Exam content Flashcards
classification of mental disorders
1) Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) -> North America
2) International Classification of Mental and Behavioral Disorders (ICD-11, issued by WHO) -> international/Europe
diagnostic heterogenity
two cases that qualify for one disorder can have no shared symptoms, sometimes opposing
psychological abnormality
behaviour, speech, or thought that impairs the ability of a person to function in a way that is generally expected of them in the context where the unusual functioning occurs
psychopathology
scientific study of psychological abnormality and the problems faced by people who suffer from psychological disorders
psychological disorder
specific manifestation of psychological abnormality, as described by some set of criteria that have been established by a panel of experts
mental disorder
often used to convey the same meaning as psychopathology, but it implies a medical rather than psychological cause
how to define abnormality?
1) statistical rarity
2) personal distress
3) dysfunction
4) violations of social norms
5) diagnosis by an expert
*consider everything: usually some combination of criteria is needed to identify a person’s behaviour as abnormal
statistical rarity
- assumes that abnormal psychological functioning occurs rarely
- however there are some issues:
1) rarity doesn’t always mean disordered
2) some examples of unusual functioning are considered advantageous (ex. genius IQ)
3) some extremely common conditions are missed
personal distress
- common of many disorders, but not all (ex. manic episodes)
- distress is also a normal part of life
personal (harmful) dysfunction
- abnormal behaviour only disordered if symptoms prevent proper functioning in an area of life
- does not consider effects on other people
violation of norms
- violations of societal expectations of behaviours
- some issues:
1) criminals (not meeting diagnostic criteria for any disorder) violate norms
2) social norms change over time and cultures (ex. homosexuality used to be part of DSM)
diagnosis by expert
- abnormality is defined when diagnosticians apply criteria for disorders as specified in manuals
- experts often disagree!
which experts can legally communicate diagnoses to the patient?
psychiatrists, clinical psychologists
psychiatrist vs psychologist?
- psychiatrist: MD, specializes in medications
- psychologist: graduate school, focus on therapy
other professionals in mental health field
psychiatric nurses, occupational therapists, counsellors, registered psychotherapists, psychiatric social workers
prehistoric concepts of abnormality
- supernatural explanations for disorders, ex. evil spirits, demons
- harsh treatments: trephination (skull drilling), magic, incantation
naturalistic explanations for psychological abnormality
ancient greek, persian and arabian world
ancient greek approaches to psychological abnormality
1) Hippocrates: considered biology; disturbances in bodily fluids (humours) caused disorders needed to be rebalanced ex. by blood letting; wandering uterus = hysteria
2) Plato: sociocultural influences on thought and behaviour (basis of not criminally responsible aka NCR)
3) Galen: first to suggest a form of psychotherapy; sympathetic listeners
Persian and Arabian World approaches to abnormality
- Quran suggested compassionate attitudes
- built asylums
- Avicenna wrote one of the first medical texts that tried to describe mental disorders, emphasizing natural causes rather than supernatural
The Dark ages of approaches to abnormality
- Europe in middle ages
- extreme treatments: exorcisms, burning at stake, torture
- milder: prayer, generally caring
- usually administered by clergy
- supernatural/spiritual view
- eventually Greco-Roman thought rediscovered
beginnings of scientific approach to abnormality
- pressure against supernatural accounts
- consideration that physical and psychological disorders had common (biological) causes
development of asylums/workhouses
- initial: cruel conditions (shackles, harsh treatments/punishments)
- some tried to integrate with society (ex. farmwork)
- reforms due to the Mental Hygiene Movement lead to compassion, clean and comfortable environment
- however state not well-equipped, leading to overcrowding and regression to cruelty
Mental Hygiene Movement
- Pinel and Rush
- desire to protect and to provide humane treatment for individuals with mental illness
understanding abnormality through biology
1) heredity
2) beginning of classification
3) infection
early heredity theories
- degeneration theory (Morel): deviations from normal functioning are transmitted by hereditary processes
- phrenology (Lombroso): shape of the skull related to inheritance of criminality (pseudoscience, but bore idea of mental mapping)
beginning of classification (syndroms)
- Kraepelin’s Clinical Psychiatry: attempted to classify mental illness, grouped symptoms into syndromes
- also proposed that biological causes underpin mental disorders (somatogenesis)
infection as a cause of mental disorder
- Krafft-Ebing suggested that general paresis of the insane (GPI) might be result of infection
- now known to be syphilis
insulin shock therapy
- inject enough insulin for coma/seizure
- Sakel used to treat morphine addition withdrawal
electroconvulsive therapy (ECT)
- introduced by Cerletti
- used to treat schizophrenia
- determined to only be beneficial for depressed patients
- continues to be a modern treatment for depression (in safer ways, when asleep)
modern shock therapies
- DBS: deep brain stimulation for depression
- VNS: vagus nerve stimulation, activates PNS
- rTMS: repetitive transcranial magnetic stimulation
- MST: magnetic seizure therapy
lobotomies and LSD in Canada’s history
- lobotomies performed despite little evidence for clear benefits
- Cameron’s brainwashing and LSD studies had no informed consent or ethical review
beginnings of psychopharmacology
- rejection of psychological perspectives, hard turn to pure biological explanations
- chlorpromazine (know this!!) was a radical antipsychotic drug
- lead to rapid deinstitutionalization of patients from hospitals
- communities did not have resources to support -> beginning of intersection between homelessness and mental illness
theories of abnormal behaviour
psychodynamic, behavioral, cognitive, biological, cross-cultural, evolutionary, humanistic -> all work together in conjunction, some try to explain all of behaviour, some focus on particular classes or disorders
usefulness of a theory
- needs to generate research and increase knowledge, does not necessarily need to be true
- null hypothesis testing: theories are better when they can be disproved
single-factor theories
attempt to trace origins of particular disorder back to one factor
interactionist theories
behaviour is product of the interaction of a variety of factors
aims of theories about mental disorders
1) explain etiology
2) identify maintenance factors (not necessarily same as etiology, ex. in phobias)
3) predict the course of the disorder
4) design effective treatments
hypnotism and birth of psychoanalysis
- Mesmer: hypnosis to realign disturbed magnetic fluid in body
- Charcot: hypnotism
- Breuer: cathartic method (talking freely under hypnosis)
- Freud: psychoanalysis (root of therapy!)
