abnormal quiz 4 Flashcards
What is a transdiagnostic construct?
• Disorders share many core features
• Transdiagnostic processes or constructs:
a. Feature across several disorders
b. Represent a causal mechanism across several disorder
Death anxiety
• Central part of the human condition
• ‘the worm at the core’ of our existence
• We are the only species to understand our own mortality
• Throughout recorded history
- Religion, ritual, myth
- literature, art and theatre
- Philosophy
- PsychologyDeath anxiety: absence of theory
• Becker (1973)
- Motivation to live + inevitability of death = crippling fear
- Cultural theory
• Death anxiety: absence of clinical theory
Terror management theory
• TMT: two buffers against death anxiety
1. Cultural worldviews - Gain virtual immortality by buying into beliefs 2. Self-esteem - Gain meaning by fulfilling expectations of cultural worldview
death anxiety - transdiagnostic
• Death anxiety might be a transdiagnostic construct
- Might underpin a number of disorders: anxiety disorders, OCD, eating disorders, PTSD, depression etc.
• Revolving door of mental health
- Separation anxiety disorder > panic disorder > OCD
Panic disorder - death anxiety
• Fears of death argued to play a central role
• “I am having a heart attack”, “I am going to die”
• Panic disorder patients reported significantly higher death fears than social phobia patients and controls
- Those with comorbid disorders also reported high levels of death anxiety than individuals who only met criteria for 1 disorder
Somatic symptoms disorder, illness, anxiety and hypochondriasis - death anxiety
• Death anxiety argued to be a central feature
• Worrying about physical health – particular physical symptoms being experienced, think this means you are unwell
• May repeatedly consult GP’s and specialists, check body (e.g. blood pressure, bruises, pulse, stools) for symptoms, or seek reassurance from others
• “is this a headache or a brain tumour?”
• Hypochondriasis patient’s vs matched medical and non-hypochondriacal psychiatric patients
• Those with hypochondriasis:
- Attended more closely to bodily sensations
- Were more likely of distrust doctor’s judgements
- Reported more fears of
death and disease
Agoraphobia and separation anxiety - death anxiety
• Many symptoms are associated with death fears
- Fears of harm when leaving home
- Increased focus on internal sensations (e.g. change in heart rate, dizziness)
- Hypochondriacal concerns
- Frequent catastrophic death-related fears
• “I can’t go out – I could be attacked”
• Onset of agoraphobia is often preceded by traumatic events (e.g. loss of a loved one or physical threat)
• Fear of death and separation anxiety are positively correlated among individuals with agoraphobia
- Suggests that fear of separation from loved ones may increase as death anxiety increases
• Increased death anxiety and separation anxiety among individuals with BPD and schizophrenia, compared to controls
- Suggest separation anxiety may mask death anxiety
Specific phobias - death anxiety
• Freud argued that fears of death underlie phobias
• Heights, snakes, spiders, water, flying – most common fears, they have potential to be fatal
• Phobias may occur when death anxiety focuses on smaller, more manageable threats
• Strachan tested whether mortality saliences could increase phobic behaviours
- 32 students who met criteria for specific phobia of spiders, 30 non-phobic
- Primed with death or control
- For those with spider phobia, reminders of death (MS):
o Increased avoidance of spider-related stimuli
o Increased perceived threat (i.e. “how likely is it that the spider in the first picture is dangerous to humans?”)
