Abnormal Psychology Flashcards
Categorical approach
The approach the DSM takes to defining and describing mental illness.
Illnesses are also categorized by general symptom clusters and the clinician decides if the patient meets the diagnostic criteria laid out
Polythetic Criteria
Criteria in the DSM don’t all have to be met to achieve a diagnosis
Allows for two people to have the same diagnosis with slightly different presentations. Accounts for heterogeneity of presentations
Nonaxial Assessment System
The DSM-5 got rid of the Axis system of diagnosing. Just list all medical and mental diagnoses together, with the primary diagnoses listed first
How to handle diagnostic uncertainty
Other specified - when you want to indicate why someone doesn’t meet criteria
Unspecified - when you don’t want to indicate why someone doesn’t meet criteria
Provisional - when person doesn’t meet full criteria but you believe they will in the future
Other specified disorders
When you want to list the reasons why someone doesn’t meet full criteria for another disorder
Unspecified disorders
When the clinician doesn’t want to list the reasons why a person doesn’t meet criteria
Provisional diagnoses
When someone is not meeting criteria for a disorder, but you believe they will in the near future
Assessment strategies for the DSM
Cross-cutting measures
Severity measures
WHODAS
Personality inventories
Cultural Formulation
Provides guidelines for assessing the clients cultural identity, cultural conceptualization of distress, stressors and cultural factors that contribute to distress, and cultural factors relevant to rapport
Neurodevelopmental Disorders
Intellectual Disability Autism Spectrum Disorder ADHD Specific Learning Disorders Tourette’s Communication Disorders
Presentation of neurodevelopmental disorders typically manifest…
Early in development, often before the child enters grade school
Three diagnostic criteria for Intellectual Disability
Deficits in intellectual fxning, confirmed by standardized testing
Deficits in adaptive functioning
Must have onset in developmental period
Early signs of intellectual disability include…
Delays in motor development
Lack of age-appropriate interest in environmental stimuli
(May not make eye contact during feeding, less responsive to voice)
Etiology of Intellectual Disability
30% unknown 30% chromosomal and exposure to toxins 15-20% environmental 10% perinatal issues 5% acquired medical 5% heredity (Tay-Sachs, fragile X...)
Primary communication disorder
Childhood onset fluency disorder
Stuttering
Characteristics of Child-Onset Fluency Disorder
Disturbance in normal language fluency and time pattering
Involves repetition of sound and syllables, broken words, etc.
Inappropriate for the persons age
Course of child onset fluency disorder
Onset 2-7 years
Symptoms become more pronounced when speech performance matters
Severity of issue by age 8 is a good indicator of prognosis, 65-85% of children recover
Treatment for childhood onset fluency disorder
Reducing stress at home
Help child cope with frustration
Habit reversal training - relax muscles in throat and diaphragm
Diagnostic criteria for Autism Spectrum Disorder
Persistent deficits in social communication (reciprocity, difficulty understanding relationships, nonverbal comm issues)
Restrictive and repetitive interests or patterns of behavior
Early developmental period onset, impairments in many domains
Associated features with ASD
Intellectual deficits
Self-injurious behavior
Language abnormalities
Onset of ASD
Earliest signs are abnormalities of social orienting and responsivity
Apparent around 12 months of age
Prognosis of ASD
Generally poor
One third may obtain some independence as an adult
Best outcomes of ASD are associated with…
IQ above 70
Later onset of symptoms
Development of verbal communication abilities by age 5 or 6
Etiology of ASD
Associated with rapid head growth in first year of life
Brain abnormalities in amygdala and cerebellum
NT abnormalities (dopamine, serotonin)
Treatment for ASD
Special education
Parent management training
Social interaction and vocational skills
For communication: shaping and discrimination training
Diagnostic criteria for ADHD
At least six sx, last six months, onset before age 12, more than two settings
Hyperactivity
Inattention
Three specifiers in ADHD
Hyperactive type - six or more hyperactive sx, less than six inattentive sx
Inattentive type - six or more inattentive sx, less than six hyperactive sx
Combined - six or more inattentive, six or more hyperactive
Associated features of ADHD
For children
Intelligence is often avg to high average, but perform lower on IQ or standardized tests
Academic and social difficulties
Associated features of ADHD
For adults
Low self-esteem
Lower educational or occupational attainment
Problems related to social relationships
Prevalence of ADHD
5% for children
2.5% for adults
Males > females
(Males combined, females inattentive
Etiology of ADHD
Genetic component
Brain abnormalities in globus pallidus, caudate nucleus, and prefrontal cortex (lower than normal activity)
Behavioral disinhibition hypothesis for ADHD
Core feature of ADHD is an inability to regulate behavior to fir situational demands
(An alternative hypothesis said that it was an inability to regulate attention)
Treatments for ADHD
Methylphenidate or CNS stimulants are effective in 75% of cases
Behavioral treatments - parent and teacher training, positive reinforcement
Medical only and medical/tx have higher outcomes but only for short-term (similar improvement long term when compared to tx only)
Three domains of adaptive functioning deficits in Intellectual Disability
Conceptual
Social
Practical
Diagnostic criteria for Specific Learning Disorder
Deficit in an academic area for at least six months despite the provision of interventions
Academic abilities must be substantially below what’s expected given age
Begin during school years
Not attributed to other conditions or disorders
Three subtypes of SLD
Reading
Writing
Mathematics
Most frequent comorbid disorder with SLD
ADHD
20-30%
Also have a higher risk for antisocial behavior
Course and prognosis of SLD
Continue to struggle from childhood through to adulthood