psychodynamic perspective
- psychosexual stages of development: fixation at a specific stage affects behaviour and personality
- ‘insight’ in therapy is the cure
- levels of consciousness: conscious, preconscious, unconscious (controls everything, inaccessible)
- levels of personality: ego, superego, id
- defense mechanisms: denial, displacement, sublimation, regression, repression (most fundamental according to Freud), projection, intellectualization
evaluation of psychodynamic perspective
limits
1) difficult to test empirically
2) biased measures, biased population (family members)
3) biased information collection: free association, childhood recollections, adult dreams
4) biased views implying superiority of men
contributions:
1) focus on early mother-infant relationship led to attachment theories
2) unconscious thoughts may be important in prejudice and stereotypes
behavioural theories
- emphasize how new behaviours are acquired through gradual/continuous process of learning
- people play passive role, learning directed by environment
traditional learning theory perspective
- classical conditioning
- still relevant in trauma, phobias, OCD, adjustment disorders
types of reinforcement or punishment in operant conditioning
- positive reinforcement: adding something pleasant
- negative reinforcement: removal of unpleasant stimulus
- positive punishment: adding something unpleasant
- negative punishment: removing something pleasant
- intermittent better than continuous
what operant conditioning principle involves avoidance?
negative reinforcement
Mowrer’s two-factor theory
1) classical conditioning establishes aversive response
2) operant conditioning reinforces avoidance
social learning theory
- importance of context and vicarious learning (via observation/inference)
Bobo doll experiment
1) adults interact with doll with either kindness or aggression
2) kids act similarly to the adult they observed
hallmarks of cognitive thoeries
1) thinking affects emotion and behaviour
2) thoughts can be monitored and changed
3) by altering one’s thoughts, a person will experience desired behavioural and emotional change
cognitive-behavioural model
- thoughts, emotions, bodily sensations, behaviour
- everything bidirectionally connected in response to environment
- CBT: find and change negative loops
rational-emotive behaviour therapy (Ellis)
- find maladaptive, rigid beliefs that influence behaviour and emotions
- combat them through argument, criticism
- this was unpleasant, and did not involve independent discovery
Beck’s cognitive theory
- more independent experimentation compared to Ellis (socratic learning - questions)
- proposed the cognitive triad:
1) dysfunctional schemas: negative representations of ourselves and world, affects view of future
2) information processing biases: negative skew towards information gathering (self-fulfilling prophecies) -> notice and adjust to modify schemas
3) automatic thoughts: find and challenge
third wave approaces to CBT
1) theory and treatment based on mindfulness: acknowledge a role for cognition but not necessarily label as bad, emphasize role of attention in distress
humanistic and existential theories
1) Maslow: self-actualization
2) Rogers: person-centered
Maslow’s theories
- hierarchy of needs
- abnormality from failure to attain self-esteem for self-actualization
Rogers’ person-centered approach
- saw personal experience as basis for improving the self- people can be their own therapists by listening to their own needs
biological models
1) genetics and behaviour: adoption studies and twin studies to separate effects of genetics and environment
2) neurotransmitters: too little or too much (production, receptors, deactivation, re-uptake) -> can sometimes be reductionist
3) PNS (specifically ANS): overactive SNS can be phobias, anxiety, while overactive PNS has protective effect
4) endocrine HPA axis: results in release of cortisol, sensitivity implicated in depression and anxiety (chronically active)
socio-cultural influences on behaviour
- stigma
1) public: typical societal response that people have to stigmatized attributes (discrimination, devaluation, negative attitudes)
2) self-stigma: internalized psychological impact of public stigma - social support, ex in PTSD
- gender stereotypes: ED in women
- race and poverty: minorities and poor more often victims of discrimination/prejudice
anti-stigma campaigns in Canada
focus on social contact and support as a means of treatment (or at least first step)
integrative theories
- all are systems theories: whole is more than sum of parts
1) diathesis-stress perspective: predisposition to disorder interacts with experience to result in disorder (commonly used to explain schizophrenia)
2) biopsychosocial model: environment, psychological response and biology all interact (DSM focus)
reasons to classify mental disorders
1) better understand and identify them
2) determine what treatments work for whom and what disorder, what are most effective
3) organize treatments
4) group people with similar features for research
5) heuristic based on symptom presentation
6) make predictions about disorder development
7) provide people with support/validation for their symptoms
the ideal diagonstic system
1) clusters of symptoms (predictable/meaningful)
2) etiology
3) prognosis
4) predict response to treatment
5) no overlap
6) perfect cure
*4-6: not true in real systems
assessment
information gathered systematically in the evaluation of a condition
diagnosis
determination or identification of disease/condition, statement of that finding
diagnostic system
- system of rules for recognizing and grouping various types of abnormal behaviour
- provides criteria for a disorder
characteristics of strong diagnostic systems
- reliability: same outcome every time
- inter-rater reliability: two or more people agree on someone’s diagnosis
- validity (needs reliability): whether a diagnostic category describes what it is supposed to and whether it predicts accurately
- concurrent validity: ability to estimate individual’s present standing on factors related to the disorder, but not part of it (ex. diagnosis correlation negative attentional biases in depression)
- predictive validity: ability to predict future course of development
in/out/day-patient
- in: staying in hospital, usually for monitoring or safety purposes
- out: normal life, go to office for appointment
- day: in-between, day in hospital, but don’t live there
history on classification of mental disorders
1) syndromes
2) WHO’s ICD
3) 1st DSM: very psychoanalytic
4) DSM-II: similar problems to first
5) DSM-II, 7th printing: homosexuality removed
6) DSM-III: some structure introduced
7) DSM-III-R: revised, removed controversial diagnoses
8) DSM-IV: disorders now required clinically significant status (dysfunction or distress)
9) DSM-IV-TR: minor revision
10) DSM-5
11) DSM-5-TR
DSM-III
- multi-axis model: typical disorders, personality, medical, environment, subjective statement of functioning
- atheoretical
- operationally defined each disorder
- polythetic orientation: people could be diagnosed without having met all criteria, just have to pass threshold
- research used for first time
cons of diagnosis in general
- stigmatization
- loss of information (continuous spectrum reduced to labelled categories or binaries)
stigmatization example