PTSD - death anxiety
• DSM-5: the person was exposed to: death, threatened death, actual or threatened serious injury or actual threatened sexual violence
• Death anxiety argued to play a role in development and maintenance
- I can’t leave the house at night – I could be attacked again’
• Suggest severe PTSD is characterised by impaired suppression of death thoughts
- Anxiety-buffering defences are disrupted in PTSD
Depressive disorders: TMT
• MS study with mildly depressed individuals
- Following priming, being given opportunity for worldview defence was associated with increased belief that life is meaningful
• Bolstering worldview beliefs may increase meaning among depressed individuals
- Consistent with idea depression is associated with weaker buffers against death anxiety
Eating disorders - death anxiety
• Women diagnosed with anorexia show significantly higher death anxiety than controls
• Goldenberg found reminders of death led women (but not men) to:
- Perceive themselves as further from their ideal thinness
- Eat 40% less in a ‘taste-testing’ task than controls
• Death anxiety may be driving women to strive for thinness promoted by their cultural worldviews
Social anxiety disorder - death anxiety
• Social exclusion meant literal death
• Strachan used MS with student’s high vs low in social anxiety
1. Primed with MS or . control
2. Allowed to decide when to join a group discussion (social avoidance)
• Reflecting on own death led socially anxious participants to wait longer before joining a group discussion
- Death priming produced significantly more social avoidance among socially anxious participants
OCD - death anxiety
- Thoughts of death can worsen OCD symptoms (e.g. hand washing)
- Double time spent washing
panic disorder - death anxiety
- Among panic disorder, illness anxiety, and somatic symptom disorder, thoughts of death can worsen symptoms
o Body checking
o Threat perception
o Reassurance seeking from GP
Implications - death anxiety
- Results of recent research suggest we may need to rethink treatment of these conditions
- What do treatments for anxiety look like?
- All of these treatments produce great pre- post- measures
- But we often assume success from a single measure of a single disorder
- Is the problem that treatment studies are measuring the thing we’re targeting in the treatment, not necessarily the core problem?
- Increased functionality, but are these contributing to the ‘revolving door’ of mental health?
Treating death anxiety
• CBT produced largest improvements in death anxiety
- Exposure therapy
o Get people to write their tombstone, write a eulogy
Anger
- Anger (17%) was the most frequently reported negative emotion, well ahead of sadness (12%) and fear (2%)
- 8% of the normal population reported that anger had been a problem for them for 6 months or more
The damage - anger
- Critical mediator in various forms of aggression, from domestic violence through to assault, murder and rape
- Consistently identified as a risk factor in hypertension and heart-related illness
- Anger interferes with judgement, problem-solving, negotiating; leads to risky behaviours
- It’s been estimated that as much as 1/3 of crashes and 2/3 o traffic related deaths are attributable to angry-aggressive driving
- Anger impacts adversely on relationships
Neuroticism partner effect
- Neuroticism partner effect: the neurotic your partner is the higher they are in negative emotions, the less satisfied you are with the relationship.
Anger and the DSM-5
- Anger in the DSM-5 is both everywhere and nowhere
- It travels across the full gamut of psychopathology, but has no real ‘home’ – there’s no (adult) anger disorder proper, much less an anger disorders section
Intermittent explosive disorder (IED)
• The disorder most commonly diagnosed to people presenting with anger issues – even without aggression)
A. Recurrent behavioural outbursts representing a failure to control aggressive impulses as manifested by either:
1. Verbal outbursts, or physical aggression that does not result in damage or injury, twice weekly (on average) for at least 3 months
2. Behavioural outbursts that do result in damage and/or injury, three times in 12 months
B. The aggression s disproportionate to the provocation
C. The outbursts are not premediated (i.e. they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g. money, power, intimidation)
D. These outbursts cause distress and/or impairment
E. The individual must be at least 6 years old
F. The outburst are not better explained by another mental disorder or medical condition (e.g. Head trauma or Alzheimer’s)
• This is an aggression disorder, not an anger disorder
Overemphasis on ‘impulse control’
- DSM appears to be suggesting that the aggression in IED is caused by a general impulse-control problem
- DSM-5 themselves concede: “IED appears to be quite common regardless of the presence or absence of ADHD or disruptive, impulse-control, and conduct disorders”
- They fail to account for the fact that most IED’s refrain from outbursts with policemen, their bosses, etc.
- IED thus fails to capture the method in the madness…
Oppositional defiant disorder (ODD)
• A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories and exhibited during interaction with at least one individual who is not a sibling.
