Department of Psychology INTRODUCTION TO ABNORMAL PSYCHOLOGY PSYC 385 Welcome to one of the most fascinating and interesting undergraduate courses. The course provides a good understanding of the nature and treatment of major psychiatric disorders. Since the textbook covers detailed background information, the main focus of the lectures will be on clinical description, illustrated by numerous and varied cases, and elaboration of therapeutic techniques. The purpose of the lectures is to make the course informative and interesting. The students will have the opportunity to observe a hypnotic demonstration. Through hypnotic induction, dissociative phenomena and mind-body interaction will be demonstrated. Students will also have the opportunity to watch video-tapes on various psychiatric disorders. Good luck and enjoy the course! INTRODUCTION TO ABNORMAL PSYCHOLOGY PSYC 385 Instructor: Dr. Assen Alladin Phone: 670-1340 E-Mail: alladin@shaw.wave.ca Hours: By appointment Office: Department of Psychology, Foothills Medical Centre, 1403-29th St. N.W., Calgary, AB T2N 2T9 Texts: Nietzel, M.T., Speltz, M.L., McCauley, E.A., & Bernstein, D.A. (1998). Abnormal Psychology, Allyn & Bacon. Foust, J. (1998). Study Guide for Nietzel, Speltz, McCauley & Bernstein Abnormal Psychology, Allyn & Bacon. Lecture Notes can be obtained from the Psychology Society Office. Exams: Three exams, Multiple Choice (50 questions in each exam) ORGANIZATION OF TEXTBOOK The textbook has been carefully selected. In my opinion it is the best available introductory textbook on Abnormal Psychology. It is very innovative in its format and presentation. The Study Guide is optional. The Study Guide is recommended for those students wishing to master the subject matter and are determined to get good marks. Each chapter is organized into 12 sections: 1. From the Case of ..... 2. Developmental Psychopathology 3. Prevention 4. Diathesis-stress Model 5. Thinking Critically 6. Connections 7. A Talk with ..... 8. Revisiting the Case of ..... 9. In Review 10. Chapter Summaries 11. Key Terms 12. Resource Materials TABLE OF CONTENTS INTRODUCTION TO ABNORMAL PSYCHOLOGY 1 CHAPTER 1 7 MAKING SENSE OF ABNORMALITY: A BRIEF HISTORY 7 A. FARAWAY PLACES, ANCIENT TIMES, AND SUPERNATURAL FORCES 7 B. THE BIRTH OF THE MEDICAL TRADITION: THE CLASSICAL PERIOD 8 C. FROM DEMONS TO INSTINCTS: THE EUROPEAN TRADITION 10 D. CONTEMPORARY APPROACHES TO ABNORMALITY 15 E. PSYCHODYNAMIC THEORIES 18 F. BEHAVIOURAL THEORIES 22 G. PHENOMENOLOGICAL THEORIES 26 H. THE SOCIOCULTURAL MODEL 27 I. THE DIATHESIS – STRESS MODEL 28 CHAPTER 2 29 ASSESSMENT AND DIAGNOSIS 29 THREE CASES 30 MENTAL DISORDER DEFINED THROUGHOUT HISTORY 31 DIAGNOSTIC CLASSIFICATION 32 An example of DSM-IV Multiaxial Diagnosis 35 ASSESSMENT OF MENTAL DISORDERS 38 ASSESSMENT TOOLS 40 CHAPTER 3 44 DISRUPTIVE BEHAVIOUR DISORDERS 45 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) 50 ANXIETY DISORDERS 53 DEPRESSION IN CHILDHOOD AND ADOLESCENCE 56 FEEDING AND EATING DISORDERS 58 ELIMINATION DISORDERS 61 CHAPTER 4 63 A. MENTAL RETARDATION 64 B. AUTISTIC DISORDERS 73 C. LEARNING DISABILITIES 76 CHAPTER 5 77 STRESS 78 SLEEP DISORDERS 89 ADJUSTMENT DISORDERS 93 CHAPTER 6 98 HEALTH PSYCHOLOGY 99 CLASSIFYING PSYCHOLOGICAL FACTORS AFFECTING HEALTH 101 THE PSYCHOLOGY OF GETTING SICK 103 THE PSYCHOLOGY OF GETTING WELL AND STAYING WELL 108 CHAPTER 7 109 1. SPECIFIC PHOBIAS 110 2. PANIC DISORDER AND AGORAPHOBIA 114 3. OBSESSIVE-COMPULSIVE DISORDER (OCD) 117 CHAPTER 8 120 DISSOCIATIVE DISORDERS 121 SOMATOFORM DISORDERS 126 CHAPTER 9 129 MOOD DISORDERS (AFFECTIVE DISORDERS) 130 SUICIDE 137 CHAPTER 10 140 WHAT IS SCHIZOPHRENIA? 141 SYMPTOMS OF SCHIZOPHRENIA 142 TYPES OF SCHIZOPHRENIA 145 CAUSES OF SCHIZOPHRENIA 146 TREATMENTS OF SCHIZOPHRENIA 147 CHAPTER 11 148 1. NORMAL AGING 149 2. COGNITIVE DISORDERS AND AGING 150 3. AMNESTIC DISORDERS AND DELIRIUM 151 4. DEMENTIA 156 5. ALZHEIMER’S DISEASE 157 CHAPTER 12 159 CHARACTERISTICS OF PERSONALITY DISORDERS 160 DIAGNOSING PERSONALITY DISORDER 161 DIMENSIONAL DESCRIPTION OF PERSONALITY DISORDERS 162 ODD/ECCENTRIC PERSONALITY DISORDERS 163 DRAMATIC/EMOTIONAL/ERRATIC PERSONALITY DISORDERS 164 ANXIOUS/FEARFUL PERSONALITY DISORDERS 165 CAUSES OF PERSONALITY DISORDERS 166 CAUSES OF BORDERLINE PERSONALITY DISORDER 167 CAUSES OF APD 168 TREATMENT OF PERSONALITY DISORDERS 169 CHAPTER 13 170 DEFINING SUBSTANCE-RELATED DISORDERS 171 DSM-IV DIAGNOSIS OF SUBSTANCE-RELATED DISORDERS 172 ALCOHOL USE AND ALCOHOL-INDUCED DISORDERS 173 OTHER DEPRESSANTS 177 STIMULANTS 178 OPIODS (Morphine, Heroin, Codeine, Methadone) 180 CANNABIS AND HALLUCINOGENS 181 CHAPTER 14 182 SEXUAL AND GENDER IDENTITY DISORDERS 182 ASPECTS OF HUMAN SEXUALITY 183 GENDER IDENTITY DISORDER 187 SEXUAL DYSFUNCTIONS 189 SEXUAL DESIRE DISORDERS 190 SEXUAL AROUSAL DISORDERS 191 ORGASMIC DISORDERS 192 TREATMENT OF SEXUAL DYSFUNCTIONS 193 PARAPHILIAS 194 CHAPTER 16 195 WHAT IS PSYCHOTHERAPY? 196 METHODS OF PSYCHOTHERAPY 197 EVALUATING PSYCHOTHERAPY 203 CHAPTER 1 MAKING SENSE OF ABNORMALITY: A BRIEF HISTORY A. FARAWAY PLACES, ANCIENT TIMES, AND SUPERNATURAL FORCES 1. No written records prior to Egyptian and Mesopotamian cultures a. Archeological discoveries and interpretation of myths b. Trephining done to allow evil spirits to escape 2. Ancient Chinese, Egyptian and Hebrew civilizations a. Blamed abnormal behavior on evil spirits and demons b. Divine punishment for disobedience or other misbehavior 3. Treatment of abnormal behavior a. Prayer and faith healing timed with movements of planets and stars b. Exorcism rituals and correction of biological processes B. THE BIRTH OF THE MEDICAL TRADITION: THE CLASSICAL PERIOD 1. Development of formal philosophy by Greeks (600-500 B.C.E.) a. Belief that humans capable of understanding and controlling selves b. Critical analysis and observation refined (Plato and Aristotle) c. Plato: humans gained knowledge rationally d. Aristotle: analyzing perceived events leads to empirical method e. Hippocrates, “father of medicine”: restore balance f. Galen: refined humoral theory; prescribed medicine THE BIRTH OF THE MEDICAL TRADITION: THE CLASSICAL PERIOD, cont’d. 2. Chinese culture and philosophy of Taoism a. Proper balance between yin and yang b. Goal is to unify the two 3. Epictetus: “Men are disturbed not by things, but by the view of things.” 4. Marcus Aurelius, in Meditations: Opinions lead to unhappiness 5. Classical Period thinkers emphasize natural over supernatural causes 6. Idea: medical doctors are experts in mental disorders lead to psychiatry C. FROM DEMONS TO INSTINCTS: THE EUROPEAN TRADITION 1. Early Middle Ages: Fall of Roman Empire in A.D. 476 a. Period of great political and economic upheaval b. Empiricism replaced by belief that God would reveal divine truths c. Contemporary mental health fields from Western European origins d. Middle East and Africa (1) Folk healers - magic, herbal medicines, and common sense (2) Both cultures stressed value of local community 2. Middle Ages and the Return of Demons a. Christian theology grew; science less important b. Supernatural forces once again responsible for abnormal behavior c. Treatments returned to exorcisms and religious rituals FROM DEMONS TO INSTINCTS: THE EUROPEAN TRADITION, cont’d. 3. Greek and Roman traditions still influence a. Islamic physician, Avicenna, wrote The Canon of Medicine (1) Philosophical traditions - Aristotle (2) Medical practices - Galen (3) Islamic physicians pioneered use of hospitals b. In Europe, monasteries served as sanctuaries 4. Late Middle Ages: A New Era a. Influence of Christian Church began to weaken (1) Church intensified search for suspected heretics and witches (2) Thousands tortured and burned at stake (3) Malleus Maleficarum or Witches Hammer published FROM DEMONS TO INSTINCTS: THE EUROPEAN TRADITION, cont’d. 5. Renaissance and the Rise of Humanism a. Marked by fall of Constantinople ending the Byzantine Empire b. Secularization of life and values known as humanism c. Facilitated by advent of printing press d. Psychological concerns equaled or surpassed theological issues e. Physicians again view human body as biological machine (1) Descartes: explains mental activity in physical terms (2) Peracelsus and Weyer: naturalistic explanation of disorders (3) Weyer often considered first psychiatrist (a) Convinced brain influenced by moon (b) Treatment required “therapeutic relationship” (c) Ridiculed beliefs in witches (d) Condemned brutal treatment f. Treatment: confinement in hospitals and asylums (1) Not much better than Middle Ages (2) “Insane” treated like prisoners; abominable conditions FROM DEMONS TO INSTINCTS: EUROPEAN TRADITION, cont’d. 6. The Enlightenment and the Rise of Science a. Late 1800’s: psychology to become a scientific discipline b. Chiarugi, Tuke, Rush ushered in moral treatment era c. Dorothea Dix