Psyc

• •Psychological
• dysfunction

• –Breakdown in cognitive, emotional, or behavioral
• functioning*

• •Distress
• or impairment

–Difficulty performing appropriate and expected roles

• –Impairment is set in the context of a person’s
• background

• •Atypical
• or not culturally expected response

–Reaction is outside cultural norms

• –Prototypes (listed as criteria) for various mental
• disorders

• •Scientific
• study of psychological disorders

• •Mental
• health professionals

–Clinical and counseling psychologists

–Psychiatrists

–Psychiatric (or non-psychiatric) social workers

–Psychiatric nurses

–Lay public and community groups

• •Keep
• up with latest developments, research

• •Evaluators
• of their work using empirical methods

• •Conduct
• research

–Describe psychological disorders

–Determine their causes

–Treat disorders

• •Begins
• with the presenting problem

• •Aim
• to distinguish clinically significant dysfunction from common human experience

–Statistical data

•Prevalence

•Incidence

•Sex ratio

• •Typical age of onset
• •Onset
• of disorders

–Acute vs. insidious onset

• •Course
• of disorders

–Episodic, time-limited, or chronic course

•Prognosis

–Good vs. guarded

•Age

What contributes to the development of psychopathology

–How can we help alleviate psychological suffering?

• –Includes pharmacologic, psychosocial, and/or combined
• treatments

–How do we know that we have helped?

–Limited in specifying actual causes of disorders

• •Deviant
• behavior as a battle of
• “Good” vs. Evil

–Caused by demonic possession, witchcraft, sorcery

• –Treatments included exorcism, torture, beatings, and
• crude surgeries

• •Deviant
• behavior caused by other phenomena—magnetic fields, moons, stars

• •Mental
• disorders attributed to disease or biochemical imbalances

• –Hippocrates: mental diseases can be treated like any
• other disease

–Galen: “Humoral theory of mental illness”

• –General paresis (syphilis) and the
• biological link with madness

–John Grey: more humane treatment

• •Abnormal
• behavior is attributed to faulty psychological development and to social
• context

• •The
• rise of moral therapy

–More humane treatment of institutionalized patients

–Encouraged and reinforced social interaction

–Asylum reform and mental hygiene movement

–Emergence of competing alternative psychological models

• •Freudian
• theory of the structure and function of the mind

• •Structure
• of the mind

• –Id (pleasure principle; illogical, emotional,
• irrational)

–Ego (reality principle; logical and rational)

–Superego (moral principles)

• •Defense
• mechanisms: unconscious protective processes to keep emotions in check

–e.g., displacement, denial,

• •Psychosexual
• stages of development

–Oral, anal, phallic, latency, and genital stages

• –Distinct patterns of gratifying our basic needs and
• satisfying our drive for physical pleasure

• •Anna
• Freud and ego/self-psychology

• –Emphasized influence of the ego in the development of
• psychological disorders

•The“neo-Freudians”: Departures from Freudian thought

–De-emphasized the sexual core of Freud’s theory

–Jung, Adler, Horney, Fromm, and Erikson

• •Melanie
• Klein, Otto Kernberg, and object
• relations theory

–Emphasized how children incorporate (introject) objects

• –Objects – images, memories, and values of significant
• others

• •Unearth
• the hidden intrapsychic conflicts or “the
• real problems”

• •Therapy
• is often long term

•Techniques

–Free association

–Dream analysis

• •Examine
• transference and counter-transference issues

• •Little
• evidence for efficacy

•Theme:

–People are basically good

–People are striving towards self-actualization

• •Focus
• on human potential and self-actualizing

–Maslow: hierarchy of needs

• –Rogers: client/person-centered therapy; unconditional
• positive regard

• •No
• strong evidence that humanistic therapies work (not enough research)

• •Also
• known as Cognitive-Behavioral Model or Social Learning Model

• •Derived
• from a scientific approach to the study of psychopathology

• •Challenged
• psychoanalysis and
• non-scientific approaches

• •Classical
• conditioning (Pavlov; Watson)

–Contingency between neutral and unconditioned stimuli

–Food (UCS) à Salivation (UCR)

• –Tone (CS) Food
• (UCS) à Salivation (UCR)

–Tone (CS) à Salivation (CR)

• –Conditioning was extended to the acquisition of and
• elimination of fear

• à Systematic
• desensitization

• •Operant
• conditioning (Thorndike; Skinner)

• –Voluntary behavior is controlled by consequences
• –Increase behavior (reinforcement)
• –Shaping (complex tasks)

• •Learning
• traditions influenced the development of behavior therapy

• –Behavior therapy tends to be time-limited and direct
• –Strong evidence supporting the efficacy of behavior
• therapies

• •Psychopathology
• is multiply determined
• •Unidimensional accounts of
• psychopathology are incomplete