• Angry/irritable mood
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry or resentful
4. Often argues with authority figures
5. Often actively defies or refuses to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or mis-behaviour Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
Disruptive mood dysregulation disorder (DMDD)
a. Severe recurrent temper outbursts that are grossly out of proportion to the situation or provocation
b. They are inconsistent with developmental level
c. They occur on average 3 or more times weekly
d. The mood between outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. parents, teachers, peers)
• Terminology aside, so far so good! …Oh, but wait:
• Criteria G and H: The Dx should not be made for the first time after 18, and the age of onset must be before 10
• Explicit directive of the DSM was not to create an anger disorder, but to prevent children being diagnosed as Bipolar.
Why is anger so neglected?
- Because the angry themselves often resist therapy, and clinicians are unwilling to treat it: supply matches demand
- Anger is often conceptualised as part of a conflict involving multiple parties, not an individual problem
- Hx of overly behavioural theories (which edit out the emotional component) and an emphasis on aggression generally because of its more obvious impact
- Hx of overly Freudian theories (which relate anger to the status of rationalisation or secondary symptom)
Anger fallacies abound…
fallacies:
- Venting is useful (pillow techniques)
- Low self-esteem is the culprit (treated as depression)
- Anger is biological, physical, genetic
- Anger is a social skills problem (assertiveness etc.)
- Anger is an impulsive problem (self-instructional training)
- Anger is classically conditioned (repeated exposure to barbs
Personality disorders: core features
- Functional inflexibility
- Failure to adapt to situations: rigid response
- Self-defeating
- Behavioural responses damaging
- Unstable in response to stress
- Emotional, behavioural and cognitive instability
• Lack of insight: failure to recognize dysfunctional aspect of personality - Lack of reflective capacity, will blame others for their impairments in functioning
- Emotional, behavioural and cognitive instability
Borderline personality disorder
people constantly test relationships, want attention and to establish that the person loves them. They continue to push the other person until the other person can’t take it anymore
DSM-5 personality disorder (summary)
• A personality disorder is an enduring pattern of inner experience and behaviour that:
- Deviates markedly from the expectations of the individual’s culture - Is pervasive and inflexible - Has an onset in adolescence or early childhood - Is stable over time - Leads to distress or impairment
DSM-5 general personality disorder
• To diagnose a personality disorder, the following criteria must be met:
- Significant impairments in self (identity or self- direction) and interpersonal (empathy or intimacy) functioning
- One or more pathological personality trait domains/facets
• In addition, these features must be:
- Relatively stable across time and consistent across situations
- Not better understood as normative for the individual’s developmental stage or socio-cultural environment
- Not solely due to the direct psychological effects of a substance (e.g. drug of abuse, medication) or a general medical condition (e.g. severe head trauma).
clusters personality disorder
- Cluster A: auto-eccentric traits
- Cluster B: dramatic and emotional traits
- Cluster C: anxious and fearful
• Not just these ten types of traits, multiple clusters show
categorical approach to PD
• DSM-5 represents a categorical approach of personality disorders (PD’s)
- More compatible with disease classification systems used in medicine
- Assumes that PD’s represent distinct clinical syndromes
• Advantages: clarity and ease of communicating information
• Disadvantages: difficult to distinguish the threshold where the person goes from what’s considered ‘normal’ personality traits through to meeting criteria for a personality disorder
DSM-IV: a multi-axial system - personality disorders
• Axis 1: major clinical disorders with acute systems that need treatment
• Axis 2: personality disorders (and intellectual disabilities)
- Early age of onset
- Enduring and more pervasive effects on daily functioning
- Involvement of self and identity
- Presumed poorer self-awareness
- Lower treatment response
• BUT high degree of co-occurrence of symptoms
• Heterogeneity within diagnoses
• Diagnostic unreliability
• Lack of robust scientific evidence
DSM-5: a single axial model
Cluster A- odd and eccentric
- Paranoid
- Schizoid
- Schizotypal
• High levels of introversion