- Rosenhan study
1) faked symptoms
2) admitted to mental hospital with schizophrenia, treated with isolation, dehumanized –> so much stigma, nobody noticed they were healthy
3) stop faking, released with schizophrenia in remission
DSM-5
- eliminated axis system to avoid emphasis of one over the other
- sections regrouped based on disorders that co-occur
- personality disorders placed on main spectrum of clinical disorders, suggests that they are amenable to change and treatment
- hoarding disorder seperated
- some dimensional approaches (spectrum disorders)
issues in DSM diagnosis
- categorical vs dimensional approach: might have people with subthreshold symptoms that are significantly impairing –> sometimes cannot get diagnosis to get treatment approved
- comorbidity: more than one disorder in the same individual, some are really commonly grouped –> lines between are arbitrary
- personality disorders: half are rare, also overlap with many primary disorders –> was supposed to have dimensional approach, but half abandoned (in appendix)
- gender bias/sexism (ex. symptom descriptions have gender associations)
- doesn’t consider stress, environment or protective factors
- cultural bias, some diagnoses are culturally-bound
- political criticism: diagnostic criteria important for health coverage
- some panel members had financial ties to drug-industries
solutions to problems with current diagnostic systems?
1) promoting dimentional systems, ex. RDOC criteria: focuses on dimensions with subconstructs that underly many disorders
2) hierarchical taxonomy of psychopathology (HiTOP): subgroups of disorders based on relationship between symptoms
RDOC criteria groups
negative valence, positive valence, cognitive, social, arousal/regulation
research methods
experimental, quasi-experimental, correlational, case studies, single-subject, epidemiological, inheritance/genetic
experimental design
- most empirical
- ideally only one variable changed to test effect of changing IV on DV
- random assignment
- control group
- null hypothesis: assumes no relationship between two variables
- ethical implications: sham treatment/waitlist –> intentionally withholding treatment
placebo effect
- people receiving sham treatment still get better
- control: inert medication, control for time
normative comparison
- compare to health controls that go through the same treatment procedure
controlling clinical-patient interactions
- eliminate natural biases
- single-blind: participant doesn’t know what condition they are in
- double-blind: neither participant nor experimenter know conditions
internal validity
extent to which changes in DV were result of IV manipulation
external validity
generalizability of findings
confounds
additional variables that exert their influence at same time as IV, making it impossible to know which is causing the effect (low internal validity)
quasi-experimental
- experimental group not randomly assigned, instead selected on the basis of certain characteristics
- no manipulation of IV
- everything else controlled
- limits: can only make correlation conclusions, can be difficult to match participants on all factors except one that is the IV
non-experimental designs
1) correlational studies
2) longitudinal studies: correlational results over time
3) case-studies and single-subject: can’t generalize
*none can make causal conclusions
case study example
KC: anterograde/retrograde amnesia
ABAB case study
- one person used as own control
- remove and introduce a particular condition
epidemiological research
- study of incidence/prevalence of disorders in a given population
- incidence: number of new cases in a time period
- prevalence: frequency of disorder at a particular point in time
inheritance/genetic studies
1) family: inferences about heritability –> if proband (starting person) and relative display same diagnosis or behaviour, they are concordant, higher concordance rates suggest more heritability
2) adoption studies
3) twin studies
*genetics never explains 100%, always some environmental effect, gene-environment interaction studies have intensified
epigenetics
study of how environment leads to changes in DNA and therefore gene expression
clinical significance
1) treatment’s practical utility
2) whether symptoms are sufficiently intense for distress or dysfunction
statistical significance
observed effect passes a threshold that suggests it was sufficiently unlikely to have occurred due to chance
limitations to assessments
only a sample of behaviour
what are good assessment tools dependent on?
- ability to accurately detect some aspect of the person being tested
- knowledge of how people in general fare on such a measure for comparison purposes (ex. norms)
test-retest reliability
same test generates same results for the same person
alternate-form reliability
two versions of the same test give correlated scores
internal consistency
degree of reliability WITHIN a test
split-half reliability
if one half is correlated to the other (ex. even responses and odd responses)
coefficient alpha
averaging intercorrelations of all items within a test
face validity
items on test resemble characteristics of concept being measured
content validity
test’s items are thorough and reflect all behaviours believed to be related to the overall construct
criterion validity
correlation between measure and tangible external criterion
construct validity
relation of measure to another measure of same concept within a specific theoretical framework (ex. self-esteem and self-efficacy)
clinical approach to prediction
- clinical intuition is most important quality to draw on all info for an accurate assessment
- better when dealing with patients case-by case
actuarial approach
- more objective, unbiased and scientifically validated methods
- more efficient for large datasets
- do not generalize to practice setting
- no prediction rules for most decisions
types of prediction
clinical, actuarial, machine learning/AI
types of assessment
biological (neuroimaging, more for etiology over diagnosis), neuropsychological, clinical assessment (interviews), intelligence, personality, behavioural/cognitive
biological assessment
- rules out underlying biological conditions
- brain imaging, neuropsychological testing (individual or multi-test batteries)
brain imaging techniques
EEG, CT/CAT, MEG, PET, MRI, fMRI, fNIRS
fNIRS
specific frequency of IR that passes through skull but not blood
EEG
- measures changes in brain current
- high temporal resolution
- low spatial resolution
CT/CAT
- x-ray images
- high spatial resolution
- small radiation doses
PET
- radioactive ligands in blood
- can study subcortical neurons, receptors, neurotransmitters
- radiation
- expensive
MEG
- changes in brain current (with magnetic waves)
- high temporal, high spatial resolution
- expensive
MRI
- images brain structure
- high spatial resolution
- expensive
fMRI
- infer brain activity by blood flow and oxygen levels
- high spatial resolution
- medium temporal resolution
- expensive
application of brain imaging
- before and after changes of psychotherapy
- how those with disorder differ from controls
neuropsychological assessment
- objective determination of cognitive capacity, determines how current behaviour relates to brain functioning (normal or abnormal)
- intelligence, memory, learning, executive function , visuospatial function, etc.
