EXAM Flashcards
obsession and compulsions
obsessions: intrusive thoughts that provoke distress or anxiety
compulsions: repetitive behaviours/mental acts to reduce anxiety/supress obsession. types: rituals (repetitive actions like checking, hand washing, reassurance seeking), neutralizations (brief actions to “undo” obsessive thought like thinking about being healthy, adding “not” to obsession)
OCD dsm criteria
A. presence of obsessions and/or compulsions
B. OC take 1+ hour per day or DnD
C, D. no better explantions
insight in OCD
can be added as a specifier (good/fair/poor)
good: knowing the compulsions are absurd but can’t stop
fair: knows it absurd but helps them feel sure
poor: feels like they truly did something wrong they cant remember, closer to psychosis, may not know the OC are connected
OCD brain
PFC dysfunction may lead to being overly focused on irrelevant details, problems with organizing relevant info, poor self-monitoring (forming concrete memory of doing something - made worse by repetition aka harder to remember if you did something if you keep checking), inability to change behaviour
Connected to serotonin
repeated checking leads to…
lowered memory confidence, increased doubt, more checking
OCT CBT Etiology
Catastrophic misinterpretations of harmless random thoughts leading to an attempt to suppress the thoughts (compulsions), validating the danger of the thoughts, thus making them worse
The loop is the disorder not the thoughts
Maintained by compulsions and the negative reinforcement of compulsions (they reduce anxiety so ill keep doing them)
OCD loop
trigger, intrusive thought, faulty appraisal (assigns scary meaning to thought and assumes responsibility to stopping it), anxiety, compulsion, relief, repeat
BDD dsm5
A. preoccupation with one or more “flaws” in appearance that appear slight to others
B. repetitive behaviours in response to appearance (mirror checking, reassurance seeking, comparing appearance)
C. DnD
D. Trait is not body weight
Specifier: muscle dysmorphia
Hoarding disorder DSM5
A. persistent difficulty parting with possessions regardless of value
B. Difficulty is bc they feel they need to save them and it is distressing to throw them out
C. accumulation of things in ACTIVE living areas that compromise intended use, if its cleared its by someone else
D. DnD
E,F. No better explanation
Subtype: animal hoarding
Hoarding risk factors
middle age, OCD, experienced major loss, poverty, indecisiveness, avoidance, difficulty planning and organizing, distractibility
OCD/BDD first line treatment
Exposure and response prevention and SSRIs are first-line.
Exposure causes anxiety by purposefully triggering obsessive thoughts, response prevention is not engaging w/a ritual (“surf the wave” of anxiety and watch as the wave lessens over time). Over time, extinguishes neg. reinforcement and reduces anxiety associated with the obsession (not necessarily the frequency of thoughts). Use the SUDS and exposure hierarchy.
Mindfulness approaches can be helpful for relapse prevention
hoarding treatments
CBT with motivational interviewing is first line (explore ambivalence to change and try to find reasons to want to change)
CBT explores dysfunctional beliefs about discarding stuff (usefulness, wasting, sentimental attachment, the need to remember). Use questions to evaluate the accuracy of these beliefs and offer alt options
Practice letting go of stuff, starting easy and increasing in difficulty up to sentimental items (exposure therapy basically, tolerate neg emotions and challenge beliefs)
CBT for OCD
challenge faulty appraisals (ignore content on obsessions) via thought records (what is a more realistic assessment of the situation)
Explores false sense of responsibility
via responsibility pie (lots of things could be the cause of something other than you)
Examine likelihoods of risk via continuum (holding baby without washing hands is not 0% danger but its much better than leaving the baby alone in a room)
BDD CBT
challenge body image equals real physical appearance
evaluate distorted thoughts about body and imagined consequences
Exposure therapy things therapists should do
Do exposure with them
ask intermittently their level of anxiety 1-10 (SUDs tracking)
point out the wave going up and down
dont try to relieve anxiety, point out the germs.
afterwards, make them feel proud and show them that the compulsion is not the only thing that can relieve anxiety - robs obsession of power and gives it to pt
Can do compulsion after but make sure anxiety came down already bc of time not compulsion.