One third have psychosocial problems as adults
Prevalence of SLD (gender)
Males > females
Etiology of SLD
Genetic component
Incomplete hemispheric dominance or other abnormalities
Cerebellar-vestibular dysfunction
Criteria for Tourette’s Disorder
At least one vocal tic
Multiple motor tics
Onset before age 18, lasts at least one year
Less than 1yr = provisional // over 1yr = persistent (chronic)
Prognosis of Tourette’s
Frequency, severity, and disruptive ness of symptoms often decline in adolescence and adulthood
Most common associated symptoms with Tourette’s
Obsessive compulsive symptoms
Etiology of Tourette’s
Increase of dopamine, hypersensitivity to dopamine
In caudate nucleus
Treatment for Tourette’s
Antipsychotics (80% effective, bad SEs)
Antidepressants, stimulants
Comprehensive behavioral treatment for tics (CBIT)
(Habit reversal training, relaxation skills, psyched)
Comprehensive Behavioral Treatment for Tics
CBIT
Habit reversal
Relaxation training
Psychoeducation
Behavioral Pediatrics
Aka pediatric psychology
Concerned with the psychological aspects of children’s medical illnesses
(Compliance with medical regimens, coping with painful procedures)
Disclosure in behavioral pediatrics
Open communication with children about their medical issues is advisable (leads to better coping)
MUST be done with developmentally appropriate
Behavioral pediatrics and medical procedures
Stress inoculation techniques to help children cope with anxiety and stress
Ex. Modeling, reinforcement, breathing exercises, distraction, imagery, behavioral rehearsal
Impact of hospitalization on medically ill children
Ages 1-4 are at highest risk of distress due to separation from family
Can be prevented by “rooming in” programs (where parents are allowed to stay at the hospital)
Impact of medical illness on children’s academic adjustment
Children with chronic medical conditions have higher rates of school-related issues
Can be due to the medical treatments themselves, or the constant absences from school
Reason for medical noncompliance in children
Lack of knowledge or skill
Parent-child conflict or communication deficits
Developmental issues
Reasons for medical noncompliance specific to adolescents
Fear of peer rejection
Desire for nonconformity
Reduced parental supervision
Questioning credibility of medical provider
Delusions
False beliefs that are firmly held in the face of contradictory evidence
In schizophrenia, they are often persecutory or bizarre
Hallucinations
Perception-like experiences that occur without an external stimulus
Auditory are most common and take the form of pejorative or threatening messages, or are a running dialogue of the persons actions
Disorganized thinking
Loosening of associations (incoherence, answers to questions that are unrelated, or slipping from topic to topic)
Grossly disorganized or abnormal behavior
Unpredictable agitation
Catatonia
Markedly disheveled appearance
Clearly inappropriate sexual behavior
Negative symptoms
A restriction in the range or intensity of emotional expression
Alogia - diminished speech output
Anhedonia - inability to feel pleasure
Asociality - lack of interest in social interactions
Avolition - decrease in goal-directed behavior
Diagnostic criteria for delusional disorder
Presence of one or more delusions for at least one month
Functioning is otherwise fine, save for functional impairment relatives directly to the delusion
Erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspec.
Types of delusions
Erotomanic - believes someone is romantically in love with them
Grandiose - great but unrecognized talent or discovery
Jealous - partner is being unfaithful
Persecutory - being conspired against, spied on
Somatic - has abnormal body functions or sensations
Mixed
Unspecified
Diagnostic criteria for schizophrenia
At least two active symptoms for one month
(Delu, halu, disorganized speech, disorganized behavior, neg sx)
Duration for at least six months
One of the symptoms must my disorganized speech, del, or halu
Associated features of Schizophrenia
Inappropriate affect
Dysphoric mood
Disturbed sleep
Lack of interest in eating
Prognosis of schizophrenia
Chronic condition, with full remission being rare
Indicators of better outcomes in patients with schizophrenia
Later onset Good premorbid functioning Insight Being female Presence of a precipitating event Brief duration No family hx of schizophrenia
Prevalence of schizophrenia
0.3-0.7%
Predictors of relapse in schizophrenia
Family with high EE
Treatment noncompliance
Comorbid diagnosis commonly seen with schizophrenia
Substance abuse disorders
Tobacco Use disorder being particularly high
Onset of schizophrenia
Late teens to early 30s
Earlier onset for men, later onset for women
Concordance rates for schizophrenia
Identical twin with schizophrenia 48%
Both bio parents have schizophrenia 46%
Fraternal twin with schizophrenia 17%
Biological sibling with schizophrenia 10%
Strong evidence that schizophrenia is highly genetic
Relatives of individuals with schizophrenia aren’t just at a higher risk for schizophrenia, but for other schizophrenia spectrum disorders
(Especially schizotypal personality disorder)
Dopamine hypothesis for schizophrenia
Overabundance of DA or oversensitivity of DA receptors
Role of DA May differ for the expression of positive and negative symptoms though
Brain abnormalities in schizophrenia
Enlarged ventricles
Decrease activity in the frontal cortex and prefrontal cortex
Smaller globus pallidus, amygdala, and hippocampus
Prenatal exposure to the influenza virus may be connected to what diagnosis
Schizophrenia
Schizophrenia vs Schizoaffective vs Mood w psychotic features
Schizophrenia - mood symptoms are brief, do not meet full criteria, and are not present during active phase
Schizoaffective - predominant mood sx will occur with psychosis and at least two week period where psychotic sx only
Mood w psychotic features - psychotic symptoms only occur during the course of a mood episode (MDD or BD)
First generation vs second generation antipsychotics
First gen - fluphenazine and haloperidol - positive sx only - bad SEs (tardive dyskinesia)