• •Must
• consider reciprocal relations between

• –Biological, psychological, social, and experiential
• factors

• •Defining
• abnormal behavior

–Complex, multifaceted, and has evolved

• •The
• supernatural tradition

–Has no place in a science of abnormal behavior

•Explain behavior in terms of a single cause

•Tend to ignore information from other areas

•Biological

•Psychodynamic

•Cognitive-behavioral

•Humanistic

–Interdisciplinary, eclectic, and integrative

–“System” of influences that cause and maintain suffering

–Draw upon information from several sources

–Abnormal behavior results from multiple influences

•Major Influences

–Biological

–Behavioral

–Emotional

–Social & cultural

–Developmental

•Equifinality

–Many routes to same destination/disorder

•Multifinality

–Same event can lead to different outcomes

•Genotype vs. phenotype

• •Genes: long molecules of deoxyribonucleic acid
• (DNA)—double helix structure

–Provide boundaries to our development

–23 pairs of chromosomes

–Dominant vs. recessive genes

•Development & behavior is often polygenetic

•Genetic contribution to psychopathology

–Less than 50%

–Examples: depression

•Epigenetics

–Genes are not the whole story

–Environmental influences may override/turn on genetics

–Complex relationship between genes and environment

–

•Brain and spinal cord

•Processes information received from our sense organs

•Somatic and autonomic branches

• •Control muscles (and somatic—conveys sensory information
• to CNS)

•Two main parts

–Brainstem and forebrain

•Three main divisions

–Hindbrain

–Midbrain

–Forebrain

–Medulla – heart rate, blood pressure, respiration

–Pons – regulates sleep stages

–Cerebellum – involved in physical coordination

–Coordinates movement with sensory input

–Contains parts of the reticular activating system (RAS)

• •Most
• sensory, emotional, and cognitive processing

–Regulation of emotion and basic learning processes

–Variety of different brain structures

•Thalamus

Hypothalamus

–Gives us our distinctly human qualities

–2 Hemispheres

–Lateralized brain functions

• •Coordinates with brain stem to make sure body is working
• properly

•Somatic branch

–Controls voluntary muscles and movement

•Autonomic branch

–Regulates cardiovascular system & endocrine system

–Sympathetic and parasympathetic branches

•Collection of glands

–Ovaries/testes, pituitary, thyroid, adrenal

•Hormones: chemical messengers

•Regulates some aspects of normal development

•Abnormalities cause psychological symptoms

–hyperthyroidism

•Functions of Neurotransmitters

–Agonists, antagonists, and inverse agonists

–Most drugs are either agonistic or antagonistic

•Main types of neurotransmitters

–Serotonin (5-HT)

–Gamma aminobutyric acid (GABA)

–Norepinephrine

–Dopamine

–Most common

–Excitatory transmitter

–Major inhibitory neurotransmitter in brain

–Reduces anxiety

–Reduces overall arousal

•5-hydroxytryptamine (5HT)

•6 major 5HT circuits in brain

•Regulates behavior, mood, thought processes

• –Low levels: vulnerable to be less inhibited, more
• impulsive

•Drugs that affect 5HT system

–Tricyclic antidepressants

–SSRIs

–St. John’s Wort

•Also called noradrenaline

• •Important for attentiveness, emotions, sleeping,
• dreaming and learning

• •Also released into blood as hormoneà
• contractions of blood vessels and increased heart rate

•Stimulates 2 groups of receptors

–Alpha adrenergic

–Beta adrenergic

•Beta blockers

• •General effect of turning on various brain circuits
• associated with certain types of behavior

•Helps control brain’s reward and pleasure centers

•Regulates movement and emotional responses

•Implicated in:

–Schizophrenia

–Addiction

–Depression

–ADHD

–Parkinson’s disease

•Relations between brain and abnormal behavior

–Obsessive Compulsive Disorder (OCD)

•Effects of therapy

• –Change brain structure & function; “re-wire
• the brain”

–Baxter et al. (1992)

• •Brain imaging of patients with OCD; after treatment,
• brain circuit had been changed

•Psychosocial factors

• –Rats in rich environment vs. “couch
• potatoes”

–Stress in early development

•Conditioning and cognitive processes

•Classical and operant conditioning

•Social learning

–Modeling and observational learning

•Attribution

•Learned helplessness

•Prepared learning

–Fear certain things more than others

–“one trial learning”

•The function of emotion

–To elicit or evoke action

•Components of emotion

–Physiological

–Cognitive

–Behavioral

–Subjective experience

–Example of fear

–Influence the form and expression of behavior

–Gender roles

–Response to stress also different

–Frequency and quality important

–Related to mortality, disease, and psychopathology

–

The rule, not the exception

–Biological

–Psychological

–Social, cultural, and developmental factors

–Understanding the causes of psychopathology

–To best alleviate and prevent psychopathology

• ¡To understand the
• individual

¡To predict behavior

¡To plan treatment

• ¡To evaluate treatment
• outcome

¡Starts broad

• ¡Multidimensional in
• approach

• ¡Narrow to specific
• problem areas

¡Arrive at diagnosis

—Reliability

• ¡Consistency in
• measurement

• ¡Examples include
• test-retest and inter-rater reliability

—Validity

• ¡What an assessment
• approach measures and how well it does so

• ¡Examples include
• concurrent, discriminant, and predictive
• validity

—Standardization

• ¡Ensures consistency
• in the use of a technique

• ¡Provides population
• benchmarks for comparison

• ¡Examples include
• structured administration, scoring, and evaluation procedures