SUDS
subjective units of distress scale
exposure for pedo/serial killer OCD
change baby, babysit kids, journal describing pedophila, reading pedo artiles
sign a contract with the devil “pls satan make me a killer”
PTSD DSM5
A. Occurs after trauma (actual or threatened death/injury/integrity of self to yourself or others, includes learning about/watching trauma done to someone else and repeated exposure that is word related)*
*unexpected
B. 1+ experiencing symptom
C. 1+ persistent avoidance symptom
D. 2+ cognitive/mood symptoms
E. 2+ hypervigiliance symptoms
F. ONE MONTH
G. DnD
F. not medication or other disorder
PTSD risk factors
women more likely to develop PTSD (more often related to rape, neglect, abuse while men are more often related to injury, natural disaster, combat)
Pre event: Low SES, low education, low IQ, previous psych history, childhood adversity
Post event: severity, lack of social support, additional stressors after event
Interpersonal trauma more likely to provoke PTSD
PTSD brain
smaller hippocampus
dysregulated endocrine system (HPA axis, cortisol)
PTSD reexperiencing symptoms
intrusive thoughts/memories
dreams
dissociative reaction (flashbacks)
intense distress when reminded
intense physiological reaction when reminded
PTSD avoidance symptoms
avoiding memories, thought, feelings associated with event
avoid external reminders of the event
PTSD cog and mood symptoms (7)
anhedonia/emotional numbing
negative beliefs/expectations about the world/oneself
persistent, distorted thoughts of blame
detachment/estrangment from others
inability to feel positive emotions
persistent negative emotional state (fear, anger, guilt)
inability to remember what happened
PTSD hypervigilance symptoms (6)
reckless/self-destructive behaviour
irritability/outbursts of anger
hypervigilance
exaggerated startle
problems with concentration
sleep problems
PTSD treatments
exposure therapy, CBT, and medication is first line
Start with imaginal (review circumstances of event, move up to details), them in-vivo if possible (walk alone at the site of trauma)
Examine maladaptive thoughts about guilt or a lack of safety everywhere
DBS or more invasive measures if treatment resistent
Acute stress disorder
Similar to PTSD but 3 days to a month
Adjustment disorder DSM5
A. Occurring before 3 months from the start of the disorder
B. DnD that’s out of proportion to the stressor, taking into account cultural factors
C. Doesnt meet criteria for another disorder
D. its not normal bereavement
E. Once stress is over, symptoms don’t persist for more than an additional 6 months
*catch all, controversial
Acute stress vs adjustment disorder
AS: occurs after sudden trauma, develops quickly, more intense
AD: after significant life change (like job change, moving, etc.), develops over a span of 3 months, less intense
history of dissociative disorders
hysteria, demonic possession, freud’s “coversion” (conversion of anxiety into physical symptoms to avoid conflict/responsibility, subconscious manifesting physically)
dissociation definition
lack of integration of features like identity, memory, consciousness, sensorimotor functioning, behaviour
“fracturing of a whole”
Dissociative Amnesia DSM5
A. Inability to recall autobiographical info, usually traumatic or stressful in nature, more than normal forgetting (can either be specific events or general identity/life history)
B. DnD
C, D. Not better explained by meds or other disorder
Dissociative fugue
Sudden memory loss and travel away from home
Acute (couple days) or chronic (months to years)
Often after traumatic event but not necessarily
Depersonalization/Derealization Disorder
A. persistent or recurrent experiences of depersonalization, derealization or both
B. During episodes, reality testing remains intact (still know who and where you are)
C. DnD
D, E. not better explained by med or other condition
Depersonalization
detachment from thoughts, feelings, action, body
Passenger in your mind/body
e.g. perceptual alterations, distorted sense or time, absent self, emotional numbing
Derealization
Dettachment from world around you, doesnt feel real
Surroundings are experienced as dreamike, foggy, lifeless, or visually distorted
Technique to treat dissociation
Grounding. ask them to notice the colour of your eyes, what is happening in the painting, throw a pillow
DID onset age and comorbid disorders
29-35
depression, anx, substance abuse, self injury, non epileptic seizure
DID DSM5
A. 2+ distinct personality states
B. Recurrent gaps in recall of everyday events (traumatic or basic personal info)
C. DnD
D. Not part of a religious or cultural practice. Not better explained by imaginary playmates in children
Distinct personality traits definition
marked discontinuity in sense of self
alterations in affect, behaviour, consciousness, memory, perception, cognition, other sensory motor functioning
observed by others or themselves
in some cultures, characterized as possession
recovered memory therapy
roots in psychoanalysis
tries to retrieve repressed memories, more often induces false memories
Dissociative disorders trauma model
Diathesis-stress
Personality traits: high hypnotisability, fantasy proneness, openness to alterned states of consciousness
Dissociation as a defence mechanism for trauma
Dissociative disorders attachment theory
Individuals with disorganized attachement as babies are more vulnerable to develop a disorder later on
Dissociative disorders socio-cognitive model
disorders are “iatrogenic” i.e manufactured or amplified by therapy
Culture/media disproportionately affects prevalence (specifically with DID)
Somatic symptoms disorder DSM5
A. One or more somatic symptoms that are causing DnD
B. Excessive preoccupation with the somatic symptoms. Manifested by at least ONE of: disproportionate thoughts about the seriousness of symptoms, persistent high anxiety about health/symptoms, excessive time and energy devoted to the symptoms.