and Clifford Beers started moral hygiene movement d. Psychiatrists believe biological disorders required medical treatment e. 1825: Deteriorative brain syndrome termed general paresis f. General paresis caused by syphilitic infection of brain g. Search to find links between mental disorders and physical causes FROM DEMONS TO INSTINCTS: EUROPEAN TRADITION, cont’d. 7. The Psychoanalytic Revolution a. Hypnotism (mesmerism) best remembered (1) Hypnotic anesthesia during surgery (2) Helpful in treatment of hysteria (3) Reawakened idea mental disorders might be psychological b. Sigmund Freud, Viennese neurologist (1) Successfully used hypnotism (2) Abnormal behavior caused by unconscious mental struggles (3) Theory of how and why these create disordered behavior (4) Applied theory of abnormality in psychoanalysis c. New mental health profession: clinical psychology (1) Devoted to scientifically studying mental disorders (2) Assessing, diagnosing, and treating them D. CONTEMPORARY APPROACHES TO ABNORMALITY 1. Models of abnormality - how and why behavior develops 2. Which aspects most important to study - overt behavior or thoughts 3. Treatment methods most likely to succeed - exorcism, drugs, talking 4. Western culture - biological, physiological, sociocultural, diathesis-stress CONTEMPORARY APPROACHES TO ABNORMALITY, cont’d. 1. Models of abnormality – how and why behavior develops 2. Which aspects most important to study – overt behavior or thoughts 3. Treatment methods most likely to succeed – exorcism, drugs, talking 4. Western culture – biological, physiological, sociocultural, diathesis- stress models CONTEMPORARY APPROACHES TO ABNORMALITY, cont’d. CONTEMPORARY MODELS OF ABNORMAL BEHAVIOR 1. Biological Model 2. Psychodynamic Models 3. Behavioral Theories or Learning Theories 4. Phenomenological Theories or Humanistic Models 5. Sociocultural Model 6. The Diathesis-Stress Model E. PSYCHODYNAMIC THEORIES 1. Freud’s psychoanalysis – behaviors influenced by unconscious forces 2. Sexual or aggressive instincts at war with moral demands of society 3. Freudian Personality Structures a. Id – most basic, unconscious instincts (food, water) (1) Provides energy called libido (2) Operates on pleasure principle b. Ego – self develops in response to cultural limits (1) Ego operates on reality principle (2) Ego seeks rational compromises between Id and culture c. Superego – insists on socially acceptable behavior 4. Constant conflict among the id, ego and superego cause guilt, anxiety, etc. a. Ego employs defense mechanisms (1) Repression – motivated forgetting (2) Regression – retreat to primitive behavior PSYCHODYNAMIC THEORIES, cont’d. 5. Stages of Psychosexual Development a. Oral Stage – first year (1) Eating, sucking, biting main source of pleasure (2) Oral needs neglected or overindulged, can become fixated b. Anal stage – second year (1) Elimination and retention of feces focus on pleasure (2) Toilet training critical feature c. Phallic stage – third or fourth year (1) Genitals focus of pleasure (2) Oedipus complex from Greek tragedy Oedipus Rex (3) Identification (boys), Penis Envy (girls) resolve d. Latency period – fifth or sixth year (1) Oedipus complex resolved (2) Love and long-term relationships PSYCHODYNAMIC THEORIES, cont’d. 6. Contemporary Psychodynamic Theories a. Theorists suggested revisions of Freud’s theories b. Carl Jung altered or rejected principles c. Alfred Adler – style of life – child pursues superiority d. Adaptive lifestyles characterized by social interest e. Erik Erikson – eight stages of psychosocial development f. Object relations theory – failure to achieve adequate separation leads to personality problems in adulthood PSYCHODYNAMIC THEORIES, cont’d. 7. Psychoanalytic Treatment a. Goal – insight into unconscious origins of behavior b. Free association – say whatever comes in mind c. Interpretation of dreams, slips of tongue, mistakes d. Transference – reliving of emotional reactions e. Ego analysts – people more capable of controlling behavior f. Object relations therapists – therapeutic relationships repair F. BEHAVIOURAL THEORIES 1. Also called learning theories – how people learn to behave 2. Operant theorists – rewards and punishment 3. Respondent – stimuli and responses 4. Cognitive-behavioral: consequences and expectations acquired 5. Operant Conditioning 6. Thorndike – learning follows law of effect a. Skinner – antecedents conditions and consequences b. Behavior strengthened through reinforcement c. Being paid to work – positive reinforcement d. Take aspirin, get rid of headache – negative reinforcement e. Punishment – negative consequences f. Extinction – absence of ant notable consequences g. Schedules of reinforcement – key to understanding behavior BEHAVIORAL THEORIES, cont’d. 7. Classical Conditioning a. Pavlov – behavior based on reflexes b. Unconditioned stimulus – food; - neutral stimulus – tone c. Unconditioned responses – salivation; -neutral stimulus – tone d. Eventually – conditioned stimulus; conditioned response e. “Little Albert” – learned 8. Behavioral Treatment a. Also known as behavior therapy or behavior modification b. Focus is on here and now c. Interventions aimed at measurable changes BEHAVIOR THEORIES, cont’d. Cognitive Theories 1. Observers say operant or classical conditioning ignores what one thinks 2. Cognitive or social learning theories developed (cognitive attribution) in 60s 3. Theories include operant, classical plus perceptions, thoughts, memories 4. Important Cognitive Processes: a. Bandura emphasizes observational learning, from models. b. Rouse: new responses, inhibit, disinhibit already learned responses c. Rotter: (expectancies), probability behavior will occur depends on: (1) What person has learned to expect (2) Value person on outcome (3) Self-efficacy, belief one can successfully perform behavior d. Appraisals – evaluations of one’s own other’s behavior e. Attributions – explanations for behavior (1) Internality – is it about ourselves or the environment? (2) Stability – is the cause enduring or temporary? (3) Globalness – is it specific to situation or all situations f. Ellis – role of irrational beliefs associated with “should” statements BEHAVIOR THEORIES, cont’d. 5. Cognitive Social-Learning Therapies a. Give new information, correct misconceptions b. Change the way they think about themselves, people, world c. Ellis – rational-emotive therapy (RET) G. PHENOMENOLOGICAL THEORIES 1. Also known as humanistic model a. Behavior determined by person’s perceptions b. Perceptions allow emotionally effective life c. Perceptions create excessive desire to meet other’s expectations 2. Carl Rogers’ Self Theory a. People have innate drive self-actualization b. All experiences are positive or negative from that outlook c. In childhood, conditions of worth – only in behavior is approved 3. Abraham Maslow and Humanistic Psychology a. Failure for full potential is caused by unmet needs b. Lower levels of needs met before self-actualization 4. Phenomenological Therapies a. Create a context in which clients feel free to explore potential b. Help clients express full range of emotions 5. Interpersonal Theory 1. Sullivan – interaction styles so rigid they become maladaptive 2. Relationships so disturbed, interactions impossible 3. Interpersonal, rather than psychosexual stages 4. Rule of reciprocity 5. Accounts for personality disorders H. THE SOCIOCULTURAL MODEL 1. Also known as ecological model 2. Emphasizes external not internal factors 3. Harmful environments, social policies, cultural traditions, powerlessness 4. Epidemiological studies – patterns and frequency of disorders related 5. Social Causation (theory) – stress, poverty, racism, inferior education, unemployment, and social changes as risk factors 6. Social Drift (social selection hypothesis) – higher rates of disorders in lower SES groups due to the disorders 7. Social Relativism – standards of abnormal do not apply in all cultures a. Koro – SE Asia – penis will enter stomach – death b. Windigo – North Americans Indians – monsters – cannibals c. Anorexia nervosa – Western societies – thinness – beauty 8. Social Labeling a. Szasz- mental illness myth created by medical professionals. b. People have “problems in living” c. Labels produce prejudice and discrimination d. Community psychology studies interventions e. Preventing abnormal behavior preferable to treatment I. HE DIATHESIS – STRESS MODEL A. Behavior disorder results from two influences 1. Diathesis – a predisposition for that disorder 2. Stressor – any event that causes a person to adjust to it B. Stressors are the triggers to convert predisposition to disorder C. Does not assume only one cause per disorder; many factors D. May be impossible to say exactly what causes disorder E. Developmental psychopathology – problems in childhood linked