Psychopathology: Trauma, Dissociative, Somatic, Bipolar, and Depression

Question 1

Diagnostic criteria for Reactive Attachment Disorder?

Answer 1

(1) persistent pattern of inhibited and emotionally withdrawn behavior toward adult caregivers - as demonstrated by a lack of seeking or responding to comfort when distressed

(2) persistent social and emotional disturbances that include at least two of the following:
(a) minimal social and emotional responsiveness to others
(b) limited positive affect
(c) unexplained irritability, sadness or fearfulness when interacting with adult caregivers

** must be a hx of extreme insufficient care, onset of sx’s before age 5, must have a developmental age of at least nine months**

Question 2

Diagnostic criteria for disinhibited social engagement disorder?

Answer 2

• persistent pattern of behavior that includes inappropriate interactions with unfamiliar adults as demonstrated by at least two of four symptoms:

(1) reduced or absent reticence in approaching or interacting with strangers

(2) willingness to accompany a stranger with little or no hesitation

(3) overly familiar behavior with strangers

(4) diminished or absent checking with adult caregivers after ebing separated from them

** requires a hx of extreme insufficient care, developmental age of at least nine months

Question 3

Diagnostic criteria for acute stress disorder?

Answer 3

• requires exposure to actual or threatened death, severe injury or sexual violation
• must have at least 9 sx from any of the 5 categories
• sx lasted 3 days - 1 month cause sig distress

5 categories: intrusion, negative mood, dissociative sx, avoidance, arousal)

Question 4

Diagnostic criteria for prolonged grief disorder?

Answer 4

• death of a person close at least 12 months ago (6 months for children/adolesents)
• grief response must include an intense yearning for the deceased person and/or preoccupation w/thoughts about the person
  +
  *3 or more of 8 symptoms nearly every day for at least the previous month:
  1 - a marked sense of disbelief about the death
  2 - avoidance of reminders of the deceased person
  3 - emotional numbness
  4 - intense loneliness as a result of the death

Question 5

Diagnostic criteria for PTSD for all ages?

Answer 5

• symptoms must have lasted for more than one month
• cause significant distress or impaired functioning
• due to exposure to actual or threatened death, serious injury, or sexual violence.
• symptoms for all age groups represent four types: 1 - intrusion (e.g., recurrent distressing memories of the event)
  2 - persistent avoidance of stimuli associated with the traumatic event,
  3 - negative changes in mood or cognition
  4 - alterations in arousal and reactivity.

Question 6

Brain and neurotransmitter abnormalities in PTSD?

Answer 6

1 - hyperactive amygdala and anterior cingulate cortex

2 - hypoactive ventromedial prefrontal cortex

3 - reduced volume of hippocampus (some studies suggest increased activity and others suggest decreased activity)

4 - reduced activity in ventromedial prefrontal cortex reduces inhibitory top-down control of the amygdala resulting in exaggerated fear response (typically the ventromedial prefrontal cortex ordinarily inhibits activity of the amygdala)

5 - increased levels/activity: dopamine, norepinephrine and glutamate

decreased levels/activity: serotonin and GABA

Question 7

What psychological treatments are recommended by the APA for PTSD?

Answer 7

1 - CBT, cognitive therapy, prolonged exposure, cognitive processing therapy (challenging negative cognitions with writing and reading a detailed description

2 - brief eclectic psychotherapy, EMDR (eye movement desensitization and reprocessing), narrative exposure therapy
(EMDR has conflicting evidence)

(ineffective and may worsen sx: single session debriefing (i.e. critical incident stress debriefing and group debriefing))

• telepsychology is similar to face to face (similar symptom reduction, attendance and drop out rates, client satisfaction) - some barriers to building therapeutic alliance such as missing nonverbals

Question 8

Who was trauma focused cognitive behavior therapy (TF-CBT) developed for?

Answer 8

Children and adolescents (3-18 y/o) who have experienced sexual abuse (also used for other trauma)

• includes family therapy, parenting skills training and conjoin parent-child therapy

Question 9

Pharmacological PTSD tx for adults?

Answer 9

• SSRIs: fluoxetine, paroxetine, sertaline
  SNRI venlafaxine

Address depression that comes with PTSD and PTSD sx like re-experiencing, avoidance/numbing and hyperareousal

Question 10

what is the dsm definition for dissociative disorders?