C. Persistently symptomatic (typically 6+ months)
Specifiers: with predominant pain (symptom(s) is mostly pain related), persistent (severe, 6+ months)
Agnostic to whether the pt is exaggerating symptoms or not
Illness Anxiety Disorder DSM
aka classic hypochronasis
A. preoccupation with having/acquiring a serious illness
B. Mild/nonexistent symptoms or preoccupation is disproportionate
C. High level of anxiety about health
D. Performs health-related behaviours or avoids hospitals/doctors altogether
E. 6 MONTHS
Conversion disorder DSM5
A. 1+ symptoms of altered voluntary motor or sensory function (loss of functioning of a body part)
B. Tests show its not bc of medical condition
C. Not better explained by another condition (can be drugs tho lol)
D. DnD
Why is conversion disorder considered dissociative
High comorbidity with other dissociative disorders
High scores on measures of dissociative experiences, hypnotizability, childhood abuse, trauma
Factitious Disorder DSM
Aka Munchausen Syndrome
A. Faking symptoms (physiogical or psychiatric), injury, diseases.
B. Presents to other as ill, impaired, injured
C. Evident in the absence of obvious external reward (money, not sympathy and attention)
D. not better explained by delusion or psychotic disorder
Somatic disorders etiology
Psychoanalytic (conversion of anxiety)
HPA axis
Dysfunctional beliefs about illness
Personality traits
Early life experiences
Social Learning (adopt the sick role)
early understandings of eating disorders
anorexia was introduced in DSM1 but very rare bc intentionally losing weight was much stranger at the time, no societal expectations of thinness and malnutrition was a bigger fear
Diagnostically included slow pulse, skin changes, no period
Bulimia introduced in DSM3
Treatment: force feeding
Viewed as hysteria converted into food problems like disgust, feeling full, psychosomatic stomach pain after eating
ARFID
Most common in children
Disturbances in eating (lack of interest, avoidance based on sensory characteristics, concern about aversive consequences) manifested by significant weight loss/failure to meet weight, nutritional deficiencies, dependence on supplemental eating, interference with psychosocial functioning
Not better explained by lack of food or culture
No weight concerns
Pica
Eating non food bc of cravings, to reduce nausea, they like the taste
May be due to a nutrient deficiency
Rumination disorder
Regurgitating and rechewing food
often in children
Amenorrhea
Lack of periods
Was a criteria of AN until DSM5
Anorexia nervosa DSM5
A. Restricted eating leading to significantly low weight
B. Intense fear of gaining weight OR behaviour that interferes with gaining weight DESPITE LOW WEIGHT (necessarily irrational/delusional)
C. Disturbance in the way their weight/shape is experienced (dysmorphia or general distress/dissatisfaction with body), undue influence of weight/shape on self-evaluation, or lack of recognition of the seriousness of low body weight
Restricting type: in the last 3 months, no binging-purging behaviour, only fasting
Binging-purging type: in the last 3 months, binging and purging behaviour has been present
Mild, moderate, severe, extreme based on BMI
Common characteristics of AN
Rituals associated with eating (only 1 pea very 5 mins)
Compensatory measures after eating like excessive exercise and purging
Often conflicts between parents and children, leading to secretive behaviour
Low self esteem
Hypervigilance in assessing body
Perceive their body to be bigger than it is
Binge eating disorder
A. Objective binge eating
B. 3+ of: eating too fast, until uncomfortably full, eating large amounts when not hungry, eating alone bc of embarrassment of how much their eating, feelings of disgust, depression, or guilt with themselves after a binge (5)
C. Distress
D. At least 1x a week for 3 months
E. Not compensatory or exclusively during BN or AN
Objective binges/binge eating definition for BED and BN
- Eating more than most ppl would eat within usually 2 hours
- Feeling out of control as if they cannot stop eating or control themselves
No firm threshold
Bulimia DSM 5
A. recurrent binge eating
B. Compensatory behaviours to prevent weight gain after binges like vomiting, laxatives, other meds, fasting, excessive exercise (“purging”)
C. Both binging and purging occur on average once a week for 3 months
D. Self evaluation is unduly influenced by weight/shape
E. Does not exclusively occur with AN (AN with binge purge subtype trumps BN)
AN vs BN
AN: Low body weight, more restrictive behaviours, purging is more associated with intentional weight loss not compensatory