- batteries: multiple tests, long and laborious but can pinpoint specific impairments
examples of neuropsychological assessment screening tools
1) bender visual-motor gestalt test: copy patterns and shapes
2) repeated battery for the assessment of NP status (RBANDS): 12 subtests that cover range of domains relevant to neurological impairment
3) montreal cognitive assessment (MoCA): brief, rapid tool for mild cognitive impairment
4) trail making test (connect numbers/letters in alternating way)
5) complex figure test: copy from memory
*need to compare these to norms
intelligence tests
- IQ = mental/chronological age X 100
- 15 = 1 std. deviation
- Stanford-Binet Intelligence Scales
- WAIS, WMS, WISC (children), WPPSI (preschool)
- very good reliability and validity, stable construct over time
- making block designs
- Raven’s progressional matricies
- arithmetic, similarities
clinical interviews
- unstructured: open-ended questions, facilitates rapport, poor reliability (different questions asked by different interviewers), missing relevant details
- semi-structured: questions guided by prompts and decision-trees, some flexibility to get details
- structured: very specific questions and order, no connection, less efficient
personality assessment
- projective tests: rorschach inkblot test, thematic apperception test (psychodynamic, validity questioned)
- standardized tests: MMPI, MCMI
thematic apperception tests
- patient interprets strange image
MMPI-2
- minnesota multiphasic personality inventory
- 567 true/false questions
- assesses multiple aspects of personality
- profile of scores on scales of personality characteristics built by comparing psychiatric and non-psychiatric groups
- contrasted approach: items were chosen only if people known to have the characteristic the scale is intended to measure responded differently to the item than did people who did not have that characteristic
MCMI
- millon clinical multiaxial inventory
- helps clinicians with diagnostic judgements about personality disorders and other clinical syndromes
- 195 true/false questions
- 25 clinical scales, 5 validity scales
personality assessment inventory (PAI)
- 4-point likert scale
- 11 clinical, 4 validity, 5 treatment-consideration, 2 interpersonal scales
- assess symptoms (mild to severe)
- ex. OCEAN
norms
1) standard or pattern, expected behaviour
2) statistical representation of population, used as reference to identify what percentile an individual lies at
down sides of self-report
- traits have overlap –> maybe there are no distinct parts to personality
- people tend not to provide accurate reports
response sets
test testing attitudes that bias self report answers
acquiescent style
says yes to everything
socially-desirable responding
respond to make themselves look good, minimize the bad
demand characteristics
answer in a way they think the tester wants them to answer
behavioural assessments
- observation
- rating scales
- reactivity: change in behaviour because they know they are being watched
- observer drift: raters suffer from an idiosyncratic bias in their ratings over time
- expensive, time-consuming
how do tests avoid dishonest answers?
- sets of questions, where one has a question that everyone will answer a certain way to: ex. do you have strange beliefs about cars? if yes, do cars have their own religion?
- detects malingering: amplifying mental health symptoms for a benefit
cognitive-behavioural assessments
- questionnaires assessing your thoughts
- self-monitoring: record own behaviours, thought, emotions
- advancements with technology: real-time assessments
- self-monitoring also fosters insight and awareness –> an intervention by itself
major depressive disorder prevalence
5-12.5%, 50% who have one episode will have another, ~90% of those who have two or three will have more
MDD episode length
average 6-9 months
MMD onset statistics
- average age: early to mid-20s, now decreasing (ex. teens)
- women at higher risk at all ages
- comorbid with anxiety disorders (>50%) contributes to more severe and chronic depression
MDD DSM diagnostic criteria
1) 5 or more of the following symptoms, one of which is depressed mood or anhedonia (both subjective or observed)
- significant weight loss when not dieting or weight gain (+5%), or decrease in appetite
- insomnia or hypersomnia (+/- 2hr)
- psychomotor agitation or retardation (observable)
- fatigue or loss of energy
- feeling worthless or excessive/inappropriate guilt, which may be delusional
- difficulty concentrating or indecisiveness
- recurrent thoughts of death, suicidal ideation, attempt or plan
*symptoms must be most of the day or nearly every day for at least a two week period in the last month
2) distress or impairment (clinically significant)
3) not due to substance or medical condition
4) no psychotic disorder
5) never had manic/hypomanic episode
comments on MDD DSM criteria
- removal of bereavement exclusion could lead to increased prevalence
- number of criteria is contentious
- some people will have full inter-episode recovery, others have lingering symptoms
anhedonia
markedly diminished interest or pleasure in all, or almost all activities (subjective or observation)
persistent depressive disorder aka
dysthymia (until DSM)
PDD prevalence
0.03
double depression
chronic low mood (PDD) + additional episodes of depression
examples of double depression
1) persistent major depressive episode (MDE): decrease in mood that stays consistent
2) intermittent MDE with current episode
examples of PDD
1) dysthymic syndrome: consistent low mood
2) intermittent MDE without current episode
PDD differences from MDD
- more chronic
- younger age of onset
- higher comorbidity
- strong family history
- lower levels of social support
- higher stress
- more dysfunctional personality traits
- less likely to respond to standard treatment, often needs combination
PDD theoretical concern
how differentiated is this from a normal-range of personality traits?
