatment.

EXAMPLE: You’re taking on a new client with an extremely rare psychological disorder. You turn to the research and decide to read up on all of the available case studies because that is the bulk of what is available, since it is such a rare condition.

Question 7

Categorical v. dimensional diagnosis

Answer 7

A categorical approach (used by the DSM) assumes that traits are either present or absent in people, like a light switch that is on or off. Many theorists argue for a dimensional approach, which would see these traits along a continuum or scale rather than as simply present or not present.

Clinical example: A clinician with a categorical approach may diagnose a woman who has volatile relationships, intense moods, self-harm practices, and manipulative tendencies with borderline personality disorder. A clinician with a more dimensional approach might assess these behaviors according to severity and the degree to which they impact the person’s life.

EXAMPLE: When using a prototypical categorical approach, you must determine that the client has a depressed mood and a decrease in pleasure, plus a certain number of additional symptoms in order to be diagnosed with depression.

EXAMPLE: A family doctor referred the client to the therapist after making a categorical diagnosis of the client having anxiety and depression. The doctor prescribed 2 separate medications, one for anxiety and one for depression. The therapist will now conduct an assessment interview with the client in order to rate the symptoms and features of anxiety and depression to then make a more dimensional diagnosis.

Question 8

Clinical significance

Answer 8

A type of significance assessed in research and measured in the participants. Clinical significance refers to a meaningful outcome of a treatment for a client. In other words, does the client achieve a meaningful amount of change or reduction in symptoms due to the treatment. Clinical significance looks at the patient’s quality of life - symptoms, remission, etc. Do they still meet criteria for diagnosis?

Clinical example: Janelle came to treatment because of paralyzing social anxiety. After 12 weeks of CBT, she is pushing herself to attend social events despite her anxiety, and is noticing a decrease in her anxiety after a few exposures. Jane reports feeling more hopeful about her ability to be social. Her outcome is clinically significant because it has made a marked difference in her life.

Question 9

Comorbidity

Answer 9

A clinical term used to describe the coexistence of two or more clinical diagnoses in the same person at the same time. There are certain disorders that frequently present together such as PTSD and substance use disorders or anxiety and depression, and it’s important to be aware of these as a therapist.

Clinical example: Substance abuse disorders are often comorbid with other mental disorders, so clinicians should assess for other disorders when treating substance abuse, and vice versa.

Question 10

Competency to stand trial

Answer 10

A person is mentally competent to stand trial if the person charged with crime has capacity to understand the charges against them and ability to assist their lawyers in preparing a defense.

• Has nothing to do with the insanity plea–competency to stand trial is about the person’s mental state at the time of the trial, not at the time of the crime.
• Requires a cognitive assessment.
• The burden is to prove incompetence (on defense)
• If found incompetent, they will be held in a mental health hospital until competent, time dependent on the charges. After the time elapses, they will either be set free or put under civil commitment.

Clinical example: Boris has been diagnosed with schizophrenia. He is arrested on murder charges. Because of his delusions and other mental instabilities, he is held in custody but declared incompetent to stand trial.

EXAMPLE: You are assessing a patient’s competency to stand trial. The patient presents with psychotic symptoms and a complete inability to communicate. He cannot even understand simple commands. You recommend that he is not competent to stand trial because you do not think he understands the charge against him nor do you think he can assist the lawyers in prepping a defense.

Question 11

Conduct disorder

Answer 11

Part of: psychopathology

Who: A childhood disorder

What: characterized by the violation of others’ basic rights by cruel or criminal behavior.

• Generally considered developmental and follows oppositional defiant disorder, and is typically more severe. (Progresses from oppositionality towards parents and adults to all authorities and eventually all of society.)
• Usually begins before age 10 and is exhibited by 6-16% of boys and 2-9% of girls.
• Etiology - poor family environment (inadequate parenting/reinforcement) and also genetic and biological factors
• Treatment is more effective at younger ages, with Parent-Child Interaction Therapy and Parent-Child Relationship Training having the greatest effects.

Clinical example: Trish has a pattern of lying to and yelling at parents and teachers. She was recently caught setting fire to a small shed in her grandparents’ backyard. She is likely to be diagnosed with conduct disorder.