BN: weight is usually maintained, binging and purging are more linked, closer in time, binges often larger (potentially more objective binges than AN)
Disorders that were previously called EDNOS
Atypical AN: all criteria met but weight in normal range
BN or BED with low frequency or limited duration
Purging disorder: purging related to weight but no binge and doesn’t meet AN criteria
Night eating syndrome
Also, other unspecified
Kleine levin symptom
hypercomnia with complusive eating
may lead to a misdiagnosis of an eating disorder
Why do ppl argue all EDs should be treated as one continuum of disorders?
Around 50% of ppl with AN will also develop BN at some point
Ppl often switch bw categories which decreases utility of diagnosis (AN usually in teens, BN in early adulthood, BED in adulthood)
Dimensions/alt models to consider for eating disorders
Age, Weight (AN<BN<BED), anxiety for AN, depression for BN/BED, different physiological symptoms for each
Incidence/prevalence of EDs
Vast majority women, huge spike at 15-19
Gay men more concerned with bein overweight than straight men
ED prognosis
Highest mortality rate, 50% ish treatment response, high relapse rate, often have another ED after, sometimes treatment can be too late
Refeeding syndrome
Lethal syndrome when nutrition is corrected too quickly
Physical consequences of EDs
osteoporosis, heart problems, fertility ssues, lethargy, hair loss, heightened sensitivity to cold, lanugo (peach fuzz to maintain warmth), amenorrhea, dental problems, Russels sign (scabs on knuckles bc of purging)
Brain EDs
Reduced serotonin density
Gender differences may be due to difference in the serotonin system - women more susceptible to dysregulated serotonin, dieting may alter serotonin in women more than men
Sociocultural factors for EDs
Internalized media ideals of thinness is believed to be a causal risk factor
Average weight is increasing in north America, discrepancy leads to increased guilt, shame, dieting, body dissatisfaction
“fitness” online
Weight concerns are culturally bound but food refusal/AN isn’t
BN IS culturally bound
Family factors for EDs
mothers who diet/have weight concerns make daughters who diet/have weight concerns
Parents who are critical and emphasize weight/appearance cause daughters with worse ED outcomes
- daughters perceive a lack of care from mothers
Personality/individual differences in EDs
Associated with AN/BN: perfectionism, obsessiveness, compliance, alexithymia (lack of emotional awareness), negative view of self
Associated with BN: impulsivity
Other EDs: low self esteem, depressive affect, poor body image, dieting, excessive exercise
More BPD/OCPD symptoms in EDs
Maturation factors of EDs
In puberty, womens bodies alter in ways incongruent with societal expectations (gain weight) while men’s alter congruently (gain muscle)
More weight leads to more body dissatisfaction
Puberty increases womens awareness of sex roles, sexuality, media, etc. causes more stress
Adverse events affect on EDs
Traumatic events especially past sexual trauma are high in eating disorders
these events have negative effects on self esteem body image sense of control
Maybe more associated with BN than AN
Treatment for EDS
SSRI may exacerbate symptoms for AN. SSRIs can be good for BN but still worse than CBT alone
20 week CBT program
Phase 1: establish regular eating thru psychoeducation, self monitoring and food diaries
Phase 2: normalize eating without dieting thru behavioural plans, problem solving skills to reduce stressors, and cognitive work to identify dysfunction thoughts about body
Phase 3: strategies to maintain change and prevent relapse thru mindfulness
Other therapies for EDs
Interpersonal therapy: focus on improving relationships with others, not related to food but surprisingly effective
Nutritional therapy and meal support: work with nutritionists and dieticians to restore weight, normalize eating behaviours, and decreasing rituals
Family therapy: places responsibility for recovery on whole family, ignores cause of the disorder, when improving, helps family return control of eating back to pt
prevention interventions for EDs
Internet-based campaigns about body image and school programs (Healthy Schools Kids Ontario)
BMDA
Brain disease model of addiction
chronic relapsing brain disease
Other models of addiction
Psychological - personal deficiencies
Learning - learned behaviour
Sociological - environmental deficiencies
Biopsychosocial - combination of other models
Alc/substance use disorder
A. Problematic usage causing DnD manifested by 2+ symptoms over a YEAR