to disorders later F. Advocates suggest treatment must include combination of techniques (1) Psychotherapy and medication for anxiety and depression (2) Medication and community support programs for schizophrenia (3) Implications for how best to prevent a disorder CHAPTER 2 ASSESSMENT AND DIAGNOSIS Lecture Outline 1. Presenting three cases 2. Definition of mental disorder 3. Classification of mental disorders 4. Assessment of mental disorders 5. Prevalence of mental disorders THREE CASES Case 1 John is in his mid-fifties. He has been complaining of feeling unhappy and depressed for the past 2 years. Recently his condition worsened. For the past three weeks he has been feeling very depressed, he has no interest in anything and it is an effort to do anything, he has difficulties sleeping at night, he has no appetite and lost 10 pounds in the past three weeks, he feels guilty for letting his wife down and he feels he is a burden to his family, he believes he will be better off dead. Case 2 Barb is a housewife in her early 30s. She is afraid to go out because she is fearful that she will faint and die. Barb is known to be a happy and fun- loving person. But for the past six months she has been confined to her home, she refuses to go out or meet anyone. This problem started 6 months ago, following an incident when she fainted while she was lining up at her local bank. Case 3 Mark, a 42-year-old single male has been out of work for over 10 years as a computer programmer. In his late 20s he started hearing voices, he thought the government was accusing him being a spy and therefore the police was monitoring his thoughts, and he was afraid he will be imprisoned for the rest of his life. MENTAL DISORDER DEFINED THROUGHOUT HISTORY a. As a deviation from social expectations b. As what mental health professionals treat c. As subjective distress d. As a label for disliked actions e. As a dysfunction that causes harm Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (1994) definition: A mental disorder “is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (p. xxi) DIAGNOSTIC CLASSIFICATION A Brief History 1. Emil Kraeplin, mental patients fit 3 categories a. Dementia praecox (schizophrenia) b. Manic-depressive psychosis (bipolar disorder) c. Organic brain disorders (dementia, delirium, etc.) 2. 1948: World Health Organization published ICD-6 3. 1952: American Psychiatric Association published DSM-I 4. 1968: ICD-8 5. 1968: DSM-II 6. Early DSM systems did not predict as a valid classification should 7. 1980: DSM-III, radically revised edition DIAGNOSTIC CLASSIFICATION, cont’d. Brief History, cont’d. 8. 1987: DSM-III-R a. Specific, clearly defined criteria b. Greatly improved the reliability of diagnoses by clinicians c. Multiaxial classification - person described along many dimensions 9. APA formed a task force to develop the DSM-IV one yr. later a. WHO was ready to publish ICD-10 b. U.S. under treaty to maintain systems consistent with WHO c. Desire to build a better empirical foundation d. 13 groups of researchers e. Field trials - research in natural environment f. 6,000 Ss, 70 locations, 100 advisors, DSM-IV Sourcebook DIAGNOSTIC CLASSIFICATION, cont’d. Diagnoses with the DSM-IV 1. DSM-IV used in U.S. and Canada 2. Rest of world officially uses ICD-10 3. Axis I: 16 groups of disorders 4. Axis II: a. Mental retardation b. 10 personality disorders c. Diagnoses continue mostly because of custom 5. Axis III: General medical conditions relevant to treatment 6. Axis IV: a. Acute problem, chronic strain, lack of social support b. General focus on stressors present during prior year 7. Axis V: a. Scale on which clinician rates level of functioning b. Summary assessment of clinical status DIAGNOSTIC CLASSIFICATION, cont’d. An example of DSM-IV Multiaxial Diagnosis Axis I: Major Depressive Disorder, Single Episode, Severe Without Psychotic Features Axis II: Dependent Personality Disorder Frequent use of denial Axis III: None Axis IV: Threat of job loss Axis V: GAF = 35 (current) DIAGNOSTIC CLASSIFICATION, cont’d. Diagnoses with DSM-IV, cont’d. 8. Criteria for Diagnosis a. Polythetic approach - person must meet number of criteria b. Create heterogeneous categories (similar but not identical) c. Classification method - every disorder is assumed to be distinct d. Yields homogeneous categories(appear very similar) e. Comorbidity - mental disorders likely to coexist f. Increasing interest in biological, cultural, and social context DIAGNOSTIC CLASSIFICATION, cont’d. Criticisms of DSM Diagnoses 1. Labeling produces stereotypes, prejudice, and harm 2. Mental disorders occur on a continuum, not in discrete categories 3. Too much attention to reliability; not enough to validity 4. DSM diagnoses imply disorder result of internal, not external causes Other important factors 1. Money, privacy 2. Diversity and assessment measures 3 Diversity and definitions of mental disorders 4. Diversity and interactions between clients and clinicians ASSESSMENT OF MENTAL DISORDERS 1. Clinical assessment - foundation of accurate diagnosis 2. Three steps of assessment: a. Clinicians gather assessment information b. Organize and process information into description of person c. Compare description with what is known of disorders - get diagnosis Reliability and Validity of Assessment a. Reliability - consistency or agreement among assessment data b. Test-retest reliability - many times with same results c. Internal consistency - information similar on other part of test d. Interrater reliability - different clinicians reach same diagnosis e. Validity - degree instrument measures what it is supposed to f. Content validity - tool measures all aspects of a domain g. Predictive validity - assessment procedure accurately forecasts h. Concurrent validity - result of one procedure agrees with another I. Construct validity - results coincide with what theory predicts j. Reliability and validity are expressed as correlation coefficient ASSESSMENT OF MENTAL DISORDERS, cont’d. Diagnostic Errors 1. Validity of clinician’s judgment is crucial 2. Two kinds of correct diagnostic conclusions (a) True positive - correctly concludes disorder is present (b) True negative - correctly concludes there is no disorder 3. Sensitivity - person with disorder will be diagnosed as such 4. Specificity - person without disorder is correctly diagnosed 5. False positive - mental disorder diagnosed - there is none 6. False negative - no disorder diagnosed - there is one 7. Both errors can have severe consequences (a) False positive - unnecessary labeling (b) False negative - keep troubled people from getting help ASSESSMENT TOOLS 1. Life records 2. Interviews 3. Psychological Tests 4. Observations 5. Biological Measures ASSESSMENT TOOLS, cont’d. 1. Life Records (a) Documents associated with important events and milestones (b) School grades, court records, police reports, medical reports (c) These can serve as undistorted facts 2. Interviews (a) Most widely used assessment tool for classification (b) Natural, inexpensive, flexible (c) Structured interview, scoreable, e.g., the Psychopathy Checklist (d) Mental State Examination (MSE) – briefly assesses for memory, mood, orientation, thinking, concentration (e) Includes social history (f) Good interrater and test-retest reliability ASSESSMENT TOOLS, cont’d. 3. Psychological Tests (a) Systematic procedure for observing and describing behavior (b) Standardized situation, standardization – uniform procedure (c) Scores compared with norms (d) Five categories of psychological tests: (1) Aptitude tests – accumulated effect of training/education e.g., Scholastic Aptitude Test (SAT) (2) Achievement Test – knowledge in a specific area, e.g., WRAT (3) Intelligence tests – general and specific cognitive abilities e.g., WAIS-III, WISC-III, Stanford-Binet (4) Neuropsychological tests – deficits in behavior, cognition, and emotion correlated with brain dysfunction/damage (battery of tests, e.g., Halstead-Reitan Battery) (5) Personality tests (a) Objective – personality tests, e.g., MMPI-II (b) Projective – subjective, e.g., Rorschach Inkblot Test ASSESSMENT TOOLS, cont’d. 4. Observations (a) Helpful, clarify conflicting information, comprehensive view of illness (b) Naturalistic, spontaneous (c) Controlled observation, standardized, e.g., video (d) Participant observation, nonparticipant observation (e) Self-monitoring 5. Biological Measures (a) Facts unavailable to naked eye, changes in body chemistry (b) Biological markers, e.g., monitoring liver enzymes in alcoholics (c) Physiological changes, e.g., HR in anxious patients (d) Neurodiagnostic procedures: (1) Computerized tomography (CT scan) (2) Positron emission tomography (PET scan0 (3) Single photon emission computed tomography (SPECT) (4) Magnetic resonance imaging (MRI) CHAPTER 3 DISORDERS OF