EXAMPLE: 13-year-old client was court-ordered to see a child therapist because of his 2nd shoplifting offense. He also has a history of drug/alcohol use, getting into fights, vandalism. He has been abusing the neighborhood cats and has been “the” bully at school since third grade. This client will be screened for a conduct disorder

Question 12

Diagnosis

Answer 12

From the Greek word “a discrimination” - a determination that a person’s problems reflect a particular disorder or syndrome in a particular classification system (typically DSM-5). Diagnostic labels make it possible for clinicians to communicate easily with each other and can aid in treatment planning (especially for identifying ESTs), but they also carry a negative connotation and a social stigma. Diagnoses also may not be accurate or perfectly fit an individual’s symptoms.

Clinical example: After an assessment interview, Claire’s symptoms of a weight below a healthy BMI for her age, starvation behavior, and fixation on thoughts of food and weight qualify her for an anorexia diagnosis.

EXAMPLE: Kara was a freshman in college and came into the counseling center presenting symptoms of an eating disorder. The counselor asked Kara about her eating habits and Kara said that she would go to the cafeteria once a day, by herself, and consume large quantities of food - especially pasta and ice cream. She would then feel so guilty about eating that she would make herself vomit and not eat for the rest of the day. Kara didn’t like to engage in this behavior but felt that she truly couldn’t stop herself once she started eating. The counselor diagnoses Kara with Bulimia Nervosa based on her symptoms which had lasted for over 6 months.

Question 13

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Answer 13

The DSM-5 is a categorical prototypical classification system, developed by the American Psychiatric Associated and updated in 2013, which lists disorders, descriptions of symptoms, and guidelines for making appropriate diagnoses. The DSM-V is used by most mental health practitioners in the US to diagnose mental disorders. It also includes dimensional information, rating how severe a client’s symptoms are and how dysfunctional the client is across various dimensions of personality and behavior.

Advantages of the DSM include that it allows for easy communication between clinicians and helps to stimulate research. Disadvantages include that diagnoses are stigmatizing and there can be significant overlap between disorders.

Clinical example: Shelley, a therapist, uses the DSM-5 to evaluate whether her clients’ symptoms indicate an official diagnosis. She uses the DSM codes when reporting to insurance companies for reimbursement.

Question 14

Diathesis-stress

Answer 14

From the biopsychosocial model, this model posits that psychological disorders result from an interaction between inherent vulnerability and environmental stress. Diathesis refers to the propensity for the disorder or problem behavior to be expressed. The greater the diathesis and the greater the stress, the more likely you will develop a particular disorder.

Clinical example: Dale had his first episode of psychosis after losing his job and girlfriend. He was eventually diagnosed with schizophrenia. Later brain scans showed increased ventricles common in people with schizophrenia. Dale’s relatively psychologically normal life up until the point of intense stress is an example of the diathesis-stress model at work.

EXAMPLE: The Diathesis-Stress model can help explain why identical twins separated at birth might have different outcomes. Say, one develops schizophrenia and the other doesn’t. Because they both have the same diathesis, we might conclude that one of the twins had a more stressful upbringing than the other.

Question 15

Dissociative disorders

Answer 15

A rare group of disorders characterized by a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment known as dissociation.

• Key features include depersonalization, derealization, a blurred sense of identity, and a profound disturbance in memory that does not have clear physical causes.
• In this family of disorders are dissociative amnesia, dissociative identity disorder (previously multiple personality), and dissociative fugue.
  
  • Dissociative Amnesia: memory loss that cannot be explained by a physical or neurological condition
    
    • With or without dissociative fugue; usually occurs in response to some sort of stressor or trauma
  • Dissociative Identity Disorder: presence of 2+ distinct identities w/ recurrent gaps in memory. (Most controversial diagnosis in DSM; VERY rare)

-Those w/ a dissociative disorder have increased risk of complications, such as self-mutilation and suicide attempts.

Clinical example: Emilia goes missing. Days later, she is found in another state, applying for a job under the name Stephanie. She is suffering from dissociative fugue.

EXAMPLE: Client comes to treatment because her parents are incredibly worried about her behavior. 2 weeks ago she went missing, and was recently found in Oregon in a homeless shelter with no recollection of her identity. Her parents filled the clinician in that she has been under extreme stress at school, her sister just died, and she lost her job, didn’t get into boarding school… Therapist diagnoses her with dissociative amnesia w/ Dissociative Fugue.

Question 16

Dopamine

Answer 16

Dopamine is a key neurotransmitter that is involved in the pleasure center of the brain affecting learning, reward, and motivation.

• Critical in use/abuse/dependence roles of substances because almost every substance directly or indirectly affects the DA system.
  