11 symptoms from 4 categories: impairment of control, social impairment, risky use indicators, pharmacological dependance
tolerance vs withdrawal
need increased amounts to achieve the same effect vs symptoms when recovering from substance
Impairment of control symptoms of SU
- substance taken in large amounts over longer period than intended
- desire or unsuccessful attempt to reduce use
- great deal of time dedicated to substance (obtaining, using, recovering)
- Cravings
Social impairement symptoms of SU
- continued use despite failure to fulfill obligations at home, school, work
- Social and interpersonal problems
- important activities given up or reduced (social, work, recreational)
risky use indicators
- using when physically dangerous to do so (drinking and driving/operating heavy machinery)
- continued use despite knowledge of it having a persistent effect on physical or psychological problems (keep drinking even when in liver failure, usually refers to internal issues but can include blackouts)
pharmacological dependance symptoms of SU
- tolerance
- withdrawl
SUD severity
mild 2-3 symptoms
moderate 4-5
severe: 6+
Other SUDs
(substance) intoxication - for the hours you are intoxicated
(substance) withdrawal
(substance)-induced __ disorder
Polysubstance abuse - no longer used - when 2+ substances are misused simultaneously
frequency of drinkers
less than/more than weekly - light vs heavy frequency drinkers
fewer than/more than 5 per occasion - heavy/light drinkers
5+ drinks in one sitting = binge drinking
gov of canada drinking guidelines
used to be no more than 2 drinks for women and 3 for men per sitting and less than 10 a week for women and 15 a week for men
its now 0 drinks - 1-2 is low risk, 3 to 6 is moderate risk, 7+ is high risk
(wernicke)-korsakoffs syndrome
“wet brain”
severe brain damage due to drinking that impairs memory and contact with reality
cell loss in hypothalamus, thalamus, and hippocampus
biological etiology of alcohol use disorder
enzyme levels, physiological sensitivity to the rewarding properties of alcohol, neurotransmitters (gaba, serotnonin, beta-endorphins), genes (related to gaba serotonin dopamin and opioid systems), male
psychological factors in alcohol use disorder
“addictive personality” as seen by traits like rebellion, aggression, impulsivity, neuroticism, more risk taking behaviour
Tension reduction hypothesis - avoiding withdrawal by continuing to drink (negative reinforcement)
Alcohol expectancy theory - cognitive beliefs around alcohol like “ill be more social”
sociocultural factors of alcohol use disorder
rite of passage
kids mimic alcohol patterns of parents
benzos
downers
started as barbituraic acid, highly addictive dependency rapid, now benzos, moderately addictive dependency slower
valium, xanax, ativan
dangerous when combined with other drugs bc effects are synergistic
effects are similar to alcohol
Chronic use of benzos could cause
depression, fatigue, mood swings, paranoia,
impairments to memory/judgment
abstince syndrome
withdrawal from benzos
insomnia, headaches, aching, anxiety, depression, and can last
for months
* Abrupt discontinuation is not advised, can cause
serious reactions like delirium, convulsions, death
nicotine and cigs interferes with
nic: thinking and problem solving, agitation and irritability, mood changes
cigs: increases alertness, improves mood, positively reinforcing
cigs are ___ reinforcing
both positively (feels good) and negatively (cravings and withdrawal are deeply uncomfortable)
nictotine in the brain
nicotine attaches to nicotinic receptors, releasing dopamine, dopamine drops, causing cravings
some ppl may be more sensitive to nicotine bc of alterations in their dopamine neurons
types of amphetamines
mimics adrenaline
used for asthma, adhd, narcolepsy, obseity
methamphatine (MDMA, ritalin) or dextroamphatmine (dexadrine)
effects of amphetamines
low: increases alertness and cog performances
higher: exhilaration, confidence
very high: anxiety, agitation
irregular heartbeat, temp flashes, nausea, seizures, weight loss, aggressive behaviour
may cause permanent cognitive defecits and depletion of serotonin
toxic psychosis
chronic use of drugs that lead to delirium parania and hallucinations
amphetamine tolerance and dependence
Quick, because of crashing, users have fatigue,
irritability, sadness, and cravings
Amphetamine Withdrawal:
Withdrawal: apathy and prolonged sleeping
cocaine effects
Low doses: euphoria, confidence, alert, talkative, reduced
appetite, increased excitement and energy
High doses: poor muscle control, confusion, anxiety,