• People isolate themselves, are suspicious of others
• Traces back to childhood
• See people as malicious and deceptive – take advantage of people
• Not disclose personal information as they think it will be used against them
• Negative perception of what people will do – always expect the worst
• Can’t take compliments
as everything is taken negatively
Paranoid PD
• Consistent and pervasive pattern of distrust, sus piousness and prolonged grudges held:
- Believes others intentionally exploit, harm or deceive them
- Reluctance to disclose personal information for fear it may be used against them
- Severely sensitive to criticism and threat > hypervigilant for signs of others to harm them
- Misinterprets comments to individuate concealed hidden or malevolent intent or motivation
- Hostility, aggression and anger to perceived insults
- Jealousy (distrust and misinterpretation)
• 2/3 meet criteria for other PD’s
- E.g. schizotypal, narcissistic borderline and avoidant
Schizoid personality disorder
• Very detached, aloof
• Cannot connect with people with this disorder
• Emotions are threatening and confronting
• Not distressed by being isolated
• Detachment and disinterest in social relationships
- Withdrawal into internal world to avoid affect and maintain distance from others
• Sees others as intrusive and controlling
• Flatness of affect: coldness, aloofness, self-absorption, social ineptitude or conceit
• Unresponsive to social criticism: sexually apathetic reflecting incapacity to form interpersonal bonds
• Anhedonia
• Comorbid with schizotypal and avoidant PD’s
Schizotypal personality disorder (prevalence 3.9-4.6%)
• Bizarre and eccentric
• Marked interpersonal deficits, behavioural eccentricities and distortions in perception and thinking (that do not meet criteria for schizophrenia_
- E.g. magical thinking, extreme superstition, belief in paranormal phenomenon
• Odd thoughts and speech patterns: vague, abstract but retains coherence
• Often seek treatment for anxiety, depression and effective dysphoria (constricted or inappropriate affect)
• Comorbid with borderline, avoidant, paranoid and schizoid PD’s
Cluster c – avoidant personality disorder
- Low self-esteem
- Believe they are inferior
- Anticipate rejection from others
- Core beliefs: I am not good, un-loveable, worthless
- Don’t like company due to this
Avoidant PD
- Pervasive social inhibition; avoidance of activities involving personal contact and groups
- Intense feelings of inadequacy, low self-esteem and self-loathing
- Underlying assumptions: “ I am no good, un-loveable” “if people get to know me they will reject me”
- Socially inept/incompetent, personally unappealing, inferior to others
- Hypersensitivity to criticism, disapproval, shame and ridicule > fear of rejection so strong that they rarely form any relationships
- Self-imposed isolation
- Comorbid with dependent PD and mood, anxiety and eating disorders
Cluster C – dependent personality disorder
- Constantly need approval of others
- Don’t say no
- Pervasive need to be taken care of
- Exaggerated fear of being incapable of doing things or taking care of things on their own – reliance on others
- Lacking self-confidence and requiring constant reassurance
- Often find themselves exploited and in abusive relationships, fearing abandonment
- Self-views: needy, weak, helpless and incompetent
- View of others: strong caretaker idealised. Function well as long as he idealised figure accessible
- Threats: rejection or abonnement
- Strategy: cultivate a dependent relationship by subordinating
- Affect: anxiety heightened – disruption to the relationship. Depression if their strong figure is removed, euphoria/gratification when dependent wishes granted
Cluster C – obsessive-compulsive disorder (OCD)
- 70% of western society show these features
- Pervasive patterns of perfectionism and orderliness
- Ridgely, inflexibility and stubbornness
- Excessive need for control interfering with ability to maintain interpersonal relationships or employment
- Preoccupied with rules, minor details, structure
- Attention to detail interferes with ability to complete tasks all together or on time
- Unrealistic standards of mortality, ethics or values
- Reluctance to delegate tasks
- Comorbid: borderline, narcissistic, histrionic, paranoid, schizotypal PD’s
- Self-view: responsible for themselves and others, driven by ‘should’
- View of others: too casual, irresponsible, self-indulgent and incompetent
- Threats: any flaws, errors, disorganisation. Catastrophic thinking: ‘things will be out of control’
- Strategy: system of rules, standards and ‘should’. Overly directing, punishing and disapproving
- Affect: regrets, disappointment, and anger toward self and others because of perfectionistic standards