• ¡Most common clinical
• assessment method

• ¡Structured or
• semi-structured
• —Confidentiality

—Mental status exam

• ¡Appearance and
• behavior

¡Thought processes

¡Mood and affect

• ¡Intellectual
• functioning

¡Sensorium

—Semistructured clinical interviews

—Physical exam

• ¡Focus on the present
• – here and now

• ¡Direct observation of
• behavior-environment relations

• ¡Purpose is to
• identify problematic behaviors and situations

• ¡ABCs – Identify
• antecedents, behaviors, and consequences

• ¡Can be either formal
• or informal

• ¡Self-monitoring vs.
• being observed by others

• ¡Problem of reactivity
• using direct observation & self-monitoring

¡

—Psychological testing

• ¡Must be reliable and
• valid

—Various types

¡Disorder specific

¡Personality

¡Intelligence/neuropsychological

• —Projective tests –
• roots in psychoanalytic tradition

• ¡Project aspects of
• personality onto ambiguous test stimuli

• ¡Require high degree
• of inference in scoring and interpretation

¡Very controversial

—Examples

• ¡The Rorschach inkblot
• test

• ¡Thematic Apperception
• Test

• ¡Sentence completion
• test

—Objective tests

• ¡Roots in empirical
• tradition

• ¡Test stimuli are less
• ambiguous

• ¡Require minimal
• clinical inference in scoring and interpretation

—Personality tests

• ¡Minnesota Multiphasic Personality
• Inventory (MMPI; MMPI-2)

• ¡Extensive
• reliability, validity, and normative database

• —Nature of
• intellectual functioning and IQ

¡

• ¡Intelligence quotient
• (IQ)—deviation from average test performance

¡Wechsler tests

• ÷Verbal and
• performance domains

¡A total measure of “intelligence”?

• ¡Generally reliable,
• and predict academic success

• —Identify and measure
• cognitive impairments and functioning

• ¡Memory (short-term,
• and long-term)

• ¡Ability to learn new
• skills and solve problems

• ¡Attention,
• concentration, distractibility

• ¡Logical and abstract
• reasoning functions

• ¡Ability to understand
• and express language

• ¡Visual-spatial
• organization and visual-motor coordination

• ¡Planning, organizing
• abilities

• —Useful for detecting
• organic brain damage/pinpoint location of brain dysfunction

• —Use as screening
• devices or pair with other assessments to decrease false negative/positive

—Psychophysiological assessment

• ¡Assess brain
• structure, function, and activity of the nervous system

—Psychophysiological assessment domains

• ¡Electroencephalogram
• (EEG) – brain wave activity.

• ¡ERP – Event related
• potentials

• ¡Heart rate and
• respiration – cardiorespiratory activity

• ¡Electrodermal response and levels
• – sweat gland activity

—Advantages

• ¡Less subject to
• voluntary control (harder to fake)

• ¡Some can be used
• while awake, some while asleep

—Limitations

• ¡Need equipment and
• trained technician ($)

• ¡Frightening/intimidating
• for some (skew results)

• ¡Individual
• differences (useful?)

• ¡Confounding variables
• (useful?)

¡ICD

• ÷International
• Classification of Diseases

÷ICD-10

• ÷Published by the
• World Health Organization (WHO)

¡DSM

• ÷Diagnostic and
• Statistical Manual of Mental Disorders

÷DSM-IV-TR

—Case study method

• ¡Extensive observation
• and detailed description of a client

• ¡Foundation of early
• historic developments in psychopathology

—Limitations

• ¡Lacks scientific
• rigor and suitable controls

• ¡Internal validity is
• typically weak

• ¡Often entails
• numerous confounds

—Limitations

• ¡Correlation ≠
• Causation

• ¡Problem of
• directionality

• —Epidemiological
• research – an example of the correlational method

• ¡Incidence,
• prevalence, and course of disorders

• ¡Examples – AIDS,
• trauma following disaster

• —Nature of
• experimental research

• ¡Manipulation of
• independent variables

• ¡Attempt to establish
• causal relations

• —Group experimental
• designs

• ¡Control
• groups—placebo effect

¡Double-blind controls

• —Comparative treatment
• designs

¡Type of group design

• ¡Compare different
• forms of treatment in similar persons

• ¡Addresses treatment
• process and outcome

—Research strategies

• ¡Cross-sectional
• designs and the cohort effect

• ¡Longitudinal designs
• and the
• cross-generational effect

• ¡Sequential designs –
• combine both strategies

• ¢Important
• roles

• —Fear:
• avoid danger

• —Anxiety:
• anticipate/prepare for important events in future

• ¢Characteristics
• of anxiety disorders

• —Pervasive
• and persistent symptoms of anxiety and fear

• —Involve
• excessive avoidance and escape

• —Cause
• clinically significant distress and impairment

• ¢Share
• similarities with mood dx.