  • Stimulated by several such as ETOH, nicotine, cocaine, caffeine, and Amphetamines.
  • repeated use of drugs impacts the DA system a lot; difficult to feel pleasure without the substance
  • Drugs like cocaine and heroin increase dopamine at key neurons, providing the pleasurable feeling that can lead to addiction, especially as naturally produced dopamine declines when it is routinely artificially introduced.
• Low dopamine activity is one of the biological reasons for major depressive disorder, and causes the extrapyramidal effects in Parkinson’s.
• Excessive dopamine activity is thought to contribute to the positive symptoms of schizophrenia, while too little dopamine is thought to contribute to the negative symptoms of schizophrenia.

Clinical example: Stan has been taking Haldol for over a decade to minimize symptoms of schizophrenia. He begins to experience severe shaking and jerky movements, a side effect of the dopamine-minimizing Haldol.

Question 17

Eating disorders

Answer 17

Part of: Psychopathology

What: Eating disorders are characterized by being preoccupied with food, weight, and appearance as well as maladaptive patterns of behavior and thinking surrounding food. Individuals w/ eating disorders often struggling with depression, anxiety, obsessiveness, and the need to be perfect.

Who: Suffered most often by adolescent women, and more prevalent in certain sports like gymnastics, wrestling, and horse jockeying.

Types of eating disorders:

• Anorexia nervosa: marked by the pursuit of extreme thinness and by extreme weight loss)
• Bulimia nervosa: marked by frequent eating binges followed by forced vomiting or other extreme compensatory behaviors to avoid gaining weight
• Binge eating disorder: marked by frequent binges without extreme compensatory acts.
• These illnesses are often accompanied by a multitude of health issues and are frequently co-morbid with anxiety and mood disorders, certain personality disorders, and substance abuse.
• Etiology”. Can be caused by learning, family dynamics, or genetic components.
• Treatments include CBT, Interpersonal Psychotherapy (focus on relationship elements and patterns in relationships - for bulimia), family counseling and medication (usually done in conjunction with talk therapy).

Clinical example: Clint started using weight loss strategies to maintain his weight class in wrestling. Over time, his thoughts and daily behavior became fixated on losing more weight, even after he reached his weight loss goal. His diet is very regimented and restrictive, and he exercises for hours each day. Clint’s coach refers him to a psychologist who diagnoses him with anorexia nervosa.

EXAMPLE: Julie’s friend told her that she would probably have a lot of boyfriends if she lost some weight. She began restricting her diet and exercising. As she began to lose weight, boys started noticing her which reinforced the behavior. She also felt a sense of control about losing the weight. Her family sent her to counseling where she was diagnosed with anorexia. She was 5’9 and weighed 90 lbs. She still believed she was fat.

Question 18

GABA

Answer 18

Part of: psychopathology

What: gamma-aminobutyric acid (GABA): an inhibitory neurotransmitter that regulates anxiety. It carries inhibitory messages: when GABA is received at a receptor, it causes the neuron to stop firing. This finding led researchers to believe that GABA plays a key role in the reduction of normal, everyday fear reactions.

• The anxiety-reducing abilities of ethanol and benzodiazepines work by increasing GABA levels.
• Low levels of GABA are associated with generalized anxiety disorder.
• Increasing GABA also vicariously increases dopamine levels in the pleasure pathway. Contributes to tolerance and withdrawal – conditioned compensatory response

Clinical example: Denise has been diagnosed with Generalized Anxiety Disorder. As part of her treatment, she is prescribed Xanax, which increases GABA activity, a deficiency thought to be common amongst people suffering from anxiety disorders.

EXAMPLE: A veteran suffering from symptoms of PTSD had started abusing alcohol shortly after his return to the United States. The psychiatrist explained the use of Alcohol has been shown to bond to GABA receptors, which lowers anxiety, making him feel better.

Question 19

Heritability

Answer 19

Part of: genetics term;

What: the proportion of observed variation in a trait or disorder that can be attributed to inherited genetic factors rather than to environmental factors; a factor in the nature vs nurture debate.

EXAMPLE: Understanding the heritability of Bipolar I disorder, the therapist asked the client if his family had a history with the disorder. She also explained to him that one of the biological explanations for the disorder suggests that individuals inherit a predisposition for the disorder.

Question 20

HPA pathway

Answer 20

Part of: developmental psychology

What: Hypothalamic-Pituitary-Adrenal (HPA) pathway: biological route connected to stress and fear reactions, one route by which the brain and body produce arousal- pituitary gland secretes ACTH (major stress hormone), which stimulates the adrenal glands which secrete corticosteroids (stress hormones).