INFANCY, CHILDHOOD, AND ADOLESCENCE Lecture Outline 1. Developmental Perspective 2. Classification and Diagnosis of Children’s Disorders 3. Disruptive Behavior Disorders Two types: (1) Oppositional Defiant Disorder (ODD) (2) Conduct Disorder (CD) 4. Attention-Deficit Disorders 5. Anxiety Disorders 6. Mood Disorders 7. Eating Disorders (1) Anorexia nervosa (2) Bulimia nervosa 8. Elimination Disorders (1) Enuresis (2) Encopresis DISRUPTIVE BEHAVIOUR DISORDERS A. Oppositional Defiant Disorder (ODD): disobedient; antisocial; defiant 1. Usually diagnosed in children 3 - 7 2. Poor control of emotions 3. Extremely non-compliant and argumentative with parents and teachers 4. Repeated conflicts with peers as result of hostile interactions 5. Blame other people for their mistakes - have chip on their shoulders 6. High need for control of social interaction - MY WAY 7. Parents usually “walking on eggs” 8. Early pattern will persist and increase over time 9. Continuing problems more likely when (a) Problems in more than one setting (school and home) (b) Aggression and hyperactivity co-occur with core ODD features (c) Covert behaviors - lying and stealing (d) Overt behaviors - excessive arguing and aggression (e) High level of stress in family DISRUPTIVE BEHAVIOR DISORDERS, cont’d. B. Conduct Disorder (CD): antisocial with aggression 1. Requires more serious antisocial behaviors 2. Vandalism, truancy, physical aggressive action 3. Taking advantage of others for personal gain 4. Infringing rights of others and violating community rules 5. Exhibit behaviors potentially harmful to the child or others or property 6. Diagnosis requires 3 symptoms previous 12 months; 1 previous 6 months 7. Some clinicians identify subtypes (a) Aggressive or nonaggressive (b) Antisocial behavior alone or in peer groups 8. Longitudinal Course (a) Adolescent onset (after age 10) more likely to dissipate (b) Childhood onset (before age 10) more likely to persist (c) Diagnosed antisocial personality disorder as adults (d) Higher risk for substance abuse and emotional disorders (e) Associated with divorce, joblessness, abusive parenting DISRUPTIVE BEHAVIOR DISORDERS, cont’d. Causes of Conduct Disorder Combination of biological, psychological, and social factors 1. Biological factors a. Possible genetic basis - children of alcoholics and criminals b. Boys show higher incidence than girls c. Correlation between aggression and testosterone d. Aggression related to neurotransmitters e. Low level of serotonin associated with high levels of aggression f. Physiological arousal - lower arousal rates; less fear of risk DISRUPTIVE BEHAVIOR DISORDERS, cont’d. Cognitive and Psychosocial Factors a. Deficits in neuropsychological abilities b. Deficiencies in executive functioning c. Parenting skills - coercive cycle - exchange of negative behavior d. Parental interaction styles, the result of having a difficult child e. Positive warm bond associated with greater child compliance f. 80% preschool boys referred for ODD show insecure attachment g. The higher the family adversity index, the more likelihood of antisocial I. Child’s social-cognitive skills (1) Trouble thinking of non-aggressive ways of solving problems (2) Accidental physical contact seen as deliberate aggression (3) Poor at communicating their sides of issue in conflict (4) Two or more factors usually at work DISRUPTIVE BEHAVIOR DISORDERS, cont’d. Treatment 1. Improve specific parenting skills - most widely used a. Use praise b. Reinforce child’s prosocial behavior c. Reserve use of negative consequences, only for serious problems d. Give clear, simple instructions e. Talk to children without nagging them f. Discipline without losing temper 2. Problems limit long-term utility of parent training 3. Cognitive-behavioral programs a. Attempt to change child’s perceptual inaccuracies b. Monitor their emotions c. Use specific problem-solving steps d. Avoid physical confrontations ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) 1. Disruptive but not antisocial 2. Marked by inattention, impulsivity, high motor activity 3. DSM-IV: (1) Symptoms must produce problems in two settings (2) “Clinically significant impairment” in day-to-day functioning (3) Behavior must be primary cause of functional problems 4. Three subtypes: inattention, hyperactivity or impulsivity, combined 5. Longitudinal Course (1) Primary symptoms highly persistent over time (2) ADHD children at risk for antisocial personality disorder (3) Children higher-than-average risk for substance abuse as adults ADHD, cont’d. Causes of ADHD 1. Biological Factors: (a) Low birth weight, premature birth (b) Prolonged oxygen deprivation at birth (c) Maternal alcohol consumption during pregnancy (d) Deficit of neurotransmitters (dopamine; norepinephrine) (e) May be genetically predisposed to develop (f) Low reticular activating system (RAS) activity (g) Deficits in frontal lobe (1) Low performance on neuropsychological tests (2) MRI shows frontal lobe smaller Psychological Factors: a. Diathesis-stress model b. Neurobiological vulnerability aggravated by psychosocial risk factors ADHD, cont’d. Treatment of ADHD a. One of 3 types of stimulant medications (psychostimulants) (1) Ritalin (2) Dexedrine (3) Cylert b. Facilitates the release and blocks the reuptake of norepinephrine and dopamine c. Children better able to focus on relevant stimuli d. Medication normalizes a child’s attention and academic efficiency e. Psychological treatment similar to those for disruptive behaviors (1) Behavior management procedures (2) Cognitive-behavioral training ANXIETY DISORDERS a. Must be persistent (lasting weeks or months) b. Must interfere significantly with responsibilities or tasks c. Observable behaviors such as trembling and avoidance d. Physiological arousal, such as upset stomach or sweating Types of Anxiety Disorder 1. Generalized anxiety disorder (GAD) 2. Panic attacks 3. Obsessive-Compulsive Disorder (OCD) 4. Separation Anxiety Disorder 5. Social phobia - fear of social contact and scrutiny by others 6. Specific phobia - fear of specific object or circumstances ANXIETY DISORDERS, cont’d. Causes of Childhood Anxiety Disorders 1. Relationship between these disorders and inhibition 2. Inhibited children show heightened physiological arousal 3. Biological diathesis depends on (a) Frequency and type of stressors child encounters (b) Degree of “goodness of fit” (c) Social relationships that reinforce fearful behavior 4. Cognitive factors (a) They expect that bad things will happen (b) Blame themselves for misfortunes (c) Lack self-confidence (d) Criticize their past performances excessively (e) Express pessimism about the future ANXIETY DISORDERS, cont’d. Treatment 1. Systematic desensitization (1) Learns to use an anxiety-inhibiting technique (2) Used in conjunction with learning-based methods 2. Desensitization in conjunction with cognitive-behavioral techniques (1) Cognitive restructuring - distorted thoughts replaced (2) Coping skills training - control negative emotion (3) Self-reinforcement - positive self-evaluative statements 3. Medications (1) Antidepressants (2) Antianxiety drugs (anxiolytics) (3) Neuroleptics (4) Antihistamine and stimulants DEPRESSION IN CHILDHOOD AND ADOLESCENCE 1. Symptoms of Depression a. DSM-IV descriptions use adult criteria b. Specific symptoms common in children (1) Mixture of strong negative emotions (2) Irritability, sadness, hopelessness, and guilt (3) Physical ailments such as stomach pains and headache (4) Low self-esteem (5) Not maintaining friendship and academic difficulties (6) Self-destructive (substance abuse, reckless driving, etc.) (7) More serious – suicidal thoughts and suicide attempts DEPRESSION IN CHILDREN AND ADOLESCENCE, cont’d. 2. Causes of Children’s Depression a. Cerebral asymmetry - < activity in left frontal region of brain b. Genetic transmission c. Family environment d. Poor affect regulation 3. Treatment of Childhood Depression a. Drugs – tricyclic antidepressants (Imipramine, Tofranil) b. Cognitive-behavioral therapy and group therapy FEEDING AND EATING DISORDERS 1. Anorexia nervosa (unreasonable fear of gaining weight) a. Causes of anorexia nervosa (1) Pathogenic family interactions (2) Dysfunction of hypothalamus b. Consequences (1) Severe malnutrition (2) Skin disease (3) Death c. Types of anorexia nervosa (1) Restricting type – extreme dieting, fasting, excessive exercise (2) Binge-eating/purging type – vomiting, laxatives, diuretics FEEDING AND EATING DISORDERS, cont’d. 5. Bulimia Nervosa (recurrent binge eating) a. Causes of Bulimia Nervosa – same as anorexia nervosa b. Subtypes of Bulimia Nervosa (1) Purging subtype – induce vomiting or use laxatives (2) Nonpurging subtype – use fasts or stringent exercise (Weight tend to be of normal, or overweight) FEEDING AND EATING DISORDERS, cont’d. Treatment of