anger, mood swings, aggression, anhedonia, weight loss,
insomnia, toxic psychosis (hallucinations, delusions)
- Death can occur in high doses
cocaine dependance
huge crash with intense cravings, depression,
paranoid, fatigue
* can take more than a month to shake this withdrawal
cocaine brain
triggers dopamine release into synapse
caffeine brain
affects on dopamine serotonin and noreprephrine
opiods
opium (morphine, codeine)
semi synthetic opiods (heroin, oxycodon)
synethetic (fentanyl)
inhibit pain by mimicing natural opiods
opioid brain
mimics endorphins
opiods effects
low doses: euphoria, relaxation, appetite suppressant, restlessness,
nausea, and vomiting
* Higher doses: dangerous effects, pupils constrict, skin turns blue and cold,
breathing slows, coma, respiratory depression
Chronic use:
* Respiratory and pulmonary problems, endocarditis (infection of heart lining tissue),
abscesses, liver disease, brain damage, HIV infection due to needles
behavioral body tolerance
Very easy to overdose because addicts sometimes die from a dosage that they previously tolerated in a different environment
dependancy opioids
withdrawal symptoms are extremely severe and begin about 8 hours after
the last dose
* 36 hours in: muscle twitching, cramps, hot flashes, changes in HR and BP,
sleeplessness, vomiting, diarrhea
* Can last for 10 days
amotivational syndrome
chronic cannabis use leading to apathy, detachment and abandonment of school/work
may be related to depression
psychadelics brain
excitatory on the CNS, mimics manic episode and
increases serotonin in the brain
* Dilated pupils, increased HR/BP, increased alertness
at risk pop for gambling
male, indigenous
gambling treatment
interventions focusing on motivation for change
internet based CBT
gambling disorder DSM5
A. persistent gambling behaviour leading to DnD in ONE YEAR as evidence by 4+ symptoms
B. not better explained by mania
gambling symptoms
- needs to gamble more and more money to achieve same excitement (tolerance)
- restless or irritable when trying to cut down
- unsuccessful efforts to cut down
- often preoccupied with gambling
- gambles when feeling distresed
- keeps returning to gambling to “make up loses”
- lies to conceal gambling
- jeopardized significant relationship, education, job bc of gamblig
- relies on others money
at risk pop for internet gaming disorder
men between 14-18
internet gaming disorder
5+ symptoms:
1. preoccupation
2. withdrawl
3. tolerance
4. unsuccessful attempt to control participation
5. loss of interest in other activities
6. continued use despite knowledge of psychosocial problems
7. deception
8. uses to escape
9. lost significant relationship, job, education opportunity
routine treatments for substance use disorders
month long inpatient program focused on biological dependance (often uses 12-step)
following this, focus on psychological dependance thru education, individual counselling, and GROUP therapy
pharmacotherapy for alcohol use disorder
benzos, gaba and opioid antagonists used to moderate withdrawl and cravings
antabuse and CCC to make alcohol unpleasant (negative punishment)
12 step programs
AA/NA: addiction is a disease, person o powerless turn to religion/higher power, complete abstinance
SMART: secular, empirical, focuses on skill building, can be abstinance or harm reduction
BT for SUDs
inc awareness of cues related to drinking, rules and rewards for small steps forward, aversive conditioning, contingency contracts
CBT for SUDs
restructing thoughts about drinking, being aware of patterns, SMART goals
relapse prevention for SUDs
relapse due to inadequate coping skills, focus on self defeating thoughts and learning from relapse
restructure guilt and failure
therapies for SUDs
bt, cbt, relpase prevention, family/martial therapy (work on potential codependance that may be fueling addiction), brief interventions
brief interventions for SUDs
1-3 sessions focusing on motivating change
explore concerns about changing
motivational interviewing
focus on how to make motivation higher
stages of motivation
precontemplation: denial, not seriously considering changing
contemplation: ambivalence about change, they recognize reasons to change but have hesitations
preparation: decided to make a change and start with minor changes
action: avoiding triggers, reaching out for help
maintenance: changes are maintained
relapse: often takes several bases thru stages to permanently end behavior
nicotine treatment
nic replacements, wellburtin, varnicline reduces pleasurable effects of nicotine
cocaine treatment
12 steps, group and ind therapy, relapse prevention, etc.