PDD DSM criteria
1) depressed mood most of the day, for more days than not for at least 2 years
2) presence, while depressed of two or more:
- poor appetite or over eating
- insomnia/hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or indecisiveness
- feelings of hopeless ness
3) during the 2-year period (1 year for children/adolescents), person has never been without symptoms in (1) or (2) for more than 2 months at a time
4) criteria for MDD may be continuously present for 2 years
5) no manic or hypomanic episode, never met criteria for cyclothymia
6) not better explained by other mood disorders or substance/medication
7) significant distress/impairment
premenstrual dysphoric disorder (PMDD)
- prevalence: 1.8-5.8%
- acute depressive symptoms that accompany menstrual cycle
- must occur in most cycles in the past year
- research focuses on hormonal mechanisms (birth control, SSRIs can help)
other specified depressive disorder
1) recurrent brief depression (5+ symptoms, 2-13 days, each month for at least 1 year)
2) short-duration depressive episode (4-13 days, 5+ symptoms)
3) depressive episode with insufficient symptoms (at least two weeks)
unspecified depressive disorder
- clinical impairment, but doesn’t meet specific criteria
- “catch-all” label
mania
- distinct period of elevated, expansive or irritable mood
- lasts at least one week OR any duration if hospitalization necessary or interaction with law enforcement
- increased energy, decreased need for sleep, racing thoughts, pressured speech, impaired attention/concentration/judgement
- can lead to altercations, reckless activities, substance use, aggression
hypomania
- less severe mania, only lasting at least 4 days
- can be longer if did not cause significant difficulties to warrant mania
- can sometimes be hard to distinguish between feeling “good”
mixed-state episodes
- rare
- depression and manic/hypomanic symptoms felt at the same time
bipolar 1 DSM criteria
1) manic episode
2) during manic episode, must have at least 3 symptoms (four if only irritable) present to a significant degree (noticeable change from usual):
- inflated self-esteem or grandiosity
- decreased need for sleep
- more talkative or pressure to keep talking
- flight of ideas or feeling of racing thoughts
- distractibility
- increase in goal-directed activity or psychomotor agitation (non-goal-directed)
- excessive involvement in risky activities
3) impairment in functioning, need of hospitalization or psychotic features
*no need for distress!
4) not attributable to substance/medical condition
bipolar 1 and MDD
- depressive history not necessary for bipolar diagnosis
- but most patients will have had MDD in the past or future
bipolar 1 prevalence and onset
- prevalence: 0.8%, equal male/female
- mean onset ~20, 50% show symptoms as teens
bipolar 2 DSM criteria
1) hypomanic episode
2) same symptoms as bipolar 1
3) episode associated with unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
4) disturbance in mood and change in function is observable to others
5) not severe enough for impairment or hospitalization, no psychotic features
6) not attributable to substance or medication
7) one or more depressive episodes
bipolar II prevalence
0.5%, equal in males/females
progression of bipolar disorders
- manic symptoms often enjoyable and pleasurable at first
- tend to progress into distress/impairment, where others are effected, risks have consequences, depressive episodes become more severe
- hypomania/mania tends to last two weeks to four months
- depressive episodes tend to last 6-9 months
- suicide rates 10-15%
cyclothymia
- chronic, less severe form of bipolar
- hypomanic and depressive symptoms, but never reaches full DSM criteria for either (faster cycling)
- at risk for developing bipolar disorders
cyclothymia prevalence and diagnosis
- 0.4-1%, equal across genders
- hard to get diagnosis: how to tell difference between normal fluctuation or disordered?
rapid-cycling specifier
- four or more manic and or depressive episodes within a year
- episodes separated by at least two months of full or partial remission, or by switch to opposite mood state
seasonal affective disorder (SAD)
- recurrent depressive episodes tied to changing seasons, usually winter months with less daylight
SAD prevalence
- general: 0.6-3%, 2-3% in Canada
- approximately 11% with MDD have SAD
SAD etiology
- focus on melatonin produced at night by pineal gland
- but, medications that suppress melatonin are not very effective
peri-partum and post-partum onset depression prevalence
- 10-15% of mothers with mood swings that do not resolve or are severe enough for MDD or manic episodes
- 0.1% have post-partum psychosis, may lead to suicide (5%) or infanticide (4%, command hallucinations)
peri/post partum onset depression risk factors
- family history of depression
- previous personal depression
- poor marital relationship
- low social support
- stressful life events concurrent/following childbirth
- could adversely affect child
biological: genetic etiology of mood disorders
- genetics
- twin studies: high heritability of MDD (36%), huge heritability of BP (75%)
- serotonin transporter gene (HTT): controls individuals reactivity to stress, short (s) allele associated with negative cognitive style and personality (higher rates of MDD in response to stress)
heritability
percent of variability that can be explained by genetics
psychological: personality etiology of mood disorders
1) dependency: relying on interpersonal relationships for identity; neediness, fearing abandonment, feeling helpless in relationships
2) self-criticism: particularly towards achievement, fearing failure, self-blame, inferiority, guild
psychological: behavioural models in etiology of mood disorders
1) Lewinsohn’s behavioural model: operant conditioning –> low rate of positive reinforcement via social and other rewards leads to extinction of those behaviours
2) Seligman’s learned helplessness model: remain in unpleasant situations because they start to believe they have no control, even when escape/control options exist
cognitive etiology of mood disorders
1) Ellis: irrational and distorted thoughts
2) Beck: negative bias in appraising stimuli from the environment –> cognitive distortions framework –> diathesis stress model: only after stressful event might schema start to cause difficulties
cognitive distortions
- automatic thoughts because of underlying schemata about the self, world or future (negative)
- awareness gives opportunity to notice and challenge them
appraisal theory
1) primary: challenge (potential for gain/growth) or threat?