Second gen - risoeridone and clozapine - positive and negative sx - loss likely to develop TD
Psychotherapy for schizophrenia
Good results when paired with medical treatment
Family interventions (if high EE), psychoed, CBT, social skills training, vocational work…
Examples of high EE
Being over emotional or overprotective
Being openly critical or hostile towards the person
Diagnostic criteria for Schizophreniform Disorder
Same as for schizophrenia, but for less than six months and more than one month
Prognosis of schizophreniform disorder
Two thirds eventually meet criteria for schizophrenia or Schizoaffective disorder
Diagnostic criteria for Brief Psychotic Disorder
One or more of delu, halu, disorganized speech, disorganized behavior (one must be one of the first three)
More than one day, less than one month
Prognosis of brief psychotic disorder
Return to premorbid functioning common
Usually occurs after a significant life stressor
Schizoaffective criteria
Concurrent schizophrenia and mood symptoms
For at least a two week period, there should be psychosis only (without any mood symptoms)
Mood symptoms are depression or mania that meet diagnostic criteria
Age as a suicide risk factor
Highest number of suicides in 45-54 age range
This is highest in women, in men it’s 75+
Gender as a risk factor for suicide
Men 4x more likely to die by suicide
(More lethal means)
Women 2-3x more likely to attempt
Ethnicity/Race as a risk factor for suicide
Alaskan Natives and American Indians age 15-34 have the highest rates (2.5x higher than the national average)
Then whites
Marital status as a risk factor for suicide
Divorced, separated, widowed are highest
Then single
Lowest rates for married persons
Statistics for suicidal thoughts and behaviors
60-80% have had a previous attempt
80% give a definite warning of their intention
Early warning signs of suicide
Threatening self harm or suicide
Talking or writing about death or suicide
Seeking means for suicide
Making preparations (will, giving away possessions, saying goodbye)
Among adolescents, completed suicide is often mmediately preceded by…
Interpersonal conflict (social or romantic rejection, argument with a parent)
Psychological disorders and suicide
MDD or BD dx are 15-20x more likely than the general population
With depression, suicide is most commonly seen after about three months of symptom improvement
Personality correlates of suicide
Hopelessness biggest predictor
Perfectionism may also be a predictor when coupled with high life stress
Biological predictors of suicide
Low levels of serotonin and 5-HIAA (serotonin metabolite)
How to decide appropriate intervention for someone who is suicidal
Outpt psychotherapy, outpt crisis intervention, or inpatient hospitalization
Depends on the level of risk, clients preference, and the potential benefits of each approach
When is hospitalization an appropriate intervention for suicide
When someone has just attempted or has a plan with access to lethal means
(+ impaired judgment, no social support, SMI or chemical dependency, history of previous attempts)
Always encourage voluntary first, then initiate a hold if need be
When is outpatient crisis intervention appropriate for suicide
Moderate risk clients - plan with a lack of access
Fair judgement, social support, decision making abilities, willingness to comply with treatment recommendations
Tx will focus on decreasing isolation, relieving sleep issues, coping skills for anger, addressing ambivalence about suicide
When is outpatient psychotherapy appropriate for suicide
Follow-up to hospitalization, or
For initial interventions for those who are at low risk (no prev attempts, good judgement, adequate support…)
Tx: CBT, CBT, IPT, Problem-Solving Therapy
Diagnostic criteria for Bipolar I Disorder
At least one manic episode
Marked impairment in functioning, requires hospitalization, may include psychotic symptoms
May include one or more episodes of depression or hypomania
Manic episode
For at least one week
At least three of: inflated self esteem or grandiosity, decreased need for sleep, excessive talkativeness, flight of ideas
Associated diagnoses with Bipolar I Disorder
Anxiety
Substance abuse
Prevalence of bipolar I disorder
0.6 percent
Men:women
1.1:1
Concordance rates for Bipolar I
0.67 to 1.0 for monozygotic twins
.2 for dizygotic twins
(Strongest genetic loading out of all the disorders)
Treatment of Bipolar I
60-90% effectiveness with Lithium
(Noncompliance due to mania highs and side effects)
May also use anti-seizure meds
TCAs may trigger mania if taken with a mood stabilizer (not so much with an SSRI)
Diagnostic criteria for Bipolar II Disorder
At least one hypomanic episode and one depressive episode
Hypomanic episode
Lasts at least four consecutive days
At least three of the criteria for mania, but not severe enough to cause marked dysfunction or hospitalization
Diagnostic criteria for Cyclothymic Disorder
Symptoms of hypomania (without meeting criteria)
Symptoms of depression (without meeting criteria)
Cause significant distress or impaired functioning
Sx last for at least two years (adults, one year for youth)…cannot be symptom free for longer than two months at a time
Diagnostic criteria for Disruptive Mood Dysregulation Disorder
Severe temper outbursts
Out of proportion to the situation (and not developmentally appropriate)
At least 12 months, in at least two settings
Onset: before age 10, can’t dx before 6yo or after 18yo
Diagnostic Criteria for Major Depressive Disorder
At least five sx of SPACERAGS for at least two weeks
At least one symptom being depressed or sad mood, or loss of interest or pleasure
Sad, psychomotor, appetite, concentration, energy, recurring thoughts, anhedonia, guilt, sleep
SPACERAGS
Sadness Psychomotor Anhedonia Concentration Energy Recurring thoughts Appetite Guilt Sleep
Specifies of MDD, BD I, and BD II
Peripartum Onset - before baby or up to four weeks after
Usually includes anxiety about the baby, or delusions
Seasonal Pattern - temporal relationship between the sx and the seasons
SAD most common in the winter in North America
Percentage of women who experience depression after giving birth
10-20%
.1-.2% postpartum psychosis
MDD vs Baby Blues