• —Negative
• emotional responses (guilt, worry, anger).

• —High
• comorbidity between mood and anxiety dx.

• —Maybe
• share common causal factors—stressful life events, cognitive factors, certain
• brain regions or neurotransmitters
• —

—

• ¢Genetic
• vulnerability

• ¢Coupled
• with stress (or other psychosocial factors)

¢Brain:

• —Depleted
• levels of GABA

• —Noradrenergic
• system

• —Serotonin
• level

• —Corticotropin-releasing
• factor (CRF) system

—

• ¢Integrated
• model

• ¢Early
• childhood - Experiences with uncontrollability and unpredictability

• —Parenting—”secure
• home basis” vs. “clear the way”.

¢Conditioning

• ¢Catastrophic
• thinking and appraisals play a role

• ¢Stressful
• life events trigger vulnerabilities

—Social/interpersonal

—Physical

• ¢Comorbidity
• is common across the anxiety disorders

• ¢Major
• depression is the most common secondary diagnosis

• ¢Share
• similarities with mood dx.

• —Negative
• emotional responses (guilt, worry, anger).

• —Maybe
• share common causal factors—stressful life events, cognitive factors, certain
• brain regions or neurotransmitters

• —Additional
• diagnoses (depression/SUDs) makes prognosis of anxiety disorders more tenuous.

• ¢General,
• diffuse emotional reaction (beyond fear) that is out of proportion to threats
• from environment.

• ¢Associated
• with anticipation of future problems.

• ¢Pessimistic
• thoughts and feelings

• ¢Attention
• turned inward, focusing on negative emotions and self-evaluation

• ¢Generalized
• anxiety disorder (GAD)

• ¢Panic
• disorder with and without agoraphobia

• ¢Specific
• phobias

• ¢Social
• phobia

• ¢Posttraumatic
• stress disorder (PTSD)

• ¢Obsessive-compulsive
• disorder (OCD)

• ¢Overview
• and defining features

• —Excessive
• uncontrollable anxious apprehension and worry

• —Worry
• about number of different activities/events

• —Persists
• for six months or more

• —Accompanied
• by (3+):

¢Restlessness, keyed up or on edge

¢Being easily fatigued

¢Difficulty concentrating, mind going blank

¢Irritability

¢Muscle tension

¢Sleep disturbance

¢Treatment:

• ¢Combination
• of medicine and cognitive-behavioral therapy (CBT) works best.

• ¢CBT—help
• to identify, understand, and modify faulty thinking and behavior patterns.
• Helps to learn how to control worry.

• ¢Meditation,
• relaxation therapy

• ¢Medications
• that may be used:

• —SSRIs—usually
• 1st choice

—SNRIs

• —Other
• antidepressants and some anti-seizure medications (severe cases)

• —Benzodiazepines—if
• antidepressants don’t control symptoms enough; issue of long-term dependence

—Buspirone (Buspar)

¢Prognosis:

• Most get
• better with a combination of medication and behavioral therapy.

• ¢Sudden,
• overwhelming experience of terror/fright

• ¢Maybe
• normal fear response triggered at inappropriate time

• ¢False
• alarm

• ¢More
• intense; sudden onset

• ¢Defined
• in terms of list of somatic or physical sensations (heart palpitations,
• sweating, numbness, nausea, chills, etc.)

• ¢Develop
• suddenly, reach peak intensity w/in 10 min.

• ¢Cognitive
• symptoms—about to die, lose control or go crazy

¢Cued or uncued

• ¢Overview
• and defining features

• —Experience
• of unexpected panic attack (i.e., a false alarm)

• —Develop
• anxiety, worry, or fear about another attack

• —Many
• develop agoraphobia

• ¢Agoraphobia:
• “fear of marketplace” = fear of public spaces
• ¢Affects
• about 2.7% of the general population.

• ¢Onset is
• often acute, mean onset between 20 and 24 years of age.

• ¢Agoraphobia
• more common among females.

• ¢Some
• develop agoraphobia without having a full-blown panic attack (agoraphobia w/o
• history of panic disorder).

• ¢Agoraphobia—primary
• phobia in elderly (>50 yrs)
• —

• ¢Nocturnal
• panic attacks

• —60% of
• people with panic disorder have experienced them.

• —Most
• often occur between 1:30am and 3:30am.

• —During
• delta (slow) wave sleep—deepest stage of sleep.