Answer 10

“a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior”

Question 11

Diagnostic criteria of dissociative amnesia?

Answer 11

• inability to recall important personal information that cannot be attributed to ordinary forgetfulness and causes sig distress (often related to victimization or exposure to trauma)
• 5 Types of amnesia:
  1 - localized (an inability to recall all events that occurred during a circumscribed period of time) - most common
  2 - selective (an inability to recall some events that occurred during a circumscribed period of time)
  3 - generalized (a complete loss of memory for one’s entire life)
  4 - systematized (a loss of memory for a specific category of information)
  5 - continuous (an inability to remember new events as they happen)

Specifier: dissociative fugue - purposeful travel or wandering thats associated with loss of memory

Question 12

What is depersonalization / derealization disorder?

Answer 12

persistent or recurrent episodes of:

depersonalization (a sense of unreality, detachment, or being an outside observer of one’s thoughts, actions, etc.)

or

derealization (a sense of unreality or detachment with regard to one’s surroundings)

accompanied by intact reality testing and significant distress or impaired functioning.

Question 13

what is somatic symptom disorder?

Answer 13

one or more somatic symptoms that are distressing or cause a significant disruption in daily life

and

are accompanied by excessive thoughts, emotions, or behaviors related to the symptom(s) or associated health concerns as indicated by the presence of at least 1 of the following:

• disproportionate or persistent thoughts about the seriousness of the symptoms
• a persistently high level of anxiety about health or symptoms
• excessive time and energy spent on health concerns or symptoms.

Specifiers: mild, moderate, severe (lasted more than 6 months)
Involve predominate pain and are persistent

Question 14

What is illness anxiety disorder?

Answer 14

• a preoccupation with having a serious illness with no or mild somatic symptoms
• excessive anxiety about health
• or excessive health-related behaviors or avoidance of health care

** sx must be present for at least 6 months (symptoms can vary through that time)

Question 15

What is functional neurological symptom disorder (conversion disorder)

Answer 15

• one or more symptoms that involve a disturbance in voluntary motor or sensory functioning (e.g., paralysis, blindness)
• Symptoms don’t match any known neurological or medical condition - cause sig distress
• specifiers indicate symptom type, acute or persistent, presence or absence of a psychological stressor

(can involve psychogenic non-epileptic seizures (PNES) - resemble bx of a seizure but do not have brain electrical activity associated with seizures - document by video EEG (records brain activity and bx)

Question 16

What is factitious disorder?

Answer 16

• imposed on self
  Individuals with factitious disorder imposed on self falsify or induce physical or psychological symptoms that are associated with a deception (e.g., ingestion of a drug to produce abnormal lab results). They present themselves to others as being ill or impaired and engage in the deception even when there’s no obvious external reward for doing so.
• imposed on another
  Factitious disorder imposed on another has the same symptoms except that they’re induced in another person (often in a child by his/her mother).

Question 17

Difference between factitious disorder and malingering?

Answer 17

“malingering is differentiated from factitious disorder by the intentional reporting of symptoms for personal gain … [while] the diagnosis of factitious disorder requires that the illness falsification is not fully accounted for by external rewards”

Malingering: intentional production of physical or psychological symptoms for the purpose of obtaining a drug, financial compensation, or other external reward.

Question 18

When and how is malingering assessed?

Answer 18

• malingering should be suspected whenever a person seeks a medical evaluation for legal reasons, there’s a marked discrepancy between the person’s symptoms and objective findings, the person is uncooperative with evaluation or treatment, and/or the person has antisocial personality disorder.
• assessed using the forced choice method: presenting the person with test items that require the person to choose the correct answer from two or more alternatives. The use of this method is based on the assumption that people who are malingering will answer items incorrectly at a higher rate than would be expected by chance alone. For instance, when each item has two alternative answers (e.g., true or false), malingering is suggested when the person answers more than 50% of the items incorrectly.

Question 19

How is feigned memory loss associated with factitious disorder and malingering different from genuine memory loss?

