Psychopathology Flashcards
Psychopathology
Definition: Study of mental disorders
Defining mental disorders: Infrequency
- Something is a mental disorder because the symptoms the person experiences are statistically infrequent (e.g. auditory and visual hallucinations)
- Doesn’t hold: While some mental disorders are statistically infrequent (schizophrenia), there are other conditions that are frequent (depression); 48% lifetime prevalence rate for having any DSM-5 mental disorder
Schizophrenia prevalence rate in general population
0.5-1.5%
Depression prevalence rates (men + women)
- 10-20% prevalence rate for women
- 5-12% for men
Defining mental disorders: Deviance
- Mental disorder as atypical behaviour for a particular context (normative/contextual deviance)
- Opponent of deviance definition: Thomas Szasz wrote a book arguing that society has defined what a mental disorder is without any real biological underpinnings (mental illness/mental health issues are a social construct)
Defining mental disorders: Distress
- Mental disorder defined by subjective distress
- Issues: Not applicable to all mental disorders, as it depends on individual’s degree of insight/self-awareness - mental disorders not always accompanied by distress (e.g. NPD)
Defining mental disorders: Disability or impairment
- Mental disorder defined by some impairment in functioning
- Issues: Individuals with mental disorders not always impaired (e.g. people with anxiety disorder who can still go to school and study)
Defining mental disorders: Danger
- Something is a mental disorder because it relates to harming themselves or others
- Issues: Not associated with every mental disorder, not frequent
Actual DSM-5 mental disorder definition:
- Associated with present distress or;
- Disability, or;
- With a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom -and;
- Must not be an expectable and culturally sanctioned response to an event - and;
- Must be considered a manifestation of a behavioural, psychological, or biological dysfunction in the individual
Emil Kraepelin
Medical doctor who came up with first modern classification system of modern mental disorders (published in 1883)
History of the DSM-5
- Diagnostic and Statistical Manual of Mental Disorders (published by the APA in 1952)
- DSM-3 (1980): Push for it to be more descriptive and less theoretical (have a symptom checklist, certain number where you meet diagnostic criteria)
- 5th edition revised in 2022 (DSM-5)
Biomedical/biological treatment
- Consider mental illness a biological disease (disease of the brain and central nervous system)
- Medication can be used to remove or at least improve symptoms of disorder, brain surgery may be used but is highly unusual
Psychological treatment: Psychodynamic (a.k.a psychoanalytic) approaches
- Developed by Freud, tried to define what was “normal” and had no interest in defining what was problematic and how to intervene
- Strong emphasis on child development (sees psychological difficulties as stemming from unresolved childhood trauma/difficulties)
- Sees behaviour as driven by powerful unconscious inner forces
- Insight-oriented approach - goal of psychoanalysis is for patients to arrive at an insight for why they are having certain difficulties
Psychological treatment: Humanistic (a.k.a positive) approaches
Focus is on teaching the patient to seek fulfilment and reach their potential; goal is to help patient discover and then achieve their potential
Psychological treatment: Behavioural approaches
- Second oldest modality, largely a rejection of psychodynamic theory
- Focus on the present, rooted in principles of classical and operant conditioning
- Goal is to: Use techniques that counter essentially-conditioned punishments (e.g. phobia of dogs treated with exposure therapy), extinguish non-productive/upsetting behaviours, reinforce desirable behaviours
Psychological treatment: Cognitive-behavioural approaches
- Focuses on the way people think, argues that the way people think about their environment influences how they feel
- Goal is to identify maladaptive, dysfunctional thoughts leading to negative emotions and challenge these thoughts, replacing them with more positive ones
Psychological treatment: Integrated/eclectic treatments
- Therapist selects techniques from various types of therapy to design a treatment that best suits the case
- Goal: Meet individual needs of the patient, mix and match techniques to do so
Anxiety definition
Apprehension about an anticipated issue (future oriented)
Forms of therapy:
- Individual
- Couple
- Family
- Group - often linked by an underlying difficulty
Fear/panic
Apprehensive response to immediate threat or danger; reflexive or autonomic response to a stimulus
Three components of anxiety and fear:
- Cognitive/subjective (what you’re thinking about, source of your anxiety)
- Physiological (both anxiety and fear produce autonomic responses)
- Behavioural (produce avoidance a.k.a. as “flight”)