Eating Disorders 1. Anorexia (a) Drugs with appetite-enhancing characteristics (b) Antidepressants; desensitization (c) Self-administered reward (effective) and punishment (not effective) 2. Bulimia (a) Group psychotherapy was superior to antidepressants (b) Drug (Fluoxetine – Prozac) (c) Cognitive-behavioral therapy most successful (d) Family therapy – improved communication make disordered eating unnecessary) ELIMINATION DISORDERS 1. Enuresis: release of urine into bedding or clothes a. Theories of enuresis (1) Lack of normal coordination of bladder muscles (2) Deficiency in which arginine vasopressin is released b. Treatment of enuresis Dry bed training (alarms can be used) (1) Child practices getting up from bed and using toilet (2) Receives reinforcement from parents (3) Must remake the bed and change clothing following accident ELIMINATION DISORDERS, cont’d. 2. Encopresis: passage of feces in inappropriate places a. Theories of encopresis (1) Dysfunctional family relationships (2) Excessive parental control (3) Children’s anger or stress b. Treatment of encopresis (1) Biofeedback training of sphincter (2) Parental reinforcement of appropriate toileting CHAPTER 4 DEVELOPMENTAL DISORDERS AND LEARNING DISABILITIES Lecture Outline 1. Mental Retardation 2. Autistic Disorders 3. Learning Disabilities A. MENTAL RETARDATION Significantly subaverage intellectual functioning before age 18 1. American Association of Mental Retardation (AAMR): IQ score 70-75 2. DSM-IV and ICD-10 retain IQ cutoff score of 70 3. AAMR, DSM-IV, ICD-10 definitions list specific deficit areas: a. Skills in communication b. Self-care c. Home living d. Health e. Safety 4. Impairment in 2 areas for diagnosis of MR A. MENTAL RETARDATION, cont’d. Classification of MR 1. Mild MR a. Subtle deficits in adaptive behavior and IQ of 50-70 b. 85% 0f all MR in this category c. Delayed in acquisition of basic language and cognitive abilities d. Middle childhood - limitations become more obvious e. As adults - hold semiskilled jobs and get married f. Parenting skills and ability to care for self suffer under stress g. At increased risk of psychopathology (1) Attention deficit disorders (2) Disruptive behavior disorders (3) Substance abuse h. Dual diagnosis - MR and other psychiatric disorder MENTAL RETARDATION, cont’d. 2. Moderate MR a. Significantly limited adaptive behavior and IQ 35-55 b. 10% of MR in this range c. Early childhood - significant delays lang., cog., motor skills d. Can learn to read and write, do simple addition and subtraction e. As adults - unskilled jobs in supervised setting f. Most live in supervised group homes g. Few marry; fewer have children 3. Severe MR a. Severe impairment indicated by IQ of 20-40 b. 3-4% MR in this range c. Early childhood - verbal communication limited d. Most do not learn to read e. Motor deficits common - may limit capabilities for self-care f. Vocational opportunities limited to sheltered workshops MENTAL RETARDATION, cont’d. 4. Profound MR a. IQ's below 20 or 25 b. 1 to 2% of MR in this range c. Pervasive neurological damage present d. Has significant adverse effects on all developmental domains e. Many wheelchair bound; constant supervision; self-care impossible f. Do not usually acquire speech MENTAL RETARDATION, cont’d. Causes of MR 1. Organic a. 300 known biological causes b. Genetic disorders c. Prenatal problems d. Vast array of perinatal and postnatal diseases and injuries e. Genetic errors (1) Abnormalities in how chromosomes are paired (Down Syndrome or Trisomy 21 - chromosome don’t separate) (2) Deletions or additions of genes to chromosomes (Fragile X Syndrome - sex-linked, excess on tip of X) (Williams Syndrome, deleted gene on chromosome 7) (3) Mutations in genes (Phenylketonuria ( PKU ) - abnormality in protein metabolism) MENTAL RETARDATION, cont’d. 2. Environmental Damage to the CNS a. Viral and bacterial infections that cross the placenta b. Rubella causes MR, deafness, etc. c. Herpes virus in mother - MR in child d. Teratogens - cocaine, tobacco, marijuana, alcohol e. Two drinks of alcohol can result in IQ drop of 7 points f. Five or more drinks associated with fetal alcohol syndrome (FAS) g. Premature birth and low birth weight cause slower development h. Head injuries, brain tumors, and infections (encephalitis) MENTAL RETARDATION, cont’d. 3. Psychosocial Adversity a. Cultural-familial - MR with no organic cause b. Due to psychosocial disadvantage c. Linked to greater number of adversities in lower SES d. Parents with limited skills more critical; less attentive e. Form of environmental deprivation MENTAL RETARDATION, cont’d. 4. Treatment of MR Treatment techniques a. Applied behavior analysis - complex to smaller units b. Target behaviors followed by positive consequences c. Formal applications - behavior modification programs d. Self-care skills (washing, dressing, eating, toileting) e. Self-instruction - repeat instructions aloud or use pictures MENTAL RETARDATION, cont’d. Institutionalization and Normalization a. Prior to 70's children institutionalized b. Residential program, staffed professionals; better care, education c. Parents protected from psychological distress d. In the 70s - Normalization Movement e. "Norms and patterns of the mainstream society" in everyday life f. Emphasis on family care; education in public schools; community g. Severe, profoundly retarded: supervised apt. dwelling, foster homes Special Education and Mainstreaming a. 1975 - special education mandatory b. Individualized education program c. Partially served in regular classrooms - mainstreaming d. Inclusion - teachers move from one class to another B. AUTISTIC DISORDERS Autism derived from Greek (autos) 1. Literal preoccupation with self 2. Incapable of relating to parents or to others 3. More interest in objects than people Kanner’s contemporary guidelines 1. Severe deficits in establishing reciprocal social relationships 2. Nonexistent or poor language skills AUTISTIC DISORDERS, cont’d. Causes of Autistic Disorder 1. Biological factors a. Genetic basis for autism suggested by twin studies b. Complications of pregnancy at birth c. Cerebellum and frontal lobes less well developed d. Serotonin levels significantly higher 2. Psychological factors a. Deficit in understanding or expression of emotional states b. Cognitive and social disabilities c. Cannot assign meaning to social stumuli – e.g., mother’s face d. Deficit in theory of mind d. Do very poorly on executive functioning tests AUTISTIC DISORDERS, cont’d. Other pervasive developmental disorders (atypical Autistic Disorders) 1. Rett’s disorder 2. Child disintegrative disorder 3. Asperger’s disorder (autistic psychopathy) 4. Pervasive developmental disorder NOS C. Treatment of pervasive developmental disorders 1. Behavior modification 2. Education 3. Medication - the antipsychotic haloperidol C. LEARNING DISABILITIES Definition 1. Underachieving children who do not have mental retardation 2. Not emotionally disturbed; not culturally deprived 3. No specific cause received empirical support 4. DSM-IV - achievement in reading, writing, math is below level 5. Discrepancy of 2 or more SDs between achievement and IQ 6. Differentiates by area of academic deficit 7. Nonverbal type - normal verbal but difficulties in visual-motor skills, social skills, and math CHAPTER 5 STRESS, SLEEP, AND ADJUSTMENT DISORDERS Lecture Outline 1. Stress and its effects 2. Sleep disorders 3. Adjustment disorders STRESS What is Stress? 1. Process occurs when environmental or social threats (called stressors) place demands on individuals 2. Way an individual experiences depends on (a) The nature and timing of the stressors (b) Person’s psychological characteristics and social situations (c) Biochemical variables that influence stress responses Types of Stressors 1. Unpredictable traumas (a) Earthquakes, floods, natural disasters, serious accidents (b) Violent encounters with other persons (c) Four major crimes (1) Rape (2) Other sexual assaults (3) Assault with weapon (4) Killing of a family member STRESS, cont’d. (d) Even if only one in lifetime – lasting psychological scars (e) Sample of adolescents’ trauma (1) 18% of boys age 10-16 victim of assault with weapon or that resulted in physical injury (2) 15% of girls victims of sexual assaults (3) 6% children victims of attempted kidnapping 2. Predictable Stressors (a) Getting married, having children, starting college, new job (b) Academic setbacks, financial losses, occupational failures (c) Marital difficulties, unemployment, illness/death of loved one 3. Occupational Stressors (a) Air-traffic controllers – life and death decisions (b) Waitresses – always urged to hurry (c) Miners – constant danger of cave-in (d) Jobs that make many demands – allow little or no control STRESS, cont’d. Individual Difference and Potential Stressors 