80% of women experience mild mood symptoms
MDD is more disabling and severe
Sleep disturbances and MDD
Sleep continuity disturbances
Reduced stage 3/4 sleep
Decreased REM latency
More REM in early night sleep
Prevalence of MDD
7%
18-29 years most prevalent
Age of onset of MDD
Mid-20s
May initially be caused by severe psychosocial stressors
(However with repeated episodes, the need for the stressor drops off)
Presentation of MDD as a function of age
Youth - somatic complaints, social isolation, irritability
(Aggression and destructiveness in preadolescent boys)
Older adults - memory loss, distractibility, disorientation, other cog sx
(Distinguishes from neurocog because onset is abrupt and distressing)
MDD in older adults vs Neurocognitive Disorder
MDD onset cognitive symptoms are abrupt, and the person is usually concerned about their functioning and deficits
True neurocognitive symptoms usually come on gradually, and the person is unaware or denies their impairments
Two biochemical theories of depression
Indolamine Hypothesis - low levels of serotonin cause depression
Catecholamine Hypothesis - low levels of norepinephrine
Lewinsohn’s Behavioral Theory of Depression
Depression is caused by a low rate of response-contingent reinforcement for social or other behaviors
Results in isolation and pessimism
Seligman’s Learned Helplessness Model of Depressin
A series of uncontrollable negative events is attributed to internal, stable, and global factors
Hopelessness is the proximal cause
Rehm’s Self-Control Model of Depression
Depression is a result of problems with self-monitoring, self-evaluation, and self-reinforcement
Beck’s Cognitive Triad Model for depression
Negative and irrational thoughts about the self, world, and the future
When psychotic symptoms occur exclusively within the context of a mood episode…
MDD (or BD) with psychotic features
MDD vs Adjustment Disorder
MDD criteria are not met with true adjustment disorder
MDD vs Uncomplicated Bereavement
UB typically presents with normal mood, but added feelings of emptiness or loss
UB tends to decrease over days to weeks - May occur in waves that are triggered by reminders of the deceased
Drug treatment for MDD
TCAs - for vegetative, classic depression that is worse in the morning
SSRI - first-line treatment that does not have the risk of overdose that TCAs do
MAOIs - last line for people who do not respond to other meds, and have atypical sx
Psychotherapy for MDD
Combine it with medication for a better effect than meds or psychotherapy alone
ECT for MDD
Severe, treatment-resistant depression
With sx of delusions or severe SUI
Side effects: temporary amnesia, confusion, disorientation
Diagnostic Criteria for Persistent Depressive Disorder
For at least two years (one for youth)
At least two CHEESE symptoms
Concentration, hopelessness, esteem, energy, sleep, eating
Cannot be sx-free for more than two months
Treatment for Persistent Depressive Disorder
SSRI, CBT, IPT
Similarities between anxiety and depression
Impaired concentration and attention Irritability Fatigue Insomnia Hopelessness
Dissimilarities between depression and anxiety
Anxiety - higher levels of positive affect and autonomic arousal
Pure depression - low mood, anhedonia, suicidal ideation, low libido
Pure anxiety - apprehension, tension, worry, nightmares
Diagnostic criteria for Separation Anxiety
Developmentally inappropriate fear or anxiety related to separation from home or an attachment figure
excessive distress when anticipating or experiencing separation
persistent fear of being alone
physical symptoms
At least four weeks in children, six months in adults
School Refusal
A manifestation of separation anxiety in children
Stomachache, headache, nausea, other physical sx
Typically occurs 5-7yrs, 10-11yrs, 14-16yrs
May be associated with social phobia, depression, change of schools…
Etiology of Separation Anxiety
Frequently precipitated by a major life stress (death of a relative or pet, divorce, or move to a new place)
Treatment for separation anxiety
Systematic desensitization
Cognitive approaches
When the sx include school refusal, the primary goal is immediate return to school to prevent academic failure and social isolation
Diagnostic Criteria for Specific Phobia
Intense fear or anxiety about a specific situation or object
Object or situation is avoided or endured with marked distress
Subtypes: animal, blood/injection/injury, environmental, situational, other
Subtypes of specific phobia
Animal Blood/injection/injury Environmental Situational Other
Two-factor theory for Specific Phobia
Avoidance conditioning
Learn to fear a neutral (conditioned) stimulus because of its pairing with a fear-arousing (unconditioned) stimulus
Avoidance of the conditioned stimulus is negatively reinforced because it because it keeps the from experiencing the anxiety
Treatment for Specific Phobia
Exposure with response prevention
(Especially in vivo exposure)
Exposes the person to the feared object while preventing them from engaging in behavioral or cognitive avoidance
Exposure therapy is most effective when…
It is paired with APPLIED TENSION
Involves repeatedly tensing and releasing the muscles in the body’s major muscle groups (to increase blood pressure)
Diagnostic criteria for Social Anxiety Disorder (Social Phobia)
Fear of one or more social situations where you may be exposed to the scrutiny of others
Fears they will exhibit symptoms and will be negatively evaluated
Typically lasts at least six months
Situations commonly association with Social Anxiety Disorder…
Public speaking
Attending parties
Initiating conversations
Speaking to authority figures
Treatment for Social Anxiety Disorder (Social Phobia)
Exposure with response prevention
Social skills, cognitive techniques
SSRI, SNRI, beta blocker propranolol
Diagnostic criteria for Panic Disorder
Recurrent, unexpected panic attacks
At least one attack being followed by a period of concern about having additional attacks (lasting at least a month)
PA sx: heart race, sweating, trembling, choking, chest pain, paresthesias, derealization, fear of losing control
Medical rule outs before a diagnosis of Panic Disorder can be rendered…
Hyperthyroidism, hypoglycemia, cardiac arrhythmia