Fight/flight response
- Occurs when confronted with danger
- Sympathetic nervous system (sweat, shaking, heart-racing, shallow breathing)
- Automatic perception of threat (physical, social, thoughts)
Yerkes-Dodson Law
Optimal area of arousal for anxiety for peak performance (certain level of anxiety as a motivator)
Anxiety disorders: Diagnosis rate
Most common psychiatric diagnosis (28% of individuals in the U.S. diagnosed at some point in life)
Types of anxiety disorders:
- Phobias (specific phobias, social phobia [social anxiety disorder], agoraphobia)
- Panic Disorder
- Generalised Anxiety Disorder (GAD)
Previously considered anxiety disorders:
- Obsessive-Compulsive Disorder (OCD)
- Post-Traumatic Stress Disorder (PTSD)
Generalised Anxiety Disorder (GAD)
- Extensive amount of apprehension and worry that individual finds uncontrollable (consistent apprehensive expectation)
- Anxiety is generalised and persistent, not situational
Panic Disorder
- Discrete period of intense fear in the absence of any real danger, unpredictable
- Sudden onset, builds rapidly (reaches peak within minutes)
- Concern about future attacks leads to avoidance, otherwise relatively free of anxiety in between attacks
Agoraphobia
- Often goes with Panic Disorder (fear of going out and being embarassed by having a panic attack)
- Marked fear about at least two of: using public transport, being in open spaces, being in closed spaces, standing in line/being in a crowd, being outside of home alone
- Feared situations produce anxiety and either avoided, require a companion to enter, or endured with intense fear or anxiety
Social Anxiety Disorder (SAD)
- Fear or anxiety about one or more social situations where the individual is exposed to possible scrutiny by others
- Individual fears that they will act in a way that will be negatively evaluated by others
- Feared social situations are avoided or endured with intense fear or anxiety
Specific phobias
- Anxiety evoked by specific circumstances or situations
- Fear is out of proportion to the situation and beyond voluntary control
- Avoidance is a characteristic feature
Common features of obsessive-compulsive related disorders:
Repetitive thoughts and behaviours which cause distress, feel uncontrollable, and take up a lot of time
Co-morbidity of obsessive-compulsive related disorders:
- 1/3 BDD comorbid with OCD
- 1/4 HD comorbid with OCD
What are the obsessive-compulsive related disorders?
- Obsessive-Compulsive Disorder (OCD)
- Hoarding Disorder (HD)
- Body Dysmorphic Disorder (BDD)
Trauma and stressor related disorders:
- PTSD
- Acute Stress Disorder (more immediate reaction to trauma instead of delayed)
Features of OCD:
- Obsessions (intrusive and recurring throughts, images, or impulses that are persistent, uncontrollable, and irrational)
- Compulsions (repetitive, excessive behaviours or mental acts person does to reduce anxiety caused by obsessions or to prevent expected consequences) - 78% “insight” (recognise compulsions as irrational)
Most common OCD obsessions:
- Contamination
- Sexual or aggressive impulses
- Body problems
- Religion
- Symmetry or order
Common OCD compulsions:
- Cleanliness and orderliness
- Repetitive “magical” acts (e.g. tapping something a certain number of times in order to save family)
- Excessive checking
DSM-5 PTSD
- Exposure to actual or threatened death, serious injury, or sexual violence
- Presence of one or more intrusive symptoms
- Persistent avoidance of associated stimuli, by one or more: avoidance of actual or external triggers for memories, thoughts, feelings
- Presence of two or more negative alterations in cognition and mood
- Negative alterations in cognition and mood (two or more)
- Two or more marked alterations in arousal and reactivity
- Duration > 1 month (needs to be at least 1 month separated from traumatic event)
- Clinically significant distress or impairment, can’t be due to substance/medical condition
Intrusive symptoms of PTSD:
- Distressing memories
- Dreams
- Flashbacks
- Distress and/or arousal response to internal/external reminders
Negative alterations in cognition and mood for PTSD:
- Amnesia
- Negative beliefs
- Blame for cause/consequences
- Negative emotional state
- Loss of interest/pleasure
- Detachment/estrangement
Alterations in arousal and reactivity for PTSD:
- Irritable
- Reckless
- Hypervigilance
- Startle response
- Concentration
- Sleep
Aetiology of anxiety and related disorders:
- Fear conditioning (environmental learning), especially for specific phobias
- Cognitive (maladaptive/dysfunctional thoughts)
- Genetic vulnerability (especially OCD, PTSD)
- Neurobiology
- Personality
Psychological treatment for anxiety and related disorders (anxiety disorders among the most treatable):
- Relaxation (helps with physiological response)
- Cognitive restructuring (challenges maladaptive thoughts)
- Exposure therapy and behavioural experiments to challenge, habituate, and learn