2) if threat, secondary appraisal: effective options (low threat) or ineffective/no options (high threat)?
examples of cognitive distortions
1) all or nothing thinking
2) over generalizing
3) mental filter (attentional bias)
4) disqualifying positive
5) jumping to conclusions: mind-reading, fortune telling
6) magnification (catastrophizing) or minimization
7) emotional reasoning: assuming that because we feel a certain way, what we think must be true
8) should, must, ought (guilt with self, frustration with others)
9) labelling (self or others)
10) personalization (assuming responsibility for things that aren’t your fault or blaming others for things that were your fault)
attentional/interpersonal etiology of mood disorders
1) attentional bias
- depressed people preferentially attend to negative info
- more likely to be judged as less socially skilled because not as animated, more negative affect, angry/depressed feelings
- manic people preferentially attend to positive stimuli
2) depressed people tend to seek confirmation of criticism and other negative interpersonal beliefs from others, can provoke further negative responses
3) interpersonal dependency or excessive reassurance seeking: learn to need assurance, may compound social aspect because of annoyance
life stress perspective of mood disorders
- depressed people 3x as likely to experience stressful life prior to onset
- sudden losses or sudden changes
- nearly 75% MDD suffered major loss event 3-6 months before
- life events related to reward/goal attainment predict increases in manic symptoms
- early child maltreatment: negative core schemas (Beck beliefs), taxes biological systems (HPA axis, cortisol)
biological: neurotransmitter etiology of MDD
- deficiency in serotonin
- SSRIs thought to raise serotonin in brain, but this may not be why they are valuable as antidepressants
biological: cascade hypothesis of depression
1) cortisol release during stress stimulates receptors in hippocampus
2) hippocampus inhibits HPA axis by negative feedback
3) chronic stressors result in sustained release of cortisol, breakdown of negative feedback (hippocampal degradation)
supporting studies
- HPA axis more reactive in females (2x depression)
- greater lifetime stress experience, smaller hippocampus
- child abuse associated with cell death in hippocampus and amygdala
sleep neurophysiology and mood disorders
- loss of slow-wave (deep) sleep and earlier on set of REM stages in MDD
- sleep deprivation can induce symptoms of mania, people suggest that BP is related to sleep dysregulation
neuroimaging mood disorders
- depression associated with decreased blood flow and reduced glucose metabolism in prefrontal cortex (reversed in mania)
- increased glucose metabolism in subgenual anterior cingulate cortex (ACC), seems to be related to attentional biases
- increased activity in amygdala, maybe also related to attentional biases
CBT for depression
- goals: increase awareness of thoughts and appraisals to events, examine their contribution to emotions
- structured format, 16-20 sessions
- socratic questioning, guided collaborative discovery
- activity monitoring and scheduling (behavioural activation): to counteract Lewinsohn’s theory, this is a critical component!
- thought records to challenge distorted thinking
- behavioural experiments
CBT success with depression
- some evidence of being superior to psychodynamic psychotherapy
- comparable results to antidepressants and IPT
- lower relapse rates in the long-term
mindfulness based cognitive therapy (MBCT)
- Buddhism principles
- promotes non-evaluative awareness of present
- detach from ruminative thinking, cultivate detached perspective
- helpful for avoiding relapse
interpersonal psychotherapy (IPT) for depression
- based on psychodynamic theories viewing loss and disordered attachment as underlying factors
- assumes depression occurs via interpersonal context
- 12-16 sessions, maintenance sessions to avoid relapse
- work to resolve:
1) interpersonal disputes
2) role transitions (life changes)
3) grief
4) interpersonal deficits - efficacy similar to antidepressants
pharmacotherapy for depression
1) TCAs: blocks NE or 5HT reuptake, rarely prescribed because of side effects
2) MAOIs: block MAO, prevents breakdown of NE, 5HT, DA, also rarely prescribed
3) SSRIs: primarily block reuptake of 5HT, more commonly prescribed (minor side effects: nausea, insomnia, sedation, sexual dysfunction)
4) SNRIs: block reuptake for 5HT, NE
5) medications for dopamine (stimulant-like)
6) miscellaneous actions: GABA, ketamine
pharmacotherapy for bipolar disorder
- can’t use antidepressants, these encourage mania
1) lithium: mechanism unkown (deactivation of GSK-3B? decreasing excitatory glutamate?) - narrow therapeutic window means regular blood draws (therapeutic dose is only slightly below toxic)
- side effects: kidney, thyroid, dehydration, weight gain, hair thinning, hand tremors
- careful with salt/coffee intake
- 40% do not respond, becomes ineffective over time for 70%
2) anticonvulsants: originally for epilepsy - mechanism also unknown
- many increase GABA
- some decrease glutamate
- some work on Ca2+ and Na+ channels
3) atypical antipsychotics: work on dopamine and serotonin, can cause tardive dyskinesia
tardive dyskinesia
- protrusion and rolling of tongue
- sucking and smacking movements of lips
- chewing motion
- facial dyskinesia
- involuntary movements of body and extremities
combination therapies for bipolar disorder
- medication first choice, but can add adjunct therapy
1) family-focused therapy (FFT): education for patient and family, communication and problem-solving training, developing positive interactions and supportive relationships
2) interpersonal and social rhythm therapy (IPSRT): regulation of routines and coping with stressful life events, targets sleep consistency, prevents relapse via sleep deprivation
3) cognitive therapy (CT): regulate sleep and daily routines, monitor mood for episode triggers, medication compliance
4) dialectical behavioural therapy (DBT): improve emotional regulation, reduced negative coping, reduced vulnerability to strong emotions
phototherapy
- useful in SAD
- light boxes emit a bright light of a certain intensity to mimic sunlight
- patients sit in front of box for 30 min in morning
- increasing temperature, serotonin production, melatonin inhibition
- no side effects, <100 dollars
treatment-resistant depression
- 40% fail to respond to at least two medications
- consider neurosurgery