• —Cause:
• physical sensations of “letting go”

• ¢Causes of
• panic disorder

• —Biological
• vulnerability for emergency alarm reaction to stress

• —Conditioning
• of internal/external cues

• —Belief
• that unexpected bodily sensations are dangerous

• —Interpret
• normal physical sensations in catastrophic ways

¢Medications

• —Target serotonergic,
• noradrenergic, and GABA systems

• —SSRIs
• (e.g., Prozac and Paxil) are preferred drugs

• —Relapse
• rates are high following medication discontinuation

• ¢Psychological
• and combined treatments

• —Cognitive-behavioral
• therapies are highly effective.

¢Exposure based treatment

¢Panic control treatment

• —No
• evidence that combined treatment produces better outcome.

• —Benzodiazepines
• may interfere with psychologoical tx.

• —D-cycloserine to help
• unlearning conditioned fear.

• ¢Persistent,
• irrational, narrowly defined fears that are associated with a specific object
• or situation.

¢Avoidance

• ¢Irrational
• or unreasonable

• Interferes
• with ability to function

• •Racing or pounding heart
• •Chest pain or tightness
• •Trembling or shaking

• •Feeling dizzy or lightheaded
• •A churning stomach
• •Hot or cold flashes; tingling sensations;
• sweating

• •Intense need to
• escape
• •“Unreal” or detached from
• yourself

• •Fear of losing control/going
• crazy
• •Feeling like you’re going to die or
• pass out
• •Powerless to
• control your fear

• ¢4 major
• subtypes

—Blood-injury-injection

• —Situational
• (planes, elevators, etc.)

• —Natural
• environment (heights, storms)

• —Animal
• type

—“Other”

• ¢Separation
• Anxiety Disorder

• ¢Females
• are again over-represented

• ¢Affects
• about 12.5% of the general population

• ¢Phobias
• tend to run a chronic course

• ¢Causes of
• phobias

• —Direct
• experiences

• —Observational
• learning experience

• —Information
• transmission

• —Inherited
• tendency; susceptibility to developing anxiety about possibility that event
• will happen again

• ¢Psychological
• treatments:

• —Cognitive-behavior
• therapies – exposure

• —Separation
• anxiety – involve parents

• —Blood-injury-injection
• phobia – exposure + muscle tension

• ¢Overview
• and defining features

• —Extreme
• and irrational fear in social/performance situations

• —Markedly
• interferes with one’s ability to function

• —Often
• avoid social situations or endure them with great distress

• —Realize
• that fear is irrational or exaggerated

• —Generalized
• subtype – affects many social situations

¢Causes

• —Evolutionary
• and biological vulnerability

• —Traumatic
• social experiences—childhood

• —Learning
• that social evaluation is dangerous

• ¢Psychological
• treatment

• —Cognitive-behavioral
• treatment (CBT): understand, change thoughts that cause anxiety

¢Group format

• —Systematic
• desensitization or exposure therapy

• —Social
• skills training: to practice social skills

• ¢Role playing, modeling
• ¢Medication
• treatment

• —Tricyclic
• antidepressants and monoamine oxidase inhibitors

• —SSRIs
• Paxil, Zoloft, and Effexer – FDA approved

• —Relapse
• rates are high following medication discontinuation

• ¢Psychological
• vs. medication treatment

• —Psychological
• tx better – lower relapse rates; degree of change due to tx.

• —Combination
• tx – mixed results

• ¢Occurs
• after experiencing/witnessing traumatic events.

• —Combat/military
• exposure; child sexual/physical abuse; terrorist attack; sexual/physical
• assault; serious accidents; natural disasters, etc.

• ¢Re-experiencing
• (memories, nightmares, flashbacks)

• ¢Avoidance
• (thoughts/feelings/memories, isolation, numbing)

• ¢Hyperarousal
• (irritability, sleep problems)

• ¢Additional
• problems: relationship, employment, drinking/drugs

• ¢Markedly
• interferes with one's ability to function

• PTSD
• diagnosis – only after one month post-trauma; before one month – acute stress
• disorder

• —Intensity
• of the trauma and one's reaction to it

• —Learn
• alarms – direct conditioning and observational learning

• —Biological
• vulnerability

• —Generalized
• psychological vulnerability—early experiences of unpredictability; family
• instability

• Extent of
• social support, or lack thereof, post-trauma

• ¢
• Psychological treatments

• —Aim: face
• trauma, process intense emotions, and develop effective coping mechanisms

• —Cognitive-behavioral
• therapies (CBT) are highly effective

—SSRIs

¢Obsessions

• —Repetitive,
• unwanted, intrusive cognitive events (thoughts/images/impulses)

¢Sudden

¢Increase subjective anxiety

• ¢Content: symmetry, “forbidden thoughts or actions,”
• cleaning or contamination. hoarding

¢Compulsions

• —Repetitive
• behaviors or mental acts that are used to reduce anxiety.