Exposure therapy
- Works on the principle of habituation - the more a person is exposed to fear-provoking stimulus, the more accustomed they get to being around it
- Systematic desensitisation: imagine the stimulus (imaginal exposure) –> focus on relaxation techniques –> eventually be directly exposed to stimulus (in vivo exposure)
- Effective in 70-90% of cases
Major Depressive Episode (MDE)
Change in previous functioning (must include either depressed mood or loss of interest), clinically signifcant distress or impairment, and five or more of the following over 2 weeks:
1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in most activities
3. Clinically significant weight loss or gain (> 5% change)
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive/inappropriate guilt
8. Diminished ability to think or concentrate, indecisiveness
9. Recurrent thoughts of death, suicidal ideation, plan or attempt
DSM-5 depressive disorders
- Major Depressive Disorder (MDD): Characterised by multiple MDEs, higher prevalence for women than men and more prevalent overall than Dysthymia
- Persistent Depressive Disorder (Dysthymia): Milder than MDD but lasts longer, slightly higher prevalence in women and less prevalent overall than MDD
Aetiology of depressive disorders: Genetics (biological factor)
Heritability for depression at 37%
Aetiology of depressive disorders: Biochemical (biological factor)
- NTs: Low levels of norepinephrine (increases energy), serotonin (mood regulation), and dopamine (processing rewards in environment) linked to depression
- Hormones: Cortisol released through the Hypothalamic-Pituitary-Adrenal (HPA) axis in response to stress, chronically excessive cortisol linked to breaking down NTs such as serotonin
Cortisol production pathway
Stressor –> amygdala –> HPA axis –> cortisol
Aetiology of depressive disorders: Brain abnormalities (biological factors)
- Limbic system (composed of amygdala and hippocampus) sends signals through our serotonergic pathways to prefrontal cortex (where info comes to our awareness) –> less serotonin in body disrupts this
- Prefrontal cortex doesn’t function very well for individuals with MDE (can’t inhibit maladaptive emotional responses that well)
- Left-frontal hemisphere asymmetry linked to depression (left frontal lobe associated with more positive emotions)
Emotion regulation system
- Emotional importance: Amygdala
- Emotion regulation: Subgenual anterior cingulate, dorsolateral prefrontal cortex (inhibition of emotional responses), hippocampus (conjuring up memories)
Diathesis-Stress Model
Argues that there is an underlying biological vulnerability to the development of a disorder, but will not develop into a disorder without experiencing certain stressors
Psychological theories of depression: Cognitive theories
- One of the founders of cognitive theories of depression and cognitive therapy was Aaron Beck
- Way we perceive environment is what contributes to depression, as well as other mental disorders (hopelessness + rumination [thinking about negative events in one’s life] –> depression)
- Negative triad: negative thoughts about self, others, and the future –> depression
- Cognitive distortions: should-ing, over-generalisation, discounting positives, black-and-white thinking, unfair comparisons
- Integrative model of depression: biological + psychological vulnerability –> activation of stress hormones which affect NTs, maladaptive cognition, social issues —> mood disorder
Psychological treatment for depressive disorders: Beck’s Cognitive Therapy
Four phases (~20 sessions):
1. Increase activities and elevate mood (e.g. going on walks)
2. Challenge automatic thoughts
3. Identify negative thinking and biases
4. Change primary attitudes/schemas
Efficacy of cognitive restructuring:
- 75+ treatment studies
- Effective and reduced risk of relapse
Biological treatment for depressive disorders: Anti-depressant drugs
- Monoamine oxidase (MAO) inhibitors - last resort for treatment
- Tricyclics - can lead to significant nausea, reduced libido
- Selective serotonin reuptake inhibitors (SSRIs) - increase amount of serotonin in the synapse → better mood, less side effects
Biological treatment for depressive disorders: Electroconvulsive Therapy (ECT)
- Place electrodes on head and “buzz” patient
- Effective for severe depression, only used for treatment-resistant depression
- Can lead to significant memory less, relapse is common
Schizophrenia vs. psychosis:
- Psychosis refers to a cluster of symptoms that are related to a range of mental disorders
- Schizophrenia is the specific type of mental disorder, defined by a subset of psychotic symptoms
Three symptom clusters of psychosis:
- Positive symptoms: Symptoms that occur in excess of what is typical
- Negative symptoms: Symptoms that are absent, but would be present in a non-psychotic individual
- Disorganised symptoms: Disruptions in thought patterns and behaviour
DSM-5 schizophrenia