dopamine enhacing drugs to combate withdrawl
opioid treatment
opioid antagonists
methadone: heroin replacement, opioid antagonist that reduces cravings
in combo with peer support etc.
contingency management
reward not taking substance or punish for taking substance
if i have a craving at 50 then go for a walk, if craving at 90 go for a meeting
SMART Goals
realistic, implementable and concrete goals
may not be total abstinence
personality vs states
consistent persistent traits of an individual vs temporary conditional patterns
personality disorder DSM5 (6)
A. Pattern of behaviour in at least two of the following areas: cognition, emotion, interpersonal functioning, impulse control
B. Behaviour across a broad range of situations
C. DnD
D. Long stable duration of symptoms starting in adolescence or earlier
E, F. not better explained
egosyntonic
not viewing problematic behaviour as impairing but instead consistent with their goals
more consistent with PDs
egodystonic
behaviour causes distress and is inconsistent with who they want to be
more common with classic mental health conditions
cluster A
odd and eccentric disorder
paranoid, schizoid, schizotypal
cluster B
dramatic emotional erratic
ASPD, BPD, NPD, histrionic
cluster c
anxious and fearful
avoidant, dependant, OCPD
why is consideration of PDs important
alliance between therapist and client
often misdiagnosed as axis 1
poor prognoses
make outcomes for axis 1 conditions worse
paranoid personality disorder
misinterpreting
fears exploitation
humorless
hypervigilant
hostile
Schizoid PD
detachment for relationships and restricted range of expressions
negative symptoms of scz
loner, lack of responsiveness, puzzles by passions of others
schizotypal PD
social/interpersonal deficits (reduced capacity for close relationships) and eccentric behaviour (odd/magical beliefs and speech)
suspicious, excessive social anxiety, superstitious
some neg and pos symptoms of scz but never to the point of delusion or hallucinations just odd
histrionic PD
excessive emotionality and attention seeking
rapid shifting and shallow emotions, uncomfortable when not center of attention, speech that is excessive but lacking in detail, suggestible, overestimates intimacy of relationships, cant develop deep relationships, dresses provacatively
NPD
pattern of grandiosity, need for admiration and lack of empathy
believes they are “special” and can only be understood by other high class ppl, exploitative, envious, arrogant
avoidant PD
pattern of inadequency, hypersensitivity to negative evalution
avoids activities bc of fear of criticism of rejection, restraint in relationships, views themselves as inferior
very close to social anx
dependant PD
pervasive need to be taken care of
submissive clingly behaviour, fear of separation, difficulty making everyday decisions alone, cant express disagreement, feels helpless, unrealistically fearful of being left alone to care for themselves
OCPD
preoccupation with orderliness, perfectionism, control at the expensive of openness, flexibility, and efficiency
preoccupied with rules to the point of being unable to complete tasks, maintain friendships of leisure time, inflexible morally, wont throw stuff away, wont spend money, rigid, stubborn
problems with pd treatment
egodystonic and dont seek treatment, dropout rates high, poor prognosis, poor therapeutic alliance
suggestions for improving pd treatment
conceptualize as both biological and psychological
assess levels of motivation for improvement
flexible treatment
goal to improve adaptability q
treatments for pds
no first line drugs
object relations therapy
CBT
DBT
object relations therapy
examines relationships and tries to differentiate pt from others (individuation)
confront interpersonal defenses and distortions
CBT for pds
restructuring and testing of core beliefs and the rigidity of those beliefs
ASPD DSM5
A. pervasive pattern of violating the rights of others starting at age 15, 3+ of the following:
1. unlawful behaviour
2. deceitfulness
3. impulsivity
4. irritability/aggressive, indicated by physical fights/assaults
5. reckless disregard for safety
6. irresponsible in work/with money
7. lack of remorse
B. at least 18 years old, no psychotic disorders
etiology of ASPD
parenting influences callousness, genetic markers of aggression and impulsivity, grew up in criminogenic environments, neglect, abuse, fearlessness hypothesis
fearlessness hypothesis
ppl with aspd may have a higher threshold for fear or anxiety due to a altered attentional mechanism that reduces fear
why abuse may cause aspd