1. Exposure to Stressors – Individual and Cultural Differences (a) People differ in responses due to meaning each gives event (b) Certain people more likely to experience stressful events (c) Possibly poor social skills or long-term psychological handicaps unintentionally bring them about (d) Repeated financial or interpersonal setbacks lead to more stress (e) Severe stressors cause change in brain chemistry (f) Ethnic differences, gender and age affect frequency and type STRESS, cont’d. Individual Differences and Potential Stressors, cont’d. 2. Reactions to Stressors – Individual and Cultural Differences (a) Subjectively perceived stress correlated with later adjustment (b) Harmful impact exists in mind of those who experience them (c) Factors determine how a person reacts and copes (1) When they have to cope alone, no social support (2) When they feel helpless or unable to control (3) Caused by intentional or careless behavior of another (4) Confident person may view stressors as challenges (5) Introverted or shy person may be traumatized STRESS, cont’d. Measuring Stress 1. Schedule of Recent Experience (SRE) 2. Life Experience Survey (LES) (a) Respondent rate positive and negative impact of event (b) More sensitive to cultural influences 3. Hassles Scale (a) How much hassle in prior month (b) Minor problems – losing things, meetings, forms, guests Effects of Stressors Three stages of General Adaptation Syndrome (1) Alarm Reaction – flight-or-fight response (2) Stressor persists – stage of resistance (3) Stressor continues long enough – stage of exhaustion STRESS, cont’d. Reactions to Stress A. Physiological Reactions (1) Alarm Reaction – hypothalamic-pituitary-adrenalcortical axis acts (a) Hypothalamus secretes corticotrophin-releasing hormone (CRH) (b) CRH starts chain of physiological and biochemical defenses (1) Pituitary secretes adrenocorticotrophic hormone (ACTH) (2) Adrenal glands release adrenal corticosteroids hormones (3) Autonomic nervous system shuts down (4) HR, BP, respiration, glucose increase (5) CRH stops, completing negative feedback loop STRESS, cont’d. A. Physiological Reactions, cont’d. (c) Hypothalamus releases epinephrine and norepinephrine (1) Catecholamines stimulate HR, raise BP (2) Stimulate CNS – attention, concentration (3) Heightened anxiety or even panic accompany changes (d) Two stress alarms interact, produce adaptive changes (1) Activate production of endogenous opiods (2) Endorphins regulate cardiovascular activity, relieve pain, facilitate psychological coping with stress (3) Physical exercise releases endorphins (stress coping) STRESS, cont’d. A. Physiological Reactions, cont’d. (2) Experiencing the Alarm Reaction (a) During stressor (1) Perceptual, cognitive, behavioral adjustments made (2) Attention riveted on the stressor (b) After stressor (1) Arms and legs shake; heart thumps; breath in gasps (2) Prolonged stress hormones – chronically high BP, damages muscle tissues, inhibits body’s ability to heal (3) Sustained corticosteroids – wear and tear on part of nervous system (4) Immunosuppression – physical illness such as cancer STRESS, cont’d. B. Stress and the Immune System (1) Compromised immunity result of (a) Sleep deprivation, final examination, divorce, loss of loved one, caring for chronically ill relatives (b) Depressed or angry mood, negative thinking, conditioned stimuli 2. Components of the Immune System (a) Innate immunity – present from birth – first defense against pathogens (1) Skin wards off germs (2) Mucus contains chemical to fight virus STRESS, cont’d. (2) Components of the Immune System, cont’d. (b) Specific immunity – acquired or innate (1) Detection of invading pathogen (2) Destruction of pathogens using T & B lymphocytes (3) Detection done by macrophages – find pathogens by antigens (4) Macrophages use chemical messenger – interleukin-1 (5) Interleukin-1 calls in T-cells and activates them for battle (6) T-helpers secrete interleukin-2 to call more T-cells, B-cells (7) T-cells produced in thymus, B-cells in bone marrow (8) Killer T-cells use chemical warfare, destroy pathogens (9) B-cells divide into plasma cells, release antibodies (10) Memory T-cells, B-cells react if pathogen come back (11) Suppressor T-cells call off troops when war is won (12) Stop killer cells from creating autoimmune disease STRESS, cont’d. 3. Stress and Psychological Disorders (a) Psychological reactions become maladaptive if last too long (b) Effects – anxiety, helplessness, frustration, hostility, insomnia (c) Severe stress contributes to several specific mental disorders (d) Examples – sleep, adjustment, PTSD, dissociative, and somatoform disorders SLEEP DISORDERS A. The Process of Sleep (1) EEG measure used in polysomographic (PSG) assessment (a) PSG done while person observed in sleep laboratory (b) Biological; measures of muscle and eye movements, heart activity (2) Stages of Sleep (a) Stage 1 – light sleep, can be easily awakened (b) Stage 2 – sleep deepens; changes in organ activity (c) Stage 3-4 – deep or delta sleep – slower delta waves (d) Immune system replenish in deep sleep (e) Stage 5 – light sleep, REM occurs (1-4 are non-REM) (f) During REM sleep muscles so relaxed, almost paralyzed (g) Locus coeruleus does not release norepinephrine during REM sleep (h) Deprived of REM sleep; retention of material poor for previous day (i) Person passes through full sleep cycle 4 to 6 times each night SLEEP DISORDERS, cont’d. (3). Biological Regulation of Sleep (a) Circadian rhythms – sleep happens about every 24 hours (b) Body is equipped with biological clock maintaining rhythms (c) Clock in supra chiasmatic nucleus of hypothalamus (d) Eyes sense darkness; pineal gland begins to produce melatonin B. Types of Sleep Disorders (1) DSM-IV classifies sleep disorders in 4 major categories (a) Sleep disorders related to another mental disorder (b) Sleep disorders due to a general medical condition (c) Substance induced sleep disorder (d) Infant sleep disorder SLEEP DISORDERS, cont’d. B. Types of Sleep Disorders, cont’d. (2) Arise from interaction of biological, psychological, behavioral, cultural (a) Primary dyssomnia – so much trouble falling asleep or staying asleep that one suffers significant distress or impairment (b) Many insomniacs engage in more active thinking at night (3) Dyssomnias (1) Infant sleep disturbance affects 15-25% infants (2) Primary hypersomnia – excessive sleepiness (3) Narcoplesy – suffers sudden attacks of REM sleep, catalepsy (4) Parasomnias (a) Nightmare disorder – repeated frightening dreams (b) Sleep terror disorder – wakes with scream or panicky cry (c) Sleepwalking disorder – person leaves bed and roams SLEEP DISORDERS, cont’d. C. Treatment of Sleep Disorders (1) Most common treatment for insomnia is medication (a) Prescription drugs: Halcion, Dalmane, Valium (b) Hypersomnia treated with Ritalin (stimulants) (c) Narcolepsy treated with antidepressants (2) Drugs have disadvantages (a) Sleepiness during the daytime (b) Often induce dependence (c) When discontinued, problem worse than when stated (3) Psychological treatments of insomnia (a) Relaxation treatments of insomnia (b) Cognitive therapy reduce tendency to ruminate and worry (c) Sleep hygiene counselling most effective (1) Not using caffeine or alcohol before bedtime (2) Going to bed same time every night; rise same time (3) Only sleep and sex in bedroom, no work or TV ADJUSTMENT DISORDERS A. DSM-IV Classification (1) Significant behavioral, psychological symptoms in response to stressor (2) Symptom occur within 3 months after; no longer than 6 months (3) Chronic last longer (e.g., financial setback, ongoing divorce) (4) Symptoms exceed what would be normally expected (5) Five subtypes of adjustment disorders (a) Adjustment disorder with anxiety (b) Adjustment disorder with depressed mood (c) Adjustment disorder with conduct problems (d) Adjustment disorder with mixed mood and conduct (e) Adjustment disorder with mixed anxiety and depression (6) Mixed common among adolescents; depressed subtype in adults (7) Typical mild and limited duration; sort of “wastebasket” category ADJUSTMENT DISORDERS, cont’d. B. Triggers of Adjustment Disorders (1) Stressors Causing Adjustment Disorders (a) Can be one-time events (divorce or repeated failure) (b) May last a short time (earthquake) (c) Stretch on lengthy period (chronic illness of a loved one) (2) Adjustment Disorders and Natural Disasters (a) Adjustment disorder with mixed disturbance of emotion (b) Fear of leaving home, fear someone at home is hurt (c) Forgetful of little things, frequent nightmares ADJUSTMENT DISORDERS, cont’d. (3) Adjustment Disorders and Technological Disasters (a) Severity of psychological problems related to extent or length of exposure to the danger (b) Floods – higher the water, longer person in them; more serious it is (c) Israeli children (Persian Gulf War) missiles near homes. families (4) Adjustment Disorders and Interpersonal Stressors (a) Development of Social Readjustment Rating Questionnaire (b) People rated divorce and marital separation as 2nd and 3rd most upsetting life events possible (1st death of spouse) (c) Interpersonal problems often chronic; usually involve shame ADJUSTMENT DISORDERS, cont’d. C. Treatment of Adjustment Disorders (1) Enhancing Problem-Focused Coping (a) Strengthening person’s ability to solve problems is effective (b) Successful in divorce, occupational stressors, financial setbacks (c) Particular success in coping skills of children and teens (d) Goal attained through friends or family or counselling (e) Effective problem solving therapy follows 7 steps (1) Define the problem clearly (2) Identify alternative strategies (3) Evaluate short-term and long-term consequences (4) List several alternative tactics for general strategy (5) Choose tactic that appears to have best chance of resolving (6) Act on decisions reached in previous steps (7) Assess; if problem not resolved, return to earlier stages ADJUSTMENT DISORDERS, cont’d. Treatment of Adjustment Disorders, cont’d. (2) Enhancing Emotion-Focused Coping (a) Expressing feelings about stressor unburdens; allows new thoughts (b) Writing ventilates negative feelings, clarifies, considers new ways (c) Study by Pennebaker et al., 1988 (3) Enhancing Social Support (a) Therapists help clients become more receptive to social support (b) Client may want an image of sturdy independence (c) Client thinks turning to others “sign of weakness” (d) They will lose respect of others (e) Therapists counter – how does client feel when asked to help (f) Client admits closeness to those who need help CHAPTER 6 PSYCHOLOGICAL FACTORS AND HEALTH Lecture Outline 1. Health Psychology 2. Classifying psychological factors affecting health 3. The psychology of getting sick 4. The psychology of getting well and staying well HEALTH PSYCHOLOGY speciality – “psychological influences on how people stay healthy, why they become ill, and how they respond when they do get ill” a. Understanding how psychological and physiological factors interact to influence illness and health b. Identifying risk factors for sickness; protective factors for health c. Developing and evaluating techniques for promoting healthy behaviors and preventing unhealthy ones d. Developing and evaluating psychological interventions that contribute to effective treatment of illness 2. Behavioral medicine: integrates behavioral science and biomedical knowledge into interdisciplinary effort to understand, treat, prevent illness 3. Health psychology and behavioral medicine adopts biopsychosocial model HEALTH PSYCHOLOGY, con’t 4. Osler believed many symptoms of heart disease brought on by anger, worry, or sudden shock 5. Major risk factors for developing chronic illnesses involve such behaviors as: smoking unhealthy eating habits alcohol abuse 6. Psychological factors in physical illness (onset or severity) a. Heart disease b. Ulcers c. Asthma d. Stomach disorders e. Cancer f. Arthritis g. Headaches h. Hypertension 7. Modern behavioral science: psychological influences on all diseases CLASSIFYING PSYCHOLOGICAL FACTORS AFFECTING HEALTH 1. More difficult to sharply divide “physical” from “mental” 2. DSM-IV deals with dilemma in 3 ways a. Axis III – general medical conditions related to mental disorder b. Special rules for mental disorders caused by drugs, medical conditions c. Use of multiple diagnoses to classify all conditions 3. Medical conditions not accountable for somatoform disorders 4. Factitious disorders – mental disorder 5. Malingering – faking CLASSIFYING PSYCHOLOGICAL FACTORS AFFECTING HEALTH, cont’d. A. Linking Psychosocial Factors and Illness 1. Various illnesses result from specific unconscious emotional problems a. Ulcers linked to oral conflicts b. Migraine headaches to repressed hostility 2. Question not whether psychological factors are linked, but how a. Disease can cause psychological changes b. Disease and psychological conditions both influenced by common underlying biological process c. Psychological and social influences exert influence on biological d. Psychological and social influence encourage unhealthy behavior THE PSYCHOLOGY OF GETTING SICK B. Psychological Factors in Cardiovascular Diseases 1. Coronary Heart Disease (CHD) a. Over half a million Americans die from CHD every year b. Main causes is atherosclerosis c. Two consequences of CHD – angina pectoris and myocardial infarctions 2. Hypertension Essential hypertension not caused by organic factors 3. Stress and Cardiovascular Diseases a. Genetics and sociocultural factors cannot explain CHD, hypertension b. Role of stress and personality c. Manuk studied monkeys’ responses different stressors THE PSYCHOLOGY OF GETTING SIC, cont’d. Psychological Factors in Cardiovascular Diseases, cont’d. 4. People react to threatening stimuli and other stressors with a. Increases in heart rates, pronounced changes in BP b. Changes in levels of epinephrine, norepinephrine, sodium secretion 5. Psychological factors affect meaning and therefore impact of stressors a. Perception of no control – anxiety and fear b. Surge in HR or “butterflies in stomach” c. Greatest reactivity to stressors – hostility or competitiveness THE PSYCHOLOGY OF GETTING SICK, cont’d. Psychological Factors in Cardiovascular Disorders, cont’d. 6. Ethnicity, gender, and age related to tendency or overreact a. Black Americans, men, older people higher rates HD b. Greater-than-average BP responses to stressors 7. Identifying the Type A Behavior Pattern a. “Hurry sickness” characteristics b. Type B behavior patterns 8. Does Type A Behavior Cause CHD? a. Unhealthy behaviors more critical to CHD than biological factors b. Unhealthy behaviors and emotional driven wear and tear on CV system may be complete explanation of CHD THE PSYCHOLOGY OF GETTING SICK, cont’d. C. Psychological Factors and Immune System 1. Psychological characteristics increase disease risk via biological mechanism – psychoneuroimmunology- brain, immune system, and psychological processes affect each other 2. Anticipatory nausea 3. Stress, immune system, and illness 4. AIDS – psychological factors implicated a. Heavy use of alcohol or drugs before sex b. Sexual activity with multiple partners c. Partners with an unknown sexual history d. Sexual activity without condoms e. Sharing of needles used to inject drugs f. Psychological coping fortify immune system THE PSYCHOLOGY OF GETTING SICK, cont’d. D. Psychological Factors and Immune System, cont’d. 5. Cancer – psychosocial factors a. Mildly related to ethnicity b. Unhealthy habits c. Type C personality E. Social Factors and Illness 1. Stressors less impact in high levels of social support 2. Socioeconomic status 3. Psychological functioning 4. Stressors 5. Unhealthy behaviors THE PSYCHOLOGY OF GETTING WELL AND STAYING WELL Most effective interventions multimodal: 1. Training in stress-reduction techniques 2. Cognitive restructuring – more adaptive thinking 3. Group programs E. Intervention for Cardiovascular Diseases F. Prevention and Coping with Aids G. Psychological Interventions with Cancer H. Increasing Compliance with Treatment Regimens I. Interventions for Promoting Health J. The Health Belief Model (HBM) CHAPTER 7 ANXIETY DISORDERS Lecture Outline 1. Specific Phobias and Social Phobia 2. Panic Disorder and Agoraphobia 3. Obsessive-Compulsive Disorder 4. Generalized Anxiety Disorder 5. Post-Traumatic Stress Disorder 1. SPECIFIC PHOBIAS Phobias a. Irrational, excessive fears b. Intense emotional distress and interferes with life Specific Phobias a. Animal phobias b. Blood, injection, and injury c. Situational - closed spaces d. Natural environment Social Phobia a. Excessive fear of being evaluated and possibly embarrassed b. Develop later in life c. Culture-general but specific - TKS (Tia-jin kyofusho) SPECIFIC PHOBIAS, cont’d. Causes of Phobias A. Psychoanalytic formulations (1) Unconscious fear of castration (2) Social phobias - unconscious impulses from sexual urges B. Behavioral and cognitive factors (1) Watson - conditioned responses (2) Extinguished by deconditioning (3) Bandura - modeling and vicarious conditioning (4) From hearing or reading vivid accounts of danger SPECIFIC PHOBIAS, cont’d. Causes of Phobias, cont’d. C. Biological Theories a. Genetic component b. Neurological differences (1) Prone to physiological activity (2) Low levels of GABA (gamma aminobutyric acid) (3) Fear originates in limbic system (amygdala) (4) Deficiency in neurotransmitter to inhibit neural activity D. Diathesis-Stress Model a. Combination of genetic predisposition, environmental experiences b. Preparedness theory SPECIFIC PHOBIAS, cont’d. E. Treatment of Specific Phobias