- Two or more of the following symptoms: Delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms
- Social/occupational dysfunction and decline
- Continuous signs of the disorder for 6 months
Positive symptoms of psychosis: Delusions
- Defined as a fixed and irrational belief that a person holds despite evidence to the contrary
- May be of: Persecution (being conspired against), grandeur (special ability like flying), reference (believing that some source is trying to connect with them), erotomania (fixed belief that someone is in love with them), somatic (belief that there is something medically wrong with them), nihilistic (belief that the world is coming to an end)
Bizarre vs. non-bizarre delusions
- Bizarre delusions: Implausible, could not happen
- Non-bizarre delusions: Plausible, even if far-fetched
Positive symptoms of psychosis: Hallucinations
- Defined as sensory experiences that are not real
- May be: Auditory, visual, olfactory, gustatory, tactile
Disorganised symptoms of psychosis: Disorganised speech or thought
- Loose association (essentially speaking a stream of consciousness, sudden shifts in topic)
- Neologisms (words made up by the person)
- Clang associations (speaks in rhymes)
- Echolalia (repeats what other people are saying)
- Echopraxia (mimicking someone’s movements)
- Word salad (jumbled, random speech - more confusing than loose association)
Negative symptoms of psychosis:
- Affective flattening (shallow emotions, reduced or absent expression of affect)
- Alogia (poverty of speech)
- Thought blocking (when someone is speaking and then completely forgets what they were saying and starts talking about something else)
- Avolition (lack of drive/motivation)
- Anhedonia (inability to experience pleasure)
Downward drift
Symptoms emerge and worsen over time
Course of schizophrenia
Three phases:
1. Prodromal: Begin to experience negative symptoms (example: withdrawing from others), and begin to have pseudo-positive symptoms
2. Active: When person reaches the criteria for schizophrenia
3. Residual: Well-managed, begins to be more negative symptoms
Typically chronic
Schizophreniform Disorder
Shortened form of schizophrenia (1 month instead of at least 6 months), sometimes goes away
Schizoaffective Disorder
- Meets diagnostic criteria for schizophrenia, as well as a mood disorder
- Typically chronic
Mood disorder with psychotic features
- Some individuals with Bipolar Disorder or depression may develop psychotic symptoms
- Psychotic symptoms only occur in the context of an active mood episode (e.g. may have grandiose sense of self in a manic episode → grandiose delusions)
- NOT a psychotic disorder
Delusional Disorder
- Focuses specifically on the presence of delusion, but no other symptoms of psychosis
- Any hallucinations directly related to delusion
- Few or no negative symptoms
- Less observable impairment
- Rare
- Better prognosis
- Delusions for 1 month or longer
Data for schizophrenia
- About 0.7-1.5% of the population suffers from schizophrenia in their lifetime
- In 3⁄4 of cases, disorder occurs between 15-45 years
- Men’s first psychotic break usually between 18-25, women’s is usually betwen 25-35
Aetiology of schizophrenia: Prenatal environmental causes
- Birth-giver having viral infection during pregnancy may affect brain development of foetus - some studies suggest that children born in winter and spring more susceptible to developing schizophrenia than children born in other seasons (mirrors pattern of viral illness)
- Pregnancy and birth complications
- Maternal drug use
Aetiology of schizophrenia (one of the most heritable mental conditions): Genetics
- Study by Sullivan found that about 80% of the symptom variation associated with schizophrenia can be attributed to genetic effects, can be 95% confident that that number is between 70-90%
- Study from Denmark (roughly same population size as NZ) compared identical and fraternal twins with respect to concordance rate of schizophrenia, calculated that it was approximately 73% (Hilker et al., 2018)
Concordance rate
Statistical measure that describes the proportion of pairs of individuals that share an attribute, given that one already possesses this trait
Aetiology of schizophrenia: Molecular genetics
- Genes DTNBP1, NGR1 - linked to NTs (dopamine), white matter development
- Genes COMT, DDNF - linked to prefrontal functioning
Aetiology of schizophrenia: Brain abnormalities
- Enlarged ventricles (linked to lower brain volume), found that when looking at identical twins, could accurately identify 12/15 identical twins with schizophrenia (Suddath et al., 1990)
- Prefrontal hypometabolism (information that is processed in the prefrontal lobe tends to be slower, less prefrontal lobe activity)
The neurodegenerative hypothesis for schizophrenia:
Individuals with schizophrenia have lower brain volumes than individuals without it, have a faster deterioration of brain matter than individuals without it