Answer 19

• genuine memory loss due to traumatic brain injury: the beginning and end of the amnestic period are gradual and hazy and these individuals often remember fragments of some events that occurred during that period. often believe that hints or clues will help them recall their lost memories.
• Feigned memory loss: the onset and termination of the amnestic period are often sudden, and these individuals do not remember any events that occurred during this period

** Test of Memory Malingering (TOMM) was developed specifically to determine if an individual is feigning memory loss.
– uses a forced-choice format that requires individuals to respond to items by indicating which of two images was presented to them just prior to testing. Individuals who are malingering perform significantly below chance level (below 50% correct), which indicates they deliberately chose wrong answers.

Question 20

What is a manic episode?

Answer 20

• for at least 1 week
• abnormally and persistently elevated, expansive, or irritable mood
• increased activity or energy
• 3 or more characteristic symptoms (inflated self esteem or grandiosity, decreased need for sleep, flight of ideas)
• marked impairment in functioning
• a need for hospitalization to avoid harm to self/others
• and/or presence of psychotic symptoms

Question 21

What is a hypomanic episode?

Answer 21

• at least 4 consecutive days
• abnormally and persistently elevated, expansive, or irritable mood
• increased activity or energy
• 3 or more symptoms of mania (inflated self esteem or grandiosity, decreased need for sleep, flight of ideas)

(not as sever as manic episode - no need for hospitalization and no psychotic features)

Question 22

What is a major depressive disorder?

Answer 22

• 5 or more characteristic symptoms - 1 sx has to be either depressed mood or loss of interest or pleasure in most or all activities
• sx last for at least two weeks
• cause sig distress/impairment

Question 23

Diagnostic criteria for Bipolar I disorder?

Answer 23

• at least 1 manic episode
  that may or may not have been preceded or followed by one or more major depressive episode or hypomanic episode

Question 24

Diagnostic criteria for Bipolar II disorder?

Answer 24

• at least 1 hypomanic episode & at least one major depressive disorder

Question 25

Diagnostic criteria for cyclothymic disorder?

Answer 25

• requires numerous periods of hypomanic sx’s that do not meet criteria for a hypomanic episode
• numerous periods of depressive sx’s that do not meet criteria for a major depressive episode
• minimum duration of sx’s is 2 years for adults (1 year for children/adolescents)

Question 26

Concordance rate for bipolar disorder?

Answer 26

.67 - 1.0 for monozygotic twins

.20 for dizygotic twins

Question 27

Neurotransmitters impacted by bipolar?

Answer 27

norepinephrine
serotonin
dopamine
glutamate

*circadian rhythm irregularities: sleep-wake cycle, secretion of hormones, appetite and core body temp

Question 28

brain abnormalities in bipolar disorder?

Answer 28

prefrontal cortex
amygdala
hippocampus
basal ganglia

Question 29

Top differential dx with bipolar disorder? and how to assess?

Answer 29

• ADHD and bipolar disorder share many sx: distractibility, irritability and accelerates speech
• Most manic specific sx’s (aka only Bipolar not ADHD) for 7-16 y/o: elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, hypersexuality

Mania in adults: euphoric, elevated or irritable mood, increased self-esteem or grandiosity, distractibility caused by thought acceleration, decreased need for sleep (usually w/o physical discomfort) - increased sexual activity
VS.
ADHD in adults: labile, dysphoric mood, reduced self-esteem, distractibility due to wandering (but not acceleration) of thoughts, fatigue and discomfort after loss of sleep - not necessarily increased sexual activity but higher rates of sexual disorders and risky sexual bx’s

Question 30

Treatment of bipolar disorder?

Answer 30

• Combination of psychosocial and pharmacotherapy

Psychosocial: psycoed, interpersonal and social rhythm therapy, CBT, family-focused therapy (similar to shizo, high expressed emotion by family members can trigger relapse)

Pharmacotherapy: lithium, anticonvulsant drugs (e.g. carbamazepine, valproic acid) and second gen antipsychotic drugs

lithium is most effective for “classic bipolar”
2nd gen antipsychotic most effective for “atypical bipolar)

Question 31

What does “classic bipolar” and “atypical bipolar” look like? What is the DSM “atypical features”?

Answer 31

classic: low likelihood of mixed mood states and rapid cycling, long periods of recovery between episodes, and an onset between 15 and 19 years of age

atypical: mixed mood states, rapid cycling, a lack of full recovery between episodes, and an onset between 10 and 15 years of age

atypical features: mood reactivity, at least 2 of the following - sig weight gain, increase in appetite, hypersomnia, leaden paralysis, interpersonal rejection sensitivity

Question 32

diagnostic criteria of major depressive disorder?