neurosurgery and invasive procedures for depression
1) ECT: used for severe and treatment-resistant cases, remission rate ~90%
2) TMS: usually applied to DLPFC (dorsolateral prefrontal cortex) where there is low activity, less effective than ECT
3) vagus nerve stimulation (VNS): invasive, helps improve 5HT/NE and blood flow, works well in long-term
4) DBS: extremely invasive electrodes in reward/attention areas
suicide stigma
- cultural and religious views impact prevalence
- wasn’t considered “legal” in some countries
- stigma prevents people from seeking help
dialectical behavioural therapy
- built to treat suicidality, although common for BPD
- emphasizes that wo things can be true at the same time
- aims for a balance between acceptance (mindfulness, distress tolerance) and change (emotional regulation, interpersonal effectiveness)
different types of suicidal behaviour
1) ideation: thoughts of death, thinking of ways it could happen
2) gestures (parasuicide): behaviours that look like a suicide attempt but are not life-threatening/have no intention
3) attempts: carrying out a plan
4) completion: successful attempt
5) self-harm
self-harm
- not immediately life-threatening
- maladaptive ways of coping
- negative reinforcement: intense release/relief after (attentional shift)
- strong predictor of suicidal behaviour or mood disorder
DBT treatment for self-harm
- behaviour chain analysis
- look at precursors to self-harming behaviour and try to intervene sooner rather than letting feelings escalate
- teach emotional regulation, mindfulness
- avoid situational/emotional triggers
- take focus away from painful feelings
schizophrenia general characteristics
- disruption of basic psychological processes
- distorted perception of reality
- altered/blunted emotion
- disturbances in thought, motivation and behaviour
schizophrenia prevalence, onset, demographics
- prevalence: 1%, 300k in Canada
- onset: 15-45 years, early 20s peak
- men/women roughly equal risk, men develop earlier
- abrupt or gradual onset
- all socioeconomic levels, but more prevalent at low (self-fulfilling prophecy, comorbidities with depression, suicidality, substance abuse)
most common type of hallucinations
auditory
complexity of schizophrenia
- heterogenous in terms of symptoms
- no reliable biological markers
- difficult to make prognosis and prediction
- what defines successful treatment? symptoms gone or disruption gone?
factors increasing schizophrenia prevalence
- industrialization
- rural vs urban living
- environmental changes
- defined disorder = more diagnoses
schizophrenia prognosis
- poorer for males and those with earlier onset
- chronic and relapsing disorder
- longer delay for treatment worsens prognosis
- favourable outcome: typically termed attenuated psychosis rather than in remission (most cases, symptoms still present, just less intense)
schizophrenia burden on society
- economy: billions of dollars on inpatient services, psychiatric case management, much more direct and frequent client care required
- stigma
- family members usually have to act as caregivers, extra loss of productivity
division of symptoms in schizophrenia
1) positive: something extra present, ex. hallucinations, delusions, disorganized speech and thoughts
2) negative: something absent or abnormal, ex. ahedonia, avolition (lack of motivation to start a task), blunted afect
3) cognitive: dysfunction in brain’s regular processes, ex. memory issues, inability to process social cues, impaired sensory perception
hallucinations
- realistic perceptions in the ABSENCE of external sensory input that occur while awake and conscious
- underlying problem: misattribution of sensory experience and inability to discriminate between internal/external sources of information
- occur in many medical disorders, and does not necessarily mean psychotic
types of hallucinations
1) auditory: heard inside or outside of head
2) visual: simple or complex, cannot be an illusion or misinterpretation of existing stimulus
3) tactile
4) taste or smell: often extreme
delusions
- implausible beliefs that persist despite reliable contradictory evidence
- disorder of thought content
- can include complex belief system or single belief
- observed correlation: may develop in people who make interpretations too quickly and jump to conclusions
- may also be a bias in reasoning (negative events always perceived as coming from environment or other people)
types of delusions
1) persecutory/paranoid: they are being conspired against, deceived or persecuted
2) referential: events, objects or other individuals have personally relevant meanings
3) somatic: change or disturbance in personal appearance or bodily function
4) religious: unusual religious experiences or beliefs, ex. describing self as living out a biblical prophecy
5) grandiose: possession of special or divine powers, abilities or knowledge
motor disruptions
- catatonia: reduction in motor responsiveness
- waxy flexibility: allowing others to move their body and limbs, then maintain that position
grossly disorganized behaviour
- difficulty with goal-directed behaviour
- unpredictable movements
- problems dressing or with hygiene
- inappropriate sexual behaviour
negative symptoms associated with…
deficits in academic and occupational functioning and adjusting to community
disorganized speech and thought disorder
- unusual-sounding, nonsensical speech
- loosening of associations: loss of logical connections between ideas
- tangential thinking: moving from one topic to another quickly
- more easily observable, can serve as objective index of disturbance (over symptoms like hallucinations and delusions)
cognitive deficits as markers of schizophrenia
1) processing speed: slow writing symbols paired with numbers
2) sensory gating: impairment filtering out redundant info
3) verbal memory
4) dichotic listening
5) phonemic word fluency: impaired generation of words rapidly
6) ability to sustain attention: slow/inaccurate detection of specified letters
progression of schizophrenia
1) premorbid
2) prodormal: clinical deterioration begins, 5-10 years before first episode
3) progression/clinical deterioration: longer period of untreated psychosis = worse prognosis, number of relapses related to greater deterioration
4) chronic residual: patients may not recover from subsequent episodes as quickly, may experience greater degrees of residual symptoms and disability
schizophrenia DSM criteria
1) two or more of following, each present for a significant portion of time during 1 month:
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behaviour
- negative symptoms
2) for significant portion of time since onset, level of function in one or more areas is below level prior to onset (work, interpersonal, self-care)
3) continuous signs of disturbance persist for at least 6 months: includes at least 1 month of symptoms (less if treated), may include periods of prodromal or residual symptoms (only negative symptoms or two or more symptoms with attenuated form)
4) rule out schizoaffective disorder, MDD or BP with psychotic features
5) not attributable to substance, medication or medical condition
6) if autism or communication disorder present, diagnosis can only be given if delusions or hallucinations present for one month (less if treated)
delusional disorder
- one or more delusions with duration of one month or more
- does not meet criteria for schizophrenia (never been met)
brief psychotic disorder
- one or more of: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behaviour
- at least one symptom from first three categories
- 1 day to 1 month, more becomes schizophreniform disorder
schizophreniform disorder
- two or more of symptoms: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behaviour, negative symptoms
- at least one from first 3
- 1 month to 6 months, more becomes schizophrenia
schizoaffective disorder DSM criteria
1) two or more symptoms, each present for significant amount of time during 1-month period + at least one from first three:
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behaviour
- negative symptoms
2) hallucinations and delusions for two or more weeks in the absence of a major mood episode during entire life time duration of illness
3) symptoms that meet criteria for major mood episode are present for the majority of the time otherwise (including active and residual portions of illness)
4) not due to substance or medical condition
5) specifiers:
- bipolar type: mania and sometimes major depression
- depressive type: only major depressive episodes
substance/medication-induced psychotic disorder
ex. cannabis
other specified psychotic disorders
- persistent auditory hallucinations (+ nothing else)
- delusions with significant overlapping mood symptoms
- attenuated psychosis syndrome (below threshold)
- psychotic disorder - not otherwise specified (NOS)
MDD + psychotic features vs schizoaffective disorder
- MDD with PF only experience psychotic features during mood episodes
- schizoaffective have 2 weeks only psychotic symptoms without mood symptoms
bipolar disorder vs schizoaffective disorder
same distinction as MDD with PF
neuropsychological and neuroimaging factors in schizophrenia
- suggest hypofrontality, affecting personality, self-awareness, motivation, thinking, impulsivity, social behaviour
- can predict schizophrenia or indicate severity, but cannot diagnose
1) fMRI: less than 50% have reduced blood flow or metabolism in frontal area during tasks - schizophrenia could be a product of lower intellectual functioning overall (50-67% lower in patient groups)
2) MRI: third and lateral ventricles are enlarged (compression or loss of existing nerve tissue) - reduced grey matter volumes in medial temporal lobe (MTL), superior temporal lobe, prefrontal cortex –> memory processing, cognitive/executive function (but not in all patients)
3) DTI: corpus callosum and connections between frontal lobe and other areas affected (connective tissues and tracts)
social cognition factors in schizophrenia
- emotional recognition (six universal) decreased (index of social functioning)
biological factors in schizophrenia
1) high genetic contribution: children of two affected parents = 35% likelihood
- molecular genetics research difficult to reproduce consistently
- single gene only increases risk by 1-1.5% because of many interactions
2) pregnancy/birth: mother exposure to flu or illness, birth-related complications
3) family environment: family hostility, lack of support, critical attitudes, over-involvement, mood/eating disorders, high expressed negative emotion directed at family members with disorder
4) other factors: high-risk children display withdrawn/socially-reclusive, antisocial, aggressive behaviour, motor difficulties, lower intellectual capabilities
psychoanalytic etiology of schizophrenia
- emotional traumas
- inadequate parenting
- severely rejecting mother: schizophrenogenic
sociocultural etiology of schizophrenia
- strong correlation with poverty
- social drift: people from lower SES get stuck bc of reduce IQ associated, more substance use, stigma, homlessness
diathesis-stress model in schizophrenia
- popular explanation
- biological vulnerability (inherited or acquired early in life) switched on by stress
meehl’s model
- most famous for schizophrenia
1) hypokrisia: biological diathesis that causes nerve cells to be abnormally reactive to incoming sensory info (can be suppressed by other genes)
2) cognitive slippage: information is disorganized, incoherent and scrambled, increases thought disorder risk (high IQ can prevent further progression)
3) aversive drift: negative symptoms from unpleasant social experiences that amplify pain, weaken pleasure and make social relationships difficult
4) schizotype: has all three predispositions, can still be spared
5) schizophrenia: more likely with exacerbating factors: shyness, anxiety, low energy, weak motivation, low ability, talent, low SES
criticism for meehl’s model
- complicated (not parsimonious)
- lacks integration of why disorder emerges in adolescence
- lack of empirical support for only three specific factors
- subtle brain injuries present in areas that normally mature in adolescence may be important –> stress of maturation on weakened brain, hormonal interaction with stress
- overall, neuroanatomical and neurochemical theories are more evolved
dopamine hypothesis in schizophrenia
- abnormal concentrations of dopamine receptors
- key medication: chlorpromazine blocks dopamine receptors (D2)
mesolimbic pathway in SCZ
- reward and regulation
- too much signaling = hallucinations/delusions
mesocortical pathway in SCZ
- emotional and cognitive functioning, executive functions
- too little signaling = negative/cognitive symptoms (hypofrontality)
historical treatments for SCZ
insula coma, psychosurgery, frontal lobotomies, shocks
typical antipsychotics
- dopamine receptor antagonists
- ex. chlorpromazine: reduced agitation, mania, mood disturbances (positive symptoms)
- may exacerbate negative/cognitive symptoms
- minority benefit, others have side effects