• ¢Examples: door checking, cleaning, repeating silent
• prayer, counting to certain number, etc.

• ¢Some senseless; most irrational in degree to which they
• need to be performed

¢Cannot resist

• ¢Tic
• disorder

• —Involuntary
• movement

• —More
• complex tics (involuntary vocalization): Tourette’s disorder

¢Hoarding

• —Fear they
• can’t throw things away b/c of potential use or sentimental value

• —Not
• aware—not willing to recognize that they have a problem

Depression

mania

• —Vary from
• person to person.

• —5 types
• of symptoms:

◦Emotional:

• –Feel
• sad/dejected

• –“miserable,
• empty, humiliated”

• –little
• pleasure from anything à anhedonia
• (inability to experience any pleasure at all)

• –Anxiety,
• anger, agitation

• –Crying
• spells
• —Motivational:

• ◦Lose
• desire to pursue activities

• ◦No drive,
• initiative, spontaneity

• ◦Social
• withdrawal

• ◦Suicide
• (6-15% commit suicide)

—Behavioral:

• ◦Less
• active, productive

• ◦More time
• alone

• ◦Move or
• speak more slowly
• —Cognitive:

• ◦Extremely
• negative views of self

• ◦Blame
• self, never giving credit to self

◦Pessimism

• ◦“hopeless,
• helpless” (vulnerable to suicidal thinking)

◦“confused”

• Poorer
• performance on memory, attention, reasoning tests

• —DSM-IV-TR—major
• depressive episode

◦5+ symptoms of depression

–Depressed mood most of the day, nearly everyday

–Markedly diminished interest/pleasure activities

–Significant weight change OR appetite change

–Insomnia/hypersomnia

–Psychomotor agitation/retardation

–Fatigue/loss of energy

–Feelings of worthlessness, excessive guilt

–Reduced ability to think/concentrate OR indecisiveness

–Recurrent thoughts of death/suicide

◦Lasting for 2+ weeks

◦Significant distress or impairment

◦

Overview and defining featuresSymptoms are milder than major depressionPersists for at least two yearsNo more than two months symptom freeSymptoms can persist unchanged over long periods (≥ 20 years)Facts and statisticsLate onset – typically in the early 20s

• —Overview
• and defining features

• ◦Major
• depressive episodes and dysthymic disorder

• ◦Dysthymic disorder
• often develops first

• —Facts and
• statistics

• ◦Associated
• with severe psychopathology

• ◦Associated
• with a problematic future course

• —Stress
• can trigger depressive episode.

• —Poorer
• response to tx if stress. Longer time to remission.

• —Depressed
• people report experiencing more stressful life events.

• —Biochemical
• Factors

• ◦Low
• activity of norepinephrine and serotonin

• ◦Interaction
• b/w norepinephrine and
• serotonin, and w/ other neurotransmitters

• ◦Endocrine
• system

• –High
• level of cortisol

• –More
• melatonin
• —Brain
• anatomy and brain circuits

• ◦Prefrontal
• cortex

◦Hippocampus

• –Reduced neurogenesis; reduced
• size

◦Amygdala

• –Greater
• activity and blood flow

◦Broadmann Area 25

–Under cingulate cortex

• –Smaller
• in depressed patients; more active with depression

—Antidepressants

• ◦Monoamine oxidase (MAO)
• inhibitors

• –Slow body’s production of enzyme “monoamine
• oxidase” (MAO)

–MAOs break down serotonin/norepinephrine

–Inhibiting MAOs, stop destruction of norepinephrine à more norepinephrine activity


–~50% who take them find MAOIs to be helpful

• –Potentially dangerous if consume foods containing
• chemical “tyramine”

◦Tricyclics

• –Acts on neurotransmitter “reuptake”
• mechanism

–60-65% improved, but need to take for at least 10 days

– —Antidepressants

• ◦SSRIs
• & SNRIs

• –Harder to
• overdose

• –No
• dietary problems

• –Better
• side effect profile

• —Electroconvulsive
• therapy (ECT)

• ◦2
• electrodes attached to head, 65-140 volts of electricity passed through brain
• for <1/2 second à brain
• seizure (~25 sec to few min)

• ◦6-12
• treatments spaced over 2-4 wks

• ◦Strong
• muscle relaxants to minimize convulsions

• ◦Also use
• anesthetics to put patients to sleep

• ◦Memory
• problems

• ◦60-80%
• improve

• —Behavioral
• model

• ◦Less
• positive rewards à fewer
• constructive behaviors

• ◦Social
• rewards

—Treatment

• ◦Increase
• positive behaviors

• ◦Ignore
• depressive behaviors, praise/reward constructive statements and bx

• ◦Social
• skills training (eye contact, facial expression, posture)

• ◦Combination
• of 2+ behavioral techniques can be helpful.
• —Cognitive
• model