Answer 32

• 5 or more sx of a major depressive episode for at least 2 weeks at least one sx depressed mood or loss of interest/pleasure in most or all activities

Question 33

Diagnostic criteria for persistent depressive disorder?

Answer 33

• depressed mood with 2 or more characteristic sx (e.g. poor appetite or overeating, insomnia or hypersomnia, feelings of hopelessness) for at least 2 years in adults (1 year in children/adolescents)

Question 34

Diagnostic criteria for disruptive mood dysregulation disorder?

Answer 34

• for at least 12 months:

(1) severe and recurrent temper outbursts that are verbal and/or behavioral - grossly out of proportion - 3 or more times a week

(2) persistently irritable or angry mood that is observable to others - most of the day and nearly every day between outbursts

Question 35

DSM specifier for peripartum refers to what time period?

Answer 35

Pregnancy and up to 4 weeks postpartum

Question 36

Difference between MDD with peripartum onset and baby blues? Prevalence of baby blues vs MDD?

Answer 36

• up to 80% of women experience baby blues (sadness, irritability, anxiety) smaller percent experience MDD - of those who have MDD postpartum 50% experience it during pregnancy

Question 37

Treatment of MDD peripartum onset?

Answer 37

CBT and Interpersonal therapy for prevention and treatment

Antidepressants (esp. sertaline) - potential neg effects on fetus and newborns being breastfed

Impact of untreated maternal depression impacts both woman and child

Inconclusive evidence on exercise as an effective treatment on its own - exercise with co-interventions are statistically more sig than co-interventions alone

Question 38

what qualifies for the seasonal pattern specifier to MDD?

Answer 38

When there is a temporal relationship between mood episodes and time of year (usually winter)

Sx: hypersomnia, overeating, weight gain, craving of carbohydrates

• linked to lower-than-normal level of serotonin, higher-than-level melatonin
• responsive to phototherapy (exposure to bright light that suppresses production of melatonin)

(also known as seasonal affective disorder [SAD])

Question 39

Gender differences in prevalence of MDD and changes with age?

Answer 39

• childhood depression rates similar between boys and girls
• adolescence - female rates increase, males stay stable - perhaps bc hormone levels at puberty sensitizes females and desensitizes males too stress of neg life events
• in adulthood females persist at a higher rate 1.5 - 3x higher than male

Question 40

Concordance rates of MDD?

Answer 40

.3 - .5 for monozygotic twins
.2 - .3 dizygotic twins
* gender accounts for some of the variability (higher for female twins than male twins)

Question 41

Neurotransmitter etiology for MDD?

Answer 41

• low levels of serotonin, dopamine, norepinephrine
• hyperactive HPA axis (hypothalamic-pituitary-adrenal axis): exposure to chronic stress esp. in early life leads to hyperactive HPA axis and hypersecretion of cortisol

Question 42

Brain abnormalities of MDD?

Answer 42

• prefrontal cortex, cingulate cortex, hippocampus, caudate nucleus, putamen, amygdala, thalamus -
• High activity in ventromedial prefrontal cortex (vmPFC)
• Low activity in dorsolateral prefrontal cortex (dlPFC)
• Treatment reverses activity for each -

Question 43

Three behavioral/cognitive explanations of MDD?

Answer 43

1: Lewinsohn’s social reinforcement theory - low rate of response-contingent reinforcement for social behaviors due to lack of reinforcement in the environment and/or poor social skills leads to social isolation, low self-esteem, pessimism and other depressive sx and therefore decrease chance of positive reinforcement (operant conditioning)

2: Seligman’s learned helplessness model - repeated exposure to uncontrollable neg life events that result in a sense of helplessness and a reformulated version of neg life events stresses the role of negative cognitive style that involves attributing negative life events to stable, internal and global factors.

2a: hopelessness theory- neg events and neg cognitive style results in a sense of hopelessness as the proximal and sufficient cause of depression

3: Beck’s cognitive theory - negative cognitive triad that consists of negative thoughts about oneself, the world, and the future

Question 44

Risk factors for MDD by age groups (younger adults vs older adults)?

Answer 44

Younger adults: genetics, stressful life events, limitations in problem-solving and cog abilities

older adults: chronic medical illness is the strongest risk factor especially when it decreases physical functioning and social isolation - more likely to endorse somatic sx’s of depression/cog changes and loss of interest

Question 45

Common comorbid conditions with MDD (in order of prevalence)?