• This pathway is most associated with PTSD and other trauma/stress disorders.
• Cortisol production tends to be elevated in people with BPD, indicating a hyperactive HPA axis in these individuals.
• Since traumatic events can increase cortisol production and HPA axis activity, one possibility is that the prevalence of higher than average activity in the HPA axis of people with BPD may simply be a reflection of the higher than average prevalence of trauma among people with BPD.

Clinical example: Since being attacked in a parking lot, Jenny reacts to stress with heightened anxiety. Her therapist explains that the trauma may have affected her HPA pathway, causing abnormal activity of cortisol and norepinephrine.

EXAMPLE: A client was diagnosed with Borderline Personality Disorder, and she did not understand why her parents sent her to a therapist who specializes in Dialectical Behavior Therapy, rather than the therapist she had been going to who specialized in CBT. The DBT therapist provided psychoeducation to the client by explaining to her that there is likely increased activity in her HPA pathway due to trauma. This produces a type of anxiety/stress that is more deep rooted in her genetics and body’s stress response than a person with Generalized Anxiety Disorder or Depression and thus takes longer for her to return to baseline. Therefore, Borderline Personality Disorder is best treated with a different type of therapy than cognitive behavioral therapy.

Question 21

Idiographic v. nomothetic assessment/understanding

Answer 21

An idiographic assessment takes an individualized approach, allowing for the understanding of symptoms in the individual’s cultural context.

A nomothetic understanding is a general understanding of the nature, causes, and treatments of abnormal functioning, in the form of laws and principles. Good assessment/practice combines idiographic and nomothetic approaches. Achieved by means of large research investigations resulting in generalizable laws of behavior. (based on the scientific method)
This type of understanding helps clinicians to have a starting point for diagnosis with each client instead of always beginning anew.
-The DSM is an example of a nomothetic tool that came from years of research.

Clinical example: In her practice, Melanie leans toward an idiographic understanding of her clients, focusing on their individual assets, experiences, and family histories.

Question 22

Insanity

Answer 22

NOT a clinical term, but rather a legal term describing an individual who was mentally ill at the time of their crime(s) and is therefore not morally responsible for the act(s).

• Developed as an attempt to protect people with mental illnesses from being punished for harmful behavior resulting from their disorder.
• The burden of proof lies on the defense to prove insanity
• Requires psychological assessment

Example: A person is on trial for assault and vandalism. The defense please not guilty by reason of insanity because their client, who has been diagnosed with schizophrenia, was delusional when he committed the crime.

Question 23

Mania

Answer 23

Part of: psychopathology

What: Characterized by an abnormal mood (irritable, expansive, or high) and at least three or more other criteria including inflated self esteem, increased energy, decreased sleep, racing thoughts, pressured or increased speech, or impulsivity and poor judgement.

• Manic episodes typically last a week or more, hypomanic 3-4 days. Productivity element huge in hypomania. Hypomania also has more irritability.
• Can include psychosis – mood congruent (grandiosity, paranoia) or incongruent (aliens). Mood congruent most common.
• Typically mania is experienced as pleasurable by the client
• Manic episodes come with increased suicide risk
• One manic episode makes following episodes more likely - a process called kindling.

Clinical example: Charlie has been awake for 36 hours working on a screenplay he believes is a work of genius. When he runs into a neighbor on a smoke break, he speaks in an energetic, frenzied, barely comprehensible manner. Charlie is experiencing mania.

Question 24

Mood disorders

Answer 24

Part of: psychopathology

What: A class of disorders characterized primarily by severe disturbances in mood.

Including: Mood disorders include major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, bipolar disorder, and cyclothymic disorder. Inadequate serotonin/dopamine function is part of what causes mood disorders.

• These typically include depression, bipolar, and variants of the two.
• Symptoms of these disorders may include depressive or manic episodes.
• Depressive episodes may include symptoms such as hopelessness, lack of energy, and anhedonia, inability to concentrate, increased/decreased appetite, etc.
• Mania may include euphoria, increased energy, racing thoughts, pressured speech
• Etiology includes a variety of causes including genetics, learning, and cognitive errors.
• Heritability 30% depressive disorders, 50% bipolar disorders
• Treatments include medication, CBT, behavioral activation, and mindfulness-based treatment, amongst others.

Clinical example: Patricia finds it difficult to get out of bed, and finds no pleasure in activities she once enjoyed. These symptoms have persisted for a month. Patricia may be diagnosed with depression, a mood disorder.

Question 25

MRI

Answer 25

Magnetic resonance imaging is a neuroimaging technique used to process images of brain structure and activity. In some cases, an MRI may be used to assist with assessment or diagnosis, especially to rule out a medical explanation for mood or behavioral symptoms. They can also be used to determine if a disorder has a biological component. Their main use is in research to learn more about disorders.

Clinical example: Doug reports severe headaches as well as hallucinations to his doctor. His doctor orders an MRI to check for tumors or other brain abnormalities. None are discovered, but enlarged ventricles indicate that Doug’s symptoms are aligned with schizophrenia.

https://www.naminys.org/images/uploads/pdfs/Neuroimaging%20(FAQ).pdf

Question 26

Obsessive-compulsive and related disorders

Answer 26

A disorder in which a person has recurrent obsessions, compulsions, or both.

• OCD is characterized by obsessive (repeated, intrusive, uncontrollable thoughts or images that provoke anxiety) and compulsive actions (a repetitive and rigid behavior or mental act that a person feels driven to perform in order to prevent or reduce anxiety).
  
  • Thoughts cause anxiety, and behaviors lessen the anxiety felt by the thoughts.
  • There are different classes of thoughts (contamination, pathological doubt, violent/sexual thoughts) and a wide variety of corresponding compulsions (washing, checking, counting, symmetry, hoarding).
  • Do not need both for diagnosis but 90% do have both
  • Almost equal male to female, female slightly higher
  • Tends to be a chronic lifelong illness but can be controlled.
  • Generally attributed to genetic and neurological sources, though can have behavioral and cognitive roots.
  • Treatment gold standard exposure therapy with response prevention and CBT.

Related disorders: hoarding disorder, trichotillomania, excoriation disorder, and body dysmorphic disorder.

Clinical example: It takes Maria two hours to leave her house each morning because she feels compelled to perform an elaborate ritual of checking locks and potential dangers in her home to ensure safety before she leaves. To skip her ritual would leave her with unbearable anxiety, sure that something terrible would happen. Maria is suffering from obsessive-compulsive disorder.

EXAMPLE: A girl came in to see a therapist because she was experiencing repeated and intrusive thoughts about her teeth being clipped off violently with nail clippers. She repeatedly pushes her fingers down on her teeth until they “feel right,” which temporarily reduces her anxiety. However, when she resists the urge to push her fingers down on her teeth after having a violent thought, her anxiety becomes severe.

Question 27

Oppositional defiant disorder

Answer 27

A childhood disorder characterized by chronic misbehavior such as frequent arguing with adults, noncompliance, and problems controlling anger. ODD can be a precursor for conduct disorder and antisocial personality disorder in some.

• Typically begins by 8 years of age; More common in boys before puberty but equals out after.
• Etiology - conflictual and hostile parents/home life, inconsistent punishments, and attention-seeking behaviors.
• Earlier the treatment begins the better. (< 13 better); Parent-Child Relationships Training and Parent-Child Interaction Training found to be most effective.

Clinical example: 7-year-old Troy fights with his parents and teacher constantly. He gets angry easily and blames others for his own mistakes. Troy is eventually diagnosed with oppositional defiant disorder.

EXAMPLE: Eric is a 13-year-old client that is in therapy because his parents describe him as “hell on wheels” and they don’t know what to do about his behavior. Told counselor he doesn’t do chores, doesn’t go to school and when he does he argues with the teacher, screams when he doesn’t get his way, and argues about everything. Bx has occurred for 7 months. Eric’s behavior is consistent with Oppositional Defiant Disorder and the therapist suggests parent training and social skills for the client and parents.

Question 28

Panic attack

Answer 28

Part of psychopathology
What: A sudden episode of intense anxiety that rapidly escalates in intensity The abrupt onset of intense fear or discomfort that reaches a peak within minutes and includes at least four of the following symptoms:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed, or faint
• Chills or heat sensations
• Paresthesia (numbness or tingling sensations)
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or “going crazy”
• Fear of dying
• 25% of the population has at least one panic attack in their lifetime.
• Panic attacks are seen in a variety of disorders such as PTSD, phobias, and can occur in the context of any disorder, designated by a panic attack specifier.

Clinical example: Janet is walking her dog when she becomes overcome with the fear that she might get hit by a car. Her heart starts pounding and her palms are sweaty. She feels so dizzy she sits down on the sidewalk and feels sure she will die there. Janet is experiencing her first panic attack.

EXAMPLE: A client comes in to see you because she called 911 last week when she started experiencing tightness in her chest. She tells you that when the ambulance arrived, they told her that she was not having a heart attack like she thought. You explain to her that she suffered from a panic attack. You assure her that many people think their first panic attack is a heart attack.

Question 29

Personality disorder

Answer 29

An enduring, rigid pattern of inner experience and outward behavior that repeatedly impairs a person’s sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy.

• There are high comorbidity rates and treatment is refractory and often unhelpful
• 9.1% of population has a personality disorder, and are most stigmatized group in psychology due to the difficulty in treating them.
• Can be attributed to genetics and/or surroundings, as behaviors may have been previously adaptive and become maladaptive later.
• Disorder never really goes away, just manage the symptoms.
• There are three clusters of personality disorder; cluster A (odd/eccentric), cluster B (dramatic/emotional), and cluster C (anxious/fearful).
  
  • A: Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder
  • B: Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, Narcissistic Personality Disorder
  • C: Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder, Avoidant Personality Disorder

Clinical example: Dan keeps to himself and avoids getting close to anyone. He is suspicious of all other people and their motives. Dan is suffering from a paranoid personality disorder.

EXAMPLE: A client comes to you after he was caught trying to con money from elderly patrons at an ATM. It was revealed that since he was 7 years old he had been bullying students at school, shoplifting, and skipping school. He had been caught stealing a car at age 19 and sent to prison for 1 year. Since then he had been charged with narcotics possession and statutory rape. He lacks remorse for any of his b/h. You believe he may have antisocial personality disorder.

Question 30

PET scan

Answer 30

A positron emission tomography (PET) scan is a neuropsychological test that examines brain functioning. The computer produced image shows rates of metabolism, blood flow, and oxygen use throughout the brain. The patient consumes a radioactive glucose solution that is picked up by the scan. Patient performs certain tasks or asked to think about certain things to see what areas of the brain are being used. PET scans may detect the early onset of disease before it is evident on other imaging tests.

Example: The dopamine hypothesis of schizophrenia proposed that excess activation of D2 receptors was the cause of the positive symptoms of schizophrenia. PET imaging studies have provided supporting evidence for this hypothesis.

Question 31

Positive v. negative symptoms

Answer 31

Labels for classifying symptoms of schizophrenia.

Positive symptoms: excesses; bizarre additions to normal thoughts, emotions or behaviors. (delusions, disorganized thinking and speech, heightened perceptions and hallucinations, inappropriate affect.)

Negative symptoms: deficits in normal thought, emotions, or behaviors. (poverty of speech (alogia), restricted affect, loss of volition (avolition), apathy, social withdrawal.

Clinical example: Lin spent all of his time alone and experienced frequent hallucinations. Lin was experiencing both positive and negative symptoms of schizophrenia.

Question 32

Placebo effect

Answer 32

A phenomenon that occurs when a patient/client sees improvement in their condition even though they are taking a placebo or are receiving a different treatment (as in the case of control groups in clinical trials). The patient’s expectancies about the outcome of treatment can have a significant effect on what outcome they will see. Many research studies include placebo groups to determine if symptoms improvement is from the actual treatment being studied.

Clinical example: Pam is part of a study about the effects of a new drug on people with anxiety disorders. Pam is part of the control group and thus receives a daily pill, but the pill is made of sucrose. She reports some relief from her anxiety symptoms, as she is experiencing the placebo effect.

Question 33

Psychosis

Answer 33

A symptom characterized by a fundamental break with reality.

• Can include hallucinations (hearing, seeing or feeling things that are not there), delusions (false beliefs, especially based on fear or suspicion of things that are not real), disorganization in thought, speech, or behavior, and disordered thinking. Depending on severity, this may be accompanied by difficulty with social interaction and impairment in carrying out daily life activities.
• Most commonly associated with schizophrenia; can also be seen with severe cases of bipolar, depression and PTSD, among other disorders.
• Psychosis shouldn’t be considered a symptom of a mental disorder until other relevant and known causes are excluded (CNS issue, disease, drugs)

EXAMPLE: A client comes in one day in a frenzy. She looks disheveled and does not make much sense because she keeps jumping around topics. She tells you that she is worried aliens have been watching. You suspect that she may be experiencing psychosis, but you decide to rule out other potential causes first.