a. Systematic Desensitization b. Exposure procedures (1) Principle of extinction (2) Exposure in vivo (live) (3) Exposure in imagination - virtual reality c. Flooding d. Participant Modeling 2. PANIC DISORDER AND AGORAPHOBIA Panic Attacks a. Periodic and unexpected attacks of intense anxiety b. Develops persistent fear of another attack c. Fears next attack will be uncontrollable d. Symptoms: attacks come “out of blue” e. Can cause derealization and depersonalization Agoraphobia a. Fear of open places b. Panic attacks may cause c. Basic fear - having panic attack away from “safe” place d. “Fear of fear” e. Panic disorder with agoraphobia vulnerable PANIC DISORDER AND AGORAPHOBIA, cont’d. Causes of Panic and Agoraphobia a. Psychodynamic formulations (1) Unresolved Oedipal complex (2) Unconscious temptation to act out sexual impulses (3) Object Relations Theory - unresolved separation anxiety b. Biological Factors (1) Genetic predisposition (2) Overactive locus coerulus (removal ends panic) c. Diathesis-Stress Model (1) Panic attacks begin as false alarms (2) Misperceptions escalate into repetitive thoughts (3) Anxiety drives activation of SNS (4) Learned alarms cause anxious apprehension (5) Triggering substance mimics internal cues - real attack follows PANIC DISORDER AND AGORAPHOBIA, cont’d. Treatment of Panic Disorder and Agoraphobia a. Cognitive Behavioral Treatment (1) Misinterpretation of physical sensations as sign of danger (2) Package (breathing, exposure to somatic cues, cognitive restructuring, group) (3) Educate not to catastrophize (4) Same for agoraphobia, plus exposure and flooding b. Drug Treatments (1) Antidepressants (imipramine or phenelzine) (2) Anxiolytics (benzodiazepines) (3) Side-effects (4) Combination more effective 3. OBSESSIVE-COMPULSIVE DISORDER (OCD) Obsessions a. Unwanted, disturbing, often irrational thoughts, feelings, or images that people cannot get out of their head b. Involve frightening images or aggressive urges Compulsions a. Repetitive, nearly irresistible acts that temporarily neutralize obsessions or relieve their anxiety b. Compulsive rituals c. Tries to resist performing rituals (understands excessive) d. Impulse to act in that way to reduce tension OBSESSIVE-COMPULSIVE DISORDER, cont’d. Causes of OCD a. Genetic predisposition b. Neurobiological factors (1) Low levels of serotonin (2) Overactive orbitofrontal cortex, caudate nucleus, cingulate gyrus (3) Head injuries, Huntington chorea, Tourette c. Cognitive-behavioral factors (1) Reactivity and obsessive thinking increase during heightened stress (2) Obsessive thoughts very anxiety-provoking (3) Ritualistic behaviors/thoughts used to neutralize anxiety (4) Distressed by compulsive thoughts (5) Strive to undo thoughts through compulsive behavior OBSESSIVE-COMPULSIVE DISORDER, cont’d. Treatment of OCD a. Difficult to treat b. Psychosugery - cinguloyomy c. Drug therapy (1) Clominpramine (blocks serotonin-uptake) (2) 50-75% improvement, relapses quickly d. Cognitive-behavior therapy (1) Based on extinction model (2) Combined exposure and response prevention (3) Sometimes combined with medication 4. Generalized Anxiety Disorder CHAPTER 8 DISSOCIATIVE AND SOMATOFORM DISORDERS Lecture Outline 1. Definition of dissociative disorders 2. Symptoms of dissociative disorders 3. Types of dissociative disorders 4. Causes of dissociative disorders 5. Treatment of dissociative disorders 6. Somatoform disorders 7. Causes of somatoform disorders 8. Treatment of somatoform disorders DISSOCIATIVE DISORDERS 1. Definitions Dissociation: a. Process by which the normally integrated processes of consciousness, memory and personal identity become splintered. b. Not being able to remember important personal experiences c. Becoming confused about identity and acting as if new identity d. Feel as if objects around person are not real e. Emotionally detached, as if client is outsider watching a movie Somatoform: a. Physical symptoms appear that suggest medical disorder with no adequate medical explanation b. Symptoms expression of underlying emotional conflicts DISSOCIATIVE DISORDERS, cont’d. 2. Symptoms of Dissociative Disorders a. Amnesia – loss of person’s memory not by organic injury or illness b. Depersonalization – observing self from outside body c. Derealization – objects in the external world are strange or unreal d. Identity confusion – uncertainty about person’s own indentity e. Identity alteration – person has assumed a new identity DISSOCIATIVE DISORDERS, cont’d. 3. Types of Dissociative Disorders a. Dissociative amnesia b. Dissociative fugue c. Depersonalization disorder d. Dissociative identity disorder e. Dissociative disorder not otherwise specified (1) Significant psychopathology, no criteria for other disorders (2) Dissociative trance disorder (i) Involuntary trance state not cultural or religious (ii) Associated with trauma or long confinement f. Dissociative identity disorder (DID, before MPD) (1) Multiple personality disorder (dual personality) (2) Three Faces of Eve; Sybil; The Minds of Billy Milligan (3) Child hood trauma, often abuse, central role g. Other dissociative disorders (1) Dissociative amnesia (2) Dissociative fugue (3) Depersonalization disorder DISSOCIATIVE DISORDERS, cont’d. 4. Causes of Dissociative Disorders a. Vulnerability to dissociative disorders (1) Imaginative involvement (2) Hypnotizability (3) Childhood trauma b. Diathesis-stress model c. Conclusions (1) Diathesis-stress model has not been supported (2) Disorders diagnosed in U.S. and among women (3) Hypnotizability, trauma, and child abuse rates do not differ enough DISSOCIATIVE DISORDERS, cont’d. 5. Treatment of Dissociative Disorders a. Long-term prognosis not favorable b. Most patients chronic impairments c. “Real” personality will emerge after alters fused or integrated d. One approach involves 2-3 years of psychotherapy e. Some clinicians treat the depression and anxiety only f. Some clinicians respond to only one personality g. No medication has been found to address core symptoms SOMATOFORM DISORDERS 1. Somatization Disorder a. Emotional distress is converted into physical symptoms b. Physical symptoms feel real to patients (not malingering) c. Medical illness more acceptable than mental illness 2. Hypochondriasis a. Focus select few symptoms b. Preoccupied with fear having serious medical illness c. Persists after medical evaluations confirm nothing is wrong d. Symptoms associated with anxiety and depression 3. Conversion disorder a. Psudoneurological symptoms come and go b. One-third indifferent (la belle indifference) c. More in women, rural, low SES 4. Pain disorder a. Predominant clinical complaint is pain b. Psychological factors play role in causing or maintaining 5. Body dysmorphic disorder (BDD) a. Dysfunctional preoccupation with one physical aspect b. Preoccupation leads to paranoid ideas c. Concern is totally out of proportion to reality SOMATOFORM DISORDERS, cont’d. 6. Causes of Somatoform Disorders Diathesis-stress model most useful (1) Combination of bio. and psycho. vulnerabilities (2) Neurological factors increase vulnerability (3) History of physical illness (4) Conversion symptoms located left side of body (5) Disorder triggered by personal conflict or stressor (6) Higher level of negative emotions (7) Hypersensivity to physical sensations (8) Interaction with long-term stressors (9) Intense emotional conflicts (10) Sociocultural acceptance of psychological symptoms SOMATOFORM DISORDERS, cont’d. 7. Treatment of Somatoform Disorders a. Patients resist psychological interpretations b. Goals of treatment in medical care system c. Conversion disorder treatment (1) Hypnosis and behavioral interventions (2) Psychotherapy d. Body dysmorphic disorder (BDD) treatment (1) Medication (2) Cognitive behavior therapy e. Pain disorder treatment (medical setting) (1) Biofeedback and relaxation techniques (2) Rehab. programs to increase physical activity (3) Cognitive behavioral therapy (4) Family and marital therapy CHAPTER 9 MOOD DISORDERS AND SUICIDE Lecture Outline 1. Definition of Mood Disorders 2. Different Types of Mood Disorders 3. Major Depressive Disorder 4. Dysthymic Disorder and Other Types of Depression 5. Bipolar Disorder 6. Causes of Mood Disorders 7. Treatment OF Mood Disorders 8. Suicide 9. Causes of Suicide 10. Prevention of Suicide MOOD DISORDERS (AFFECTIVE DISORDERS) 1. Emotional Disturbances a. Persistent difficulty, maintaining productive emotional state b. Interfere with work, relationships, family life, health c. Depression – low, unhappy mood (unipolar) d. Mania – expansive feelings, unrealistically positive e. Manic depressive or bipolar disorder 2. Depressive Disorders a. What differentiates it from “the blues” b. Accompanied by comorbid problems (1) Alcohol or drug abuse (2) Negative affect – combination of depression