Answer 45

• substance use disorder is the most common (alcohol use)
• anxiety
• personality disorder
• Sleep abnormalities
• coronary heart disease
• stroke
• diabetes
• parkinson’s disease
  (bidirectional influence - dep increases risk of myocardial infarction and and MI increases risk of depression and anxiety)

Question 46

Sleep abnormalities to MDD?

Answer 46

• prolonged sleep latency (longer time to fall asleep)
• reduced REM latency (shortened time from sleep onset to REM sleep)
• reduced slow-was (stage 3 and 4) sleep
• increased REM density (more rapid eye movement per unit of time)

Question 47

What do studies show as the most effective treatment for MDD?

Answer 47

combine psychotherapy and pharmacotherapy was more effective than either on their own (in terms of response and remission rates)

Question 48

Depression treatment recommendations for children and adolescents?

Answer 48

• children: insufficient evidence to recommend any particular psychosocial or pharmacological treatment
• adolescent: CBT or interpersonal therapy for adolescents (IPT-A) and fluoxetine (not enough evidence to recommend one over the other)

Question 49

MDD treatment recommendations for adults?

Answer 49

• psychotherapy (CBT, mindfulness based cognitive therapy, interpersonal, behavioral, psychodynamic, support - all have equal effectiveness) or 2nd gen antidepressants (SSRI or SNRI)
• for treatment resistant depression: CBT, IPT and an anti-depressant (also based on patient preferences)
• for older adults: group -CBT or combination of IPT and 2nd gen antidepressant (not enough evidence for bibliotherapy)

Question 50

What is st. john’s wort benefits and risks?

Answer 50

• similar therapeutic effects to SSRIs for mild or moderate depression as well as lower dropout rates and fewer side effects
• not effective for severe depression and interacts with other drugs (alprazolam [xanax], bupropion [wellbutrin], or immunosuppressive drugs)

Question 51

What is ketamine used for?

Answer 51

(previously used as an anesthetic since the 1960s) - used as a fast acting treatment for treatment resistant depression and suicidal ideation.

• it increases glutamate levels and is prescribed as a nasal spray (esketamine) in conjuction with oral antidepressant. Self administered under supervision of healthcare provider because of severe potential side effects.

Question 52

When is ECT (electroconvulsive therapy) indicated and what are the risk factors?

Answer 52

• effective treating severe depression (esp. when other tx’s weren’t effective and high suicide risk)
• advantages: higher response rate (reduction in sx), higher remission rate and faster time to remission (absence or near absence of sx)

ECT response rate: 80% vs psychotherapy/pharmacotherapy response rate 30-60%

ECT remission rate: 70% vs psychotherapy/pharmacotherapy remission rate 25-45%

ECT remission in 1-3 weeks
IPT/CBT remission in 6-10 weeks
Antidepressants in 4-12 weeks

disadvantages:
* anterograde amnesia (an inability to form new memories after ECT) - usually resolves within a few weeks after the last ECT session.

• retrograde amnesia (an inability to recall events that occurred before ECT, more recently acquired memories more than remote memories) It begins to resolve within weeks to several months after the last ECT session, with older memories returning before more recent ones.
  – many patients experience persistent gaps in memory for events that occurred pre-ECT.
  – Retrograde amnesia is more severe for bilateral placement of electrodes than for right unilateral placement and for a larger number of treatment sessions and less time between sessions

Question 53

What is repetitive transcranial magnetic stimulation (rTMS)?

Answer 53

noninvasive technique that uses a magnetic field to stimulate the left dorsolateral prefrontal cortex - used for treatment resistant depression

• it has lower response and remission rate than ECT
• dosen’t require sedation or cause memory loss

Question 54

Suicide statistics?

Answer 54

• Rates increased in US from 2000-2018
• Rates decreased in US from 2018-2020
• Rates have been consistently higher for males than females (2000-2020 3-4x higher for males)

– suicide rates were highest in 2020 for:
75 and older and AIAN, then
White
Latinos
Black
API

– in 2020 highest rate among men, 75 and older, highest rate for females among 45-64
– in 2020 highest rate among AIAN, Latinos, Black 25-34 y/o, among White 45 to 54, among API 85 and older