• ◦Learned helplessness—become depressed when: 1) no
• control over rewards/punishments; 2)
• responsible for helpless state

◦Attribution-helplessness theory

◦Negative thinking (Beck)

–Maladaptive attitudes

–Cognitive triad

–Errors in thinking

• –Automatic thoughts
• —Cognitive
• treatment = cognitive therapy

• ◦Behavioral
• activation

• ◦Challenge
• automatic thoughts

• ◦Identifying
• negative thinking and biases

• ◦Changing
• primary attitudes

• —Experience
• both depression and mania

• —Emotional
• roller coaster

• —Number of
• sufferers become suicidal

• —Tremendous
• impact on friends and family

—

• —Elevated,
• expansive mood or extreme irritability for at least 1 week

• —5 types
• of symptoms.

—Motivational:

• —Want
• constant excitement, involvement, companionship

• —Enthusiastically
• seek out people, interests

• —Little
• awareness that their social style is
• overwhelming, domineering, excessive.

—Behavior:

• ◦Very
• active

• ◦Move
• quickly (not enough time)

• ◦Talk
• fast, loud

◦Flamboyant

• ◦Dressing
• in flashy clothes

• ◦Getting
• involved in dangerous activities
• —Cognitive

• ◦Poor
• judgment/planning

• ◦Inflated
• opinion of themselves (grandiose self-esteem)

• ◦May not
• be coherent or in touch with reality

—Physical

• ◦High
• level of energy

• ◦Little
• sleep, but wide awake

• —Full
• manic episode: abnormally high or irritable mood for > 1 week + 3 other symptoms of mania

• ◦Inflated
• self-esteem or grandiosity

• ◦Decreased
• need for sleep

• ◦More
• talkative than usual or pressure to keep talking

• ◦Flight of
• ideas or experience that thoughts are racing

◦Distractibility

• ◦Increase
• in activity or psychomotor agitation

• ◦Excessive
• involvement in pleasurable activities that have a potential for painful
• consequences

• —Bipolar
• I:

• ◦Full
• manic and major depressive episodes

• ◦Most
• experience alternation of episodes

• ◦Some have
• mixed episodes

• —Bipolar
• II:

• ◦Hypomanic and
• major depressive episodes

• —Cyclothymic
• disorder:

• ◦Numerous
• periods of hypomanic symptoms and mild depressive
• symptoms

• ◦Continue
• for 2+ yrs, interrupted for days/weeks

• ◦Milder
• symptoms can blossom into bipolar I or II disorder

—Neurotransmitters

• ◦High
• activity level of norepinephrine in mania

• ◦Low
• activity level of 5-HT

• —Brain
• structures

• ◦Smaller
• basal ganglia and cerebellum

• —Genetic
• factors

• ◦Identical
• twins 40% vs. fraternal twins 5-10%

• ◦Number of
• chromosomes identified

—Lithium

• ◦Silvery
• white element found in various simple mineral salts

• ◦Primary
• drug of choice

• ◦Take 1-2
• weeks for effectiveness

• ◦Need
• blood tests

• —Other
• mood stabilizers

◦Antiseizure drug

–Carbamazepine (Tegretol)

–Valproate or valproic acid (Depakote)

–

–

• —Emphasize
• importance of continued medication regimen

• —Focus on
• family, social, school and occupational problems related to bipolar disorders.

• —Reduces
• hospitalizations, improves social functioning, increases ability to obtain and
• hold a job.

• —Stressful
• events

• ◦Loss of
• loved one, loss of job
• —Alcohol/drug
• use

• ◦Lower
• fears of committing suicide, impairs ability to think and problem-solve

• —Mental
• disorders

• ◦Majority
• of people who attempt suicide have some kind of a mental disorder

• Depression,
• alcohol dependence, schizophrenia, borderline personality disorder
• ◦Serious
• illness, abusive environment,
• occupational stress

• —Mood and
• thought changes

• ◦Increase
• in sadness, anxiety, tension, frustration, anger, shame

• ◦“psychache” feeling
• of psychological pain that seems intolerable

• ◦Preoccupied
• w/ problems, lose perspective, see suicide as only option

• ◦Sense of
• hopelessness

• ◦Dichotomous
• thinking

• —Preoccupation with
• eating or not eating

• —Feeling out of
• control in presence of food

• —Obsessions about
• food, weight and body shape

• —Often a way of
• managing emotional distress and coping with life’s demands

• —Refusal to maintain
• body weight above a minimally normal weight for age and height

• —Intense fear of
• gaining weight, even though underweight

• —Disturbed body
• perception, undue influence of weight or shape on self-evaluation, denial of
• seriousness of current low weight

• —In post-menarcheal females, amenorrhea
• (absence of at least 3 consecutive menstrual cycles)

• —Amenorrhea—absence of
• menstrual cycles

—Other problems:

• ◦Lowered body
• temperature

◦Low blood pressure

◦Body swelling

• ◦Reduced bone mineral
• density

◦Slow heart rate

• ◦Metabolic/electrolyte
• imbalances

• ◦Skin problems,
• brittle nails, cold hands/feet, hair loss, lanugo growth

—Binge-purge syndrome

—DSM:

• ◦Recurrent episodes of
• binge eating

• ◦Recurrent
• inappropriate compensatory behavior in order to prevent weight gain

• ◦Symptoms continuing,
• on average, at least 2x a week for 3 months

• ◦Undue influence of
• weight or shape on self-evaluation

—Similarities

• ◦Typically begin after
• period of dieting by people who are fearful of becoming obese; driven to become
• thin; preoccupied with food, weight and
• appearance; need to be perfect

• ◦Believe they weight
• too much and look too heavy regardless of actual appearance

• ◦Disturbed attitudes
• toward eating

◦ —Differences

• —AN tends to be more
• chronic and resistant to tx

• —BN more concerned
• about pleasing others, being attractive to others and having intimate
• relationships

• —BN more histories of
• mood swings, become easily frustrated or bored, trouble coping effectively and
• controlling impulses and strong emotions

—Medical complications

–½ women with BN amenorrheic

• –BN erosion of dental
• enamel

• –BN electrolyte
• imbalance

• –BN à Kidney
• failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon
• damage

–

—Biological Factors

• ◦Run in families;
• genetic component

• ◦Relatives of patients
• with EDs 4-5x more likely than general population to have ED

• ◦Inherit nonspecific
• personality traits

• –Emotional
• instability, poor impulse control?

• –Perfectionistic traits with negative
• affect

• ◦Hypothalamus &
• major neurotransmitter systems

• Low
• levels of serotonergic activity
• (impulsivity, binge eating)
• —Psychological
• dimensions

• ◦Diminished sense of
• personal control and confidence in abilities/talents (low self-esteem)

◦Perfectionistic tendencies

• ◦“Perfect storm” of
• low self-esteem & perfectionistic tendencies

• ◦Preoccupied with what
• others think

• ◦Subgroup of patients
• have difficulties tolerating any negative emotion (mood intolerance)

—Two main goals:

• ◦Correct dangerous
• eating patterns as quickly as possible

• ◦Address broader
• psychological and situational factors that have led to and maintain eating
• problem

• —Immediate goal to
• help regain lost weight, recover from malnourishment and eat normally again

• —Life-threatening
• situations, force tube and intravenous feeding

• —Others, behavioral
• weight-restoration approaches

• —Combination of
• supportive nursing care, nutritional counseling, relatively high-calorie diet
• —Longer term goal

• ◦Must overcome
• underlying psychological problems

• ◦Combination of
• education, psychotherapy, family approaches

• ◦CBT: identify “core” beliefs fueling restricted
• eating, monitor feeling/hunger/food intake, coping skills, teach appropriate
• ways to exercise self-control, change attitudes about eating/weight
• —Family therapy

• ◦Identify troublesome
• family patterns, and help to make appropriate changes

• ◦Help person with AN
• to separate her feelings and needs from those of others

• —Treatment generally
• effective, but recovery is not always permanent

• —More weight they had
• lost, and more time they had before entering treatment, the poorer the recovery
• rate

—

• —Goals: eliminate
• binge-purge patterns and establish good eating habits, eliminating underlying
• causes for BN (thoughts, etc.)

• —Emphasizes education
• and therapy

—CBT:

• ◦Behavioral: keep
• eating records, monitor hunger/fullness, other feelings. Also use exposure and
• response prevention

• ◦Cognitive:
• recognize/change their maladaptive attitudes towards food/eating/weight/shape.

• Helpful
• for as many as 65% of patients
• —Interpersonal
• psychotherapy

• —Supplemented by
• family therapy

• —All therapies can be
• in group format

• —Antidepressant
• medications can be helpful for those with BN

• —Combination of CBT +
• antidepressants may be best

• —With treatment, 40%
• improve

• —10 years after
• treatment, 70% have recovered fully, 19% recovered partially.

This is the top-level diagnosis that usually represents the acute symptoms that need treatment; Axis 1 diagnoses are the most familiar and widely recognized (e.g., major depressive episode, schizophrenic episode, panic attack)

Axis II, is for personality disorders and developmental disorders such as mental retardation. Axis II disorders, if present, are likely to influence Axis I problems. For example, a student with a learning disability may become extremely stressed by school and suffer a panic attack (an Axis I diagnosis)

Axis III is for medical or neurological conditions that may influence a psychiatric problem. For example, diabetes might cause extreme fatigue which may lead to a depressive episode.

Axis IV identifies recent psychosocial stressors such as a death of a loved one, divorce, losing a job, etc.Psychosocial and Environmental Problems

Axis V identifies the patient's level of function on a scale of 0-100, (100 is top-level functioning). This is known as the Global Assessment of Functioning (GAF) Scale