Question 34

Primary v. secondary gain

Answer 34

Describes the significant subconscious psychological motivators patients may have when presenting with symptoms. Mainly seen in somatic disorder.

• Primary gain: the gain people derive when their somatic symptoms keep their internal conflicts out of awareness; ; distracts them from the ‘real’ underlying problem/issue
• Secondary gain: the gain people derive when their somatic symptoms elicit kindness from others or provide an excuse to avoid unpleasant activities; things they get out of as a result of sxs
  - Helps maintain sxs through positive reinforcement

Clinical example: Every time Anna complains of stomach cramps, her mother makes her special food and lets her stay home from track practice. Anna is experiencing secondary gains.

EXAMPLE:One of your severely depressed patients gets out of going to work because of her diagnosed mental disorder. This is an example of secondary gain.

Question 35

Remission

Answer 35

A period during which symptoms of disease are reduced (partial remission) or disappear (complete remission); usually means that the client is no longer experiencing clinical levels of symptoms related to the original issue.

• The course of schizophrenia can include a residual, partial remission phase in which positive symptoms have decreased but negative symptoms still remain.
• Eysenck postulated that ⅔ of patients with mental disorders will spontaneously remit without psychotherapy; this prompted a close examination of the effective of psychotherapy

EXAMPLE: The female patient was responding well to ACT therapy. She was accepting the fact that her husband had left her for another woman. She was committed to setting goals of adapting to her new life of being divorced. And she was taking action one step at a time. The therapist noted that these positive steps had resulted in a partial remission of her depression as she was functioning much better than she had been.

Question 36

Schizophrenia

Answer 36

A chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality

• Two types of symptoms – positive symptoms (excess of behaviors) or negative symptoms (absence of behaviors), with key symptoms of grossly disorganized behaviors, hallucinations and delusions [pt must have one of those]
• Three phases; prodromal (before episode- appears more social at first; only applies to pre-schizophrenia), active (psychotic episode), and residual (partial remission; decrease pos sxs neg sxs remain).
• Age of onset is between 16-25; 1% of population; men and women equal; > african americans vs whites; > lower SES vs high
• CLEAR genetic link but environment still plays a role; also altered neurochemistry.
• Treatment is generally antipsychotic medication along with various forms of therapy, including family treatment and skills training in order to help prevent relapse.

Clinical example: Will is overcome with the belief that he is a messiah. He spends hours of the day standing rigidly, reciting prophecies. After assessment, he is diagnosed with schizophrenia.

Question 37

Serotonin

Answer 37

Serotonin is a neurotransmitter responsible for regulating mood, appetite, sleep, memory, and other cognitive functions. Serotonin activity levels are low in people who complete suicide, suffer from depressive and bipolar disorders, antisocial personality disorders, and eating disorders.

• Serotonin regulates the activity of norepinephrine (NE) and dopamine (DA)
• SSRIs can aid in regulating serotonin levels and are used to treat depression and OCD
• Illicit drugs such as Ecstasy and LSD cause a massive rise in serotonin levels.

Clinical example: Ben has been diagnosed with major depressive disorder. As part of his treatment, he is prescribed an SSRI (selective serotonin reuptake inhibitor) to increase serotonin activity and reduce depressive symptoms.

EXAMPLE: A client was referred to the therapist by her family doctor after having been prescribed an SSRI to treat depression that she had been experiencing for 6 months. The family doctor thought it would be helpful for the client to go to a CBT therapist in order to treat the depression in addition to the medication.

Question 38

State v. trait anxiety

Answer 38

Refers to the two recognizable ways which anxiety manifests itself. “State” anxiety is in response to a stimulus; “trait” anxiety is related to worldview, more pervasive, and not situationally specific.

Part ofpsychopathology; this refers to the two recognizable ways in which anxiety manifests itself.
State anxiety refers to undesirable emotional arousal in the face of threatening demands or dangers
Trait anxiety refers to a relatively enduring disposition to feel stress, worry, and discomfort; a personality trait

Example: A client comes in because she just got a new job where she will have to engage in a lot of public speaking. The client has always experienced anxiety about getting up in front of others and speaking, yet she does not struggle with anxiety in other areas. The therapist tells her she likely has state anxiety and begins to employ mindfulness and CBT exercises to help the client with her fear of public speaking.