Prevalence of Panic Disorder
2-3% in a twelve month period
Females twice as likely as males
Treatment for Panic Disorder
CBT
Panic Control Therapy (PCT) - psychoed, relaxation, cognitive restructuring, interoceptive exposure (expose to physical sensations of panic)
Also responsive to TCAs, SSRIs, SNRIs, and benzos
But if med only you have a 30-70% chance of sx rebound once you discontinue
Diagnostic criteria for Agoraphobia
Fear or anxiety about being in at least two spaces:
Public transportation, open spaces, enclosed spaces, standing in line, crowd, being outside of the home alone
Fears or avoids because escape may be difficult or help will not be available if panic occurs
At least six months
Agoraphobia vs Specific Phobia vs Social Anxiety
Specific - anxiety only for a single situation, concern is related to something other than experiencing panic
Social anxiety - anxiety is related to being scrutinized, may increase sx when in the presence of family or friends
Agoraphobia - anxiety is related to panic, in multiple situations, may be helped by the presence of a family member or friend
Treatment for Agoraphobia
In vivo exposure with response prevention
Graded vs nongraded have similar effects in the short term
Nongraded exposure has better effect in the long term
Diagnostic criteria for Generalized Anxiety Disorder
Excessive worry about multiple events
At least six months
Difficult to control
At least three (1 for children): restlessness, fatigue, muscle tension, irritability, difficulty with concentration, sleep disturbance
Cormorbid diagnoses with GAD
50% of patients with GAD have a second diagnosis
MDD, PDD, SUD, Phobia, Social Anx
Age-related anxiety features
Children and adolescents - performance in school, sport, natural disasters
Young Adults - work, family, finances, future
Older Adults - personal health, minor or routine matters
Treatment for GAD
CBT and pharmacotherapy
SSRIs, SNRIs, and benzos or Buspar when those don’t work
Obsessions
Persistent thoughts, impulses, or images that a person experiences as intrusive or unwanted, that they cannot ignore or suppress
Ex. Repeated thoughts of contamination, repeated doubts of one’s abilities
Compulsions
Repetitious and deliberate behaviors or mental acts that a person feels driven to perform (either in response to an obsession or according to rigid rules)
Goal of the behavior is to reduce distress or prevent a dreaded situation from happening (but the behavior is excessive or not logically connected)
Diagnostic criteria for Obsessive-Compulsive Disorder
Recurrent obsessions and/or compulsions
Time consuming
Cause impairment in functioning
Gender and OCD
Equal prevalence in males and females
More prevalent in younger males because onset is earlier in males
Etiology in OCD
OCD is caused by low levels of serotonin
Increased activity in the right caudate nucleus
Responsible for conversing sensory input into actions
OCD vs OCPD
OCPD does not involve obsessions or compulsions
(Preoccupation with perfection, control, orderliness)
Rituals are performed to
- reduce anxiety (OCD)
- gain perfection (OCPD)
Treatment of OCD
Exposure with response prevention
SSRI
Don’t just medicate without therapy, the risk of relapse is really high for medication-only patients
Body Dysmorphic Disorder
(Obsessive-Compulsive and Related Disorders)
Preoccupation with a perceived defect or flaw in appearance
That is minor or unobservable to others
Hoarding Disorder
Persistent difficulty discarding or parting wit possessions
Regardless of their actual value
Reactive Attachment Disorder
Emotionally withdrawn behavior with adult caregivers
(At least 2) irritability, low positive affect, limited emotional responsiveness, sadness, fearful…when with caregiver
Must have experienced extreme insufficient care
Developmentally older than 9mo, sx must present before 5yo
Disinhibited Social Engagement Disorder
Inappropriate actions with unfamiliar adults
(At least 2) absence of hesitance with unfamiliar adults, overly familiar with unfamiliar adults, diminished checking for approval from caregiver, following unfamiliar adult with little/no hesitation
Child must have experienced extreme insufficient care
Must be developmentally older than 9mo, sx onset must be before 5yo
Acute Stress Disorder diagnostic criteria
Nine sx from PTSD categories
Three days to one month
PTSD criteria
Exposure to actual or threatened death/injury/violence
(In one of four ways)
At least one intrusion sx
Avoidance of stimuli associated with event
Two negative changes or affect or mood
Two changes to arousal or reactivity
More than one month
Four ways to meet PTSD criteria for exposure to events
Direct experience
Witnessing the event
Learning the event occurred to a loved one
Repeated exposure to adverse effects of the event
Treatment for PTSD
CBT - exposure, cognitive restructuring, anx mgmt
SSRI - for comorbid depression or anxiety - may lead to relapse without psychotherapy
Two controversial treatments for PTSD
Eye movement desensitization and reprocessing (EMDR)
- beneficial, but nothing to demonstrate this is something special
Cognitive incident stress debriefing (CISD)
- one lengthy session within 72 hours of trauma, regardless of whether or not the person is evidencing trauma sx
- may actually worsen symptoms
Adjustment Disorder
Emotional or behavioral sx after one or more identifiable psychosocial stressors
Must occur within three months of the stressor
Must remit after six months of the stressor or its consequences
Not diagnosed when symptoms represent normal bereavement
Delayed onset specified for PTSD
When full diagnostic criteria are not met until at least six months after the traumatic event
Diagnostic criteria for dissociative identity disorder
One individual experiencing two or more distinct personality states
Gaps in recall of ordinary events, personal information, or traumatic events that are not consistent with ordinary forgetfulness
Important ruleout for dissociative identity disorder
Cultural considerations
May be acceptable form of religious expression
Dissociative Amnesia criteria
Inability to recall personal information that cannot be attributed to ordinary forgetfulness.