if punishment was not contingent with behaviour it may lead to an indifference to physical punishment or oppositional behaviour to control abuse
burnout factor
symptoms of ASPD and bpd tend to decline around 40
ASPD treatment
psychoeducation, beliefs about aggression, skills to manage impulsivity, substance use, problem solving
may respond to antipsychotics and sedatives
responsivity factor
treatment to aspd relys on this, in which treatment works better when matched to pts interpersonal style
dark triad of personality traits
Machiavellianism - callous, manipulative, amoral to achieve power - may rationalize hurting others for personal gain
psychopathy: same as above, lack remorse and emotional depth - don’t care about hurting people at all
- tend to be con artists, target ppl who are easy to manipulate, good at picking these ppl from a crowd, violent crimes
narcissism
- selectively impulsive compared to typical ASPD
etiology of psychopathy
insensitive to emotional content of information, use different means to processing emotional material to compensate (lower amygdala or PFC)
abnormalities in PFC, hippocampus, basal ganglia, amygdala
lower serotonin and increased dopamine
BPD DSM5
A. pattern of instability in relationships, self image, affect, and impulsivity beginning in early adulthood. 5+:
1. avoid abandonment
2. unstable/intense relationships shown by splitting
3. unstable sense of self
4. impulsivity in 2+ areas
5. suicidality
6. unstable mood
7. emptiness
8. intense inappropriate anger
9. dissociative or paranoid symptoms
characteristic of BPD
inability to change emotional expressions
dysregulated behaviours in BPD seen as a consequence of
inability to cope effectively
caregivers model….
emotional regulation, characterized as being flexible
biological/psychosocial factors for bpd
greater sensitivity to emotions, experience emotions more intensely, longer latency to return to baseline
invalidating environment (parents), diminished opportunities for learning emotional regulation
splitting
alternating between ideation and devaluation
black and white thinking, holistic
may be a defense mechanism from abuse, allows ppl to split the abusive person into 2
4 DBT approaches
rogerian: validate suffering nonjudgmentally, their behaviour makes sense given their suffering
learning theory: behaviour is establish thru classic learning mechanisms
zen buddism: suffering results from attachment to thing being a certain way, must accept reality as it is, suffering is because of the gap between what you want and how it is
CBT: change is required to feel better, skills based learning
DBT format
ind 1 hour, group 2 hours per week for 6 months to a year
hierarchy of DBT goals
- reduce suicidality
- reduce therapy interefering behaviour
- reduce behaviours interfering with quality of life
- increase emotional regulation skills
- decrease PTS behaviour
- increase self respect behaviour
dialectic
the process of achieving balance between two opposing processes, acceptance and change
integrate a whole
how can a therapist be validating
paraphrase, find kernal of truth, treat hem as someone who is competent
how to get pts to commit to change dbt
pros and cons of current and modified behaviour, devils advocate why you should change, generate hope, highlight freedom to choose
behavioural chain analysis
- identify behaviour
- identify vunerabilities
- identify prompting events
- identify links between prompting events and the behaviour
- identify consequences
Then, problem solving skill
pd diagnostic issues
low reliability, poorly understood etiology, weak treatment effect
- are they even disorders or just constellations of maladaptive traits
cultural and gender biases (women and Hispanic ppl get diagnosed more with emotional pds, “eccentric” beliefs may be culturally founded)
May not be as chronic as first believed (bdp is usually not significant after 10 years)
Lots of comorbidity and diagnostic overlaps Vague criteria
Attachment theory of pds
children learn how to relate to other thru parents - if early attachment is poor, it may lead to lack of skills and confidence in relationships
CB perspective of pds
children develop schemas that the world is untrustworthy etc. that may have been useful in an abusive childhood environment but no longer are. developed strategies to avoid the schema
parents may model this themselves and reinforce it
biological theory for pd
may be due to transmission of a non-disorder specific genetic risk
therapy seekers demographics
women, uni degrees, young to middle aged adults