Question 39

Substance-related disorders

Answer 39

A pattern of long-term maladaptive behaviors and reactions brought about by repeated use of a substance. Significant impairment categorized by the DSM as two or more of the following: Failure to fulfill major role obligations; drug use in situations when it’s physically hazardous; use despite persistent social/interpersonal problems caused by or exaggerated by effects of substance; tolerance; withdrawal symptoms (different for each substance); substance taken in larger amounts than intended; desire or unsuccessful efforts to cut down/control use, significant time spent acquiring, using, or recovering; and social, occupational, recreational activities sacrificed.

• High rates of comorbidity with other mental illnesses such as PTSD and depression. Polysubstance use disorder very common - increases lethality
• Etiology - clear genetic component, DA plays crucial role, learning comes into play (pos/neg reinforcement, cues for cravings), and social and cognitive aspects as well
• Treatment includes Motivational interviewing, AA/NA, CBT, amongst others. There are medications available, but they are not best practice. Harm reduction may be a better approach than abstinence.

Clinical example: Lucy has just gotten her second DUI. She cannot pay the fines associated with it because she is already in debt, and has recently lost one of her two jobs after failing a drug test. Many friends have cut her off or distanced themselves because of her behaviors around drinking. Lucy is suffering from an alcohol use disorder.

Question 40

Tolerance v. withdrawal symptoms

Answer 40

Part of substance use disorder; these are key symptoms to look for when determining a substance related disorder, and can be indicative of physical dependence.

Tolerance means that when a person habitually uses a substance, they need to use more of the substance to feel the same effects. Result of adaptive physiological changes in brain and organ systems to accommodate use. Behavioral tolerance can occur through drug-independent learning; context-dependent.

Withdrawal occurs when a person who routinely uses a substance stops using it for a period of time, and experiences physical symptoms because their body is not habituated to going without the substance.

Clinical example: Jim is arrested for selling drugs. He is high on opioids at the time. When he has been in custody for several hours, he begins to sweat and shake. He is agitated and eventually vomits. He is experiencing withdrawal. When questioned by a counselor about his opioid use, he says it began when he developed chronic pain after a procedure and was prescribe oxycontin. Soon the dose of oxy wasn’t enough to reduce his pain and he found himself turning to illegal opioids to increase his dose. Jim had developed a tolerance for opioids.

Question 41

Trauma and stress or related disorders

Answer 41

Trauma and stress disorders include posttraumatic stress disorder, acute stress disorder and dissociative disorders. These disorders are marked by an overactive sympathetic nervous system and heightened stress response. In the case of trauma disorders, the disorder is triggered by a traumatic event.

-70% of people exposed to at least one trauma in their life
-PTSD has 4 core symptoms:
1. intrusions
2. negative alterations in cognitions and mood
3. avoidance
4. arousal and reactivity
Timeframe of sxs > 1 month
-Women 2:1 over men; > for lower SES
-High rates of comorbidity, often with depression and substance abuse.
-Etiology – neurobiology aspects: trauma triggers physical changes in brain and body; cognitive-behavioral aspects: develop fear structures in response to trauma (stimuli, response, cognitions) inadequate processing due to avoidance; and maintenance of PTSD via neg/pos reinforcement
-Acute Stress Disorder has the same core symptoms as PTSD but symptoms last < 4 weeks
-Treatment typically includes medication (SSRIs, benzos), exposure therapy, and cognitive and behavioral therapies, though other types have been used successfully.

Clinical example: Since she was in a bad car accident, Sheila has nightmares that replay the crash. She avoids driving altogether and feels unduly stressed by daily events. She has begun drinking heavily to relax at night. Sheila is suffering from PTSD.

Question 42

Borderline personality disorder

Answer 42

Part of: Clinical Psychopathology

What: Borderline Personality Disorder is characterized by problems with interpersonal relationships, impulsivity, problems managing emotions, self-harm, and suicidality. Individuals with BPD often have a tremendous fear of abandonment and a poor sense of self.

Etiology: genetic component, abuse or trauma in childhood, hyper-responsive HPA axis

Who: more common in women (but could be overdiagnosis of women as too emotional)

Treatment: Most effective treatment is dialectical behavior therapy which focuses on harm reduction, emotion regulation, mindfulness, and social skills training - developed by Marsha Linehan.

Clinical Example: A client presents after her third suicide attempt. Her father reports she has trouble maintaining relationships, wild emotional outbursts, and uses alcohol almost daily. She has been cutting her mother left the family when she was eleven. Based on her history and symptomology, her therapist screens her for Borderline Personality Disorder.