Often related to the exposure of a traumatic event
5 types: localized (all events around a period of time), selective (some events around a period of time), generalized (encompasses whole life), continuous (from a certain point until present), systematized Ed to a certain caregory)
Five types of amnesia
Localized - all events within a circumscribed period of time
Selective - some events within a circumscribed period of time
Generalized - whole life
Continuous - from a period open time until present
Systematized - can’t remember reacted to a specific category
Depersonalization and Derealization Disorder
Depersonalization - sense of detachment, unreality
Derealization - detached from one’s surroundings
More than six months in duration
Somatic Symptom Disorder criteria
One or more somatic sx that cause distress
Accompanied by excessive thoughts, feelings, behaviors, related to the symptoms
Disproportionate worry about seriousness, excessive time devoted to health, high anx about medical…
More than six months in duration
Illness Anxiety Disorder
Preoccupation with having a serious illness
No somatic symptoms (or very mild)
High level of anxiety about one’s health
For at least six months
Conversion disorder
Incompatibility between your symptoms and the medical issues they may represent
Ex. Paralysis, blindness, seizures, etc.
Two subtypes of factitious disorder
Imposed in self
Imposed on another
Criteria for Factitious disorder
Falsify physical or psychological conditions
Present self or other as being impaired
Engage in the deceptive behavior without an external reward
Falsification can include: feigning, exaggerating, simulating, induction
Differential diagnosis for Factitious Disorder
Malingering
For secondary gain, external rewards
Should be considered when someone is being evaluated for legal reasons
Pica
Eating nonnutritive food items
At least one month
Most common during childhood
Not part of a culturally sanctioned practice
Criteria for Anorexia Nervosa
RESTRICTION
Intense fear of gaining weight or becoming fat
Disturbance in the way a person views their body shape
Levels of severity based on BMI
Associated diagnoses with AN And BN
Anxiety and depression
Anxiety is commonly a precursor to the feeding disorder, and depression can have onset before or after
Physical symptoms of anorexia nervosa
Cold intolerance Constipation Abdominal pain Lethargy Bradycardia
Prevalence and onset of eating disorders
Adolescence and young adult
90% females
Biological etiology of Anorexia
Genetics
High serotonin
Psychological etiology for anorexia nervosa
Highly correlated with perfectionism
Environmental etiologies for anorexia nervosa
Inconsistent results related to family functioning
Maybe high levels of family conflict, rigid parents, concern in home with thinness, domineering dads…
Treatment of anorexia nervosa
Primary goal is weight gain!
(Hospitalization, contingency management with weight maintenance)
Garner’s CBT
Est positive alliance, normalize eating and weight, modify negative beliefs about weight and food, relapse prevention
Family therapy for the treatment of anorexia nervosa
May be beneficial
If family has high EE, then do family therapy without the patient and treat them separately… family treatment with the patient and a high EE family could lead to increased risk of relapse
Diagnostic criteria for Bulimia Nervosa
Binging (sense of lack of control)
Compensatory behavior
Self-evaluation is unduly influenced by weight and body shape
Binging and compensation need to occur at least once a week for three months
What can commonly trigger a binge eating episode
Interpersonal stress
Dysphoric mood
Difference between BN and AN binge/purge type
AN bpt - still has restriction as a component, no insight
BN - no restriction, realizes there’s a problem, not necessarily underweight
Medical complications associated with BN
Fluid and electrolyte imbalances…
Can cause cardiac arrhythmia and arrest
Dental problems, metabolic acidosis or alkalosis, menstrual abnormalities
Narcolepsy
Attacks of irresistible needs for sleep
At least three times per week, for three months
Includes: cataplexy (muscle weakness), hypocretin deficiency, REM latency
What can trigger narcolepsy
Anger, surprise, or other strong emotions
Can trigger cataplexy more specifically
Non-REM Sleep Arousal Disorders
2 types
Sleep walking
Sleep terrors
No recall of the episode
Occurs most commonly in children
Non-REM sleep issues usually occur during what sleep stages
3 and 4
Rule out conditions for Sexual Dysfunctions
Nonsexual mental disorders
Relationship distress or other stressor
Effects of substances, medication, or other medical condition
Erectile disorder
Problems maintaining an erection during sexual activity
Maintaining an erection until the completion of sexual activity
Marked decrease in erectile rigidity
Occurs during all or nearly all sexual encounters
For at least six months
Premature Ejaculation
Persistent pattern of premature ejaculation
(Within one minute of penetration, or before the person desires it)
Occurs during all or nearly all sexual encounters
For at least six months
Treatment methods for premature ejaculation
Viagra
Senate focus - reduce performance anxiety
Squeeze techniques - control the ejaculatory reflex
Gender Dysphoria
Marked incongruence between assigned gender at birth and one’s expressed or perceived gender
Manifests as intense desires or urges to dress like, look like, be treated like, engage in social interests like the gender you are identifying as
Must meet criteria (and marked distress) for at least six months
Oppositional Defiant Disorder
Angry/irritable behavior
Defiant/argumentative
Vindictiveness
At least six months
With at least one person who is not a sibling
Cause distress to person or individuals in immediate social environment
Intermittent Explosive Disorder
Inability to control aggressive impulses…
(1) manifested as verbal or physical aggression
(2) occurring at least 2x/week for at least three months
(3) or, three outbursts that cause damage/destruction in 12mo
Agitation is not proportional to the triggers
Must be at least six years old
Diagnostic criteria for conduct disorder
Aggression to people or animals
Destruction of property
Deceitfulness or theft
Serious violation of rules
Cannot be assigned to individuals over the age of 18
Specifiers for Conduct Disorder
Childhood-onset
(At least one symptom prior to age 10)
Adolescent-onset
(No symptoms prior to age 10)
Unspecified onset
Two types of Conduct Disorder
Per Moffitt
Life-course persistent type
(Begins as early as 3yo, with increasingly serious issues into adulthood…related to neuro impairment, temperament, poor env)
Adolescent-limited type
(Caused by maturity gap between developmental maturity and the opportunities for adult behaviors and rewards, temporary, usually done with peers)
Treatment for Conduct Disorder
Best when delivered to preadolescents through family interventions
Parent management training (PMT) - replace punishing negative behaviors with reinforcing positive ones
Multisystemic therapy (MST) - targets multiple levels of people in multiple different ways
General criteria for Substance Use Disorder
At least two criteria within 12 months
Four major categories... Impaired control (can’t quit or reduce), social impairment, risky use, and pharmacological criteria (tolerance and withdrawal)
Can be applied to all drugs except caffeine
Tension-Reduction Hypothesis for substance use disorder
Substances (alcohol) reduces fear, anx, etc. causing people to drink to avoid those feelings, eventually leading to addiction.
Addiction is the result of negative reinforcement
Most common precipitation of substance relapse
Experience of anxiety, frustration, depression, or other negative emotional state
Abstinence Violation Effect
Mariatt And Gordon
Reaction to a relapse is shame, guilt, anxiety, depression…
Those negative feelings leads to another increased risk for relapse
Reduce the potential for another relapse by viewing the episode of substance use as a mistake resulting from specific, external, controllable factors
Relapse Prevention Therapy
Mariatt and Gordon
RPT involves identifying the circumstances that increase the risk of relapse for the person, and then implement behavioral and cognitive strategies to prevent future lapses and cope more effectively if they do occur
Difficulty on treating Tobacco Use Disorder
People are addicted to the nicotine…
…so they smoke for its inherent reinforcing effects and to avoid nicotine withdrawal
Cravings for nicotine can also last months or years
Smoking Cessation Intervention
Posits that the likelihood of ling-term smoking cessation increases when…
(1) there is nicotine replacement therapy
(2) behavioral therapy includes skills training and stimulus control
(3) there is support and assistance from a clinician
Substance-Induced Disorders
Potentially severe, usually temporary, but somewhat persisting CNS syndromes that develop in the context of the effects of substances of abuse, medication, or toxins
Must have developed within one month of the intoxication
Cannot be better explained by another medical condition or mental disorder
Criteria for Alcohol Withdrawal
2+ of the following, within several hours to a few days of abrupt cessation or reduction…
Anxiety Autonomic hyperactivity Generalized tonic-clonic seizures Hand trembling Insomnia Nausea or vomiting Psychomotor agitation Transient hallucinations
Alcohol-Induced Major Neurocognitive Disorder
Aka. Korsakoff Syndrome
Evidence of a significant decline in one or more cognitive domains that interferes with independence in everyday activities
Also includes anterograde or retrograde amnesia and confabulation (attempts to falsify memories to make up for memory loss)
Alcohol-Induced Sleep Disorder
Typically insomnia that occurs in the intoxication or withdrawal phase
Intox - immediate sedation, increased stage 3/4 sleep, decreased REM
followed by increased wakefulness, increased REM with anxiety-provoking dreams, and decreased stage 3/4 sleep
With - vivid dreams and severe disruption in sleep continuity
Opioid withdrawal symptoms
Diarrhea Dysphoric mood Fever Insomnia Lacrimation (watery eyes) Muscle aches Nausea or vomiting Pupil dilation or sweating Yawning
Tobacco withdrawal symptoms
Irritability or anger Anxiety Impaired concentration Increased appetite Restlessness Depressed mood Insomnia
Occurs within 24 hours of abrupt cessation or reduction in tobacco use
Areas of cognitive functioning impacted by neurocognitive disorders…
(Six domains)
Complex attention Executive function Learning and memory Language Perceptual motor Social cognition
Criteria for delirium
Disturbance in attention and awareness that develops over a short period of time
Represents a change in baseline functioning
Tends to fluctuate in severity (worsening at night usually)
At least one additional cognitive domain must show impairment
Five groups of people identified to be at high risk for delirium
(Per Wise)
Older adults
People with decreased cerebral reserve (dementia, stroke, HIV)
Postcardiotomy patients (heart surgery)
Burn patients
People with drug dependence experiencing withdrawal
Treatment goals for Delirium
Treat the underlying cause of the delirium
Reduce agitation (Environmental manipulation, meds, psychosocial interventions (Family or friend stay with patient))
Major Neurocognitive Disorder criteria
(Dementia)
Significant decline from previous level of functioning
One or more cognitive domains
Interferes with ability to perform everyday activities independently
Mild Neurocognitive Disorder criteria
(Cognitive Disorder NOS is included here)
Modest decline from previous functioning
One or more cognitive domains
Does not interfere with independently performing everyday activities
(But may require greater effort and compensatory strategies)
Neurocognitive Disorder d/t Alzheimer’s
Major
Evidence of a causative genetic mutation
Clear decline in memory and another cognitive domain
Steady and gradual decline without extended plateaus
Neurocognitive Disorder d/t Alzheimer’s
Mild
May or may not be evidence for causative genetic mutation
Clear evidence of decline in memory and learning
Steady and progressive decline in cognition without extended plateaus
How to definitively diagnose Alzheimer’s
Autopsy or brain biopsy
Confirms extensive neuron loss and the presence of:
Amyloid plaques and tau tangles
Three stages of deterioration in Alzheimer’s…
(1) 1-3 years - anterograde amnesia (esp for declarative memories), wandering and visuospatial deficits, indifference, irritability, sadness, and anomia (word finding deficits)
(2) 2-10 years - increasing retrograde amnesia, flat or labile mood, restlessness and agitation, delusions, fluent aphasia (receptive), acalculia, ideomotor apraxia (inability to translate an idea into movement)
(3) 8-12 years - severely deteriorated intellectual functioning, apathy, incontinence, limb rigidity
Stage one of Alzheimer’s decline
1-3 years
Anterograde amnesia (esp for declarative memory)
Deficits in visuospatial skills (wandering)
Indifference, apathy, and sadness
Anomia (word finding trouble)
Stage 2 of Alzheimer’s decline
2-10 years
Increasing retrograde amnesia Flat or labile mood Restlessness and agitation Delusions Fluent aphasia (receptive) Acalculia Ideomotor apraxia (inability to transform an idea into movement)
Stage 3 of Alzheimer’s decline
8-12 years
Severely deteriorated intellectual functioning
Limb rigidity
Incontinence
Cluster A Personality Disorders are characterized by what general traits?
Odd or eccentric behavior
Name the three Cluster A personality disorders
Paranoid PD
Schzoid PD
Schizotypal PD
Paranoid Personality Disorder
Pervasive pattern of suspiciousness that entails interpreting the motives of others as malevolent
(4+) suspects others are harming without sufficient evidence, preoccupied with unjustified doubts about the trustworthiness of others, reluctant to confide in others, reads demeaning content from benign interactions, bears grudges, perceived attacks on character and responds with hostility, perceived infidelity from sexual partner
Symptoms of Schizoid Personality Disorder
Displays a pervasive detachment from interpersonal relationships with a restricted range of emotion in social settings
(4+) doesn’t enjoy close relationships, chooses solitary activities, no interest in sexual relationships, little pleasure from activities, indifferent to praise or criticism, emotional coldness, lack of friends other than first degree relatives
Criteria for Schizotypal Personality Disorder
Pervasive social deficits and eccentricities in cognition, perception, and behavior
(5+) ideas of reference, odd beliefs that influence behavior, unusual perceptions, odd thinking and speech, paranoia, inappropriate affect, peculiarities in behavior or appearance, social anxiety, lack of friends other than first degree relatives
General characteristics of Cluster B Personality Disorders
Dramatic, emotional, erratic
List the four Cluster B personality disorders
Borderline PD
Histrionic PD
Narcissistic PD
Antisocial PD
Antisocial Personality Disorder
Pattern of disregard for, and the violation of the rights of others that has occurred since age 15 (w prev dx of Conduct Disorder)
(3+) failure to conform to norms or laws, deceitfulness, aggressive, reckless disregard for safety of self or others, irresponsibility, lack of remorse
Prognosis for ASPD
Symptoms (especially involvement with criminal behavior) typically become less severe by the fourth decade of life
Borderline Personality Disorder diagnostic criteria
Instability in interpersonal relationships, sense of self, and affect
(5+) frantic attempts to prevent abandonment, unstable relationships, disturbance in identity, impulsivity in at least two areas, recurrent SUI threats or gestures, affective instability, chronic emptiness, inappropriate and intense negative emotions, stress-related paranoia or dissociation
Treatment for BPD
DBT
Group skills training
Individual therapy to maintain motivation
Phone calls for consultation
Prognosis for BPD
Symptoms begin to remit into the 40s, with more than half no longer meeting criteria
Impulsivity remits fastest, affective symptoms were most pervasive
Etiology of BPD
Per Linehan
Biosocial model
Genes
Invalidating environment
Excessive emotional vulnerability
Inability to modulate distressing emotions
Histrionic Personality Disorder criteria
High levels of emotionality and attention-seeking behavior
(5+) discomfort when not the center of attention, inappropriately sexually provocative, rapidly shifting of shallow emotions, physical appearance changes to garner attention, impressionistic speech, exaggerated emotional expression, easily influenced by others, considers relationships to be much more serious than the actually are
Narcissistic Personality Disorder criteria
Pattern of grandiosity, a need for admiration, and a lack of empathy
(5+) grandiose self-importance, requires excessive admiration, beliefs uniqueness can only be understood by important others, preoccupied with unlimited success, entitlement, lacks empathy, envious of other or believes others are envious of them, arrogant
General traits consistent with Cluster C Personality Disorders
Anxiety and fearfulness
Three clusters for personality disorders
A - odd and eccentric
B - dramatic, erratic, emotional
C - anxious and fearful
Avoidant Personality Disorder criteria
Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
(4+) avoids activities due to fear of criticism, unwilling to get involved with others for fear of not being liked, restraint in relationships for fear of rejection, overly concerned with criticism, inhibited in new relationships due to inadequacy, views self as inept, reluctant to try new things for fear of embarrassment
Dependent Personality Disorder criteria
Pervasive and excessive need to be taking care of, leading to submissive, clinging behavior and fear of separation
(5+) difficult making decisions without reassurance, needs others to assume responsibility for many aspects of life, fears disagreement, difficulty initiating things on their own, goes to great lengths to obtain support from others, urgently seeks new relationships when old ones end, unrealistically occupied with having to fend for self
Three Cluster C Personality Disorders
Dependent PD
Avoidant PD
Obsessive-Compulsive PD
Obsessive-Compulsive Personality Disorder criteria
Preoccupation with orderliness, perfectionism, and the mental control severely limits their flexibility, openness, and efficiency
(4+) preoccupation with details and rules so that the point of the activity is lost, perfectionism interferes with task completion, devoted to work at cost of friends and leisure, overconscientious and inflexible about ethics and values, cannot discard worthless objects, reluctance to delegate work, miserly about spending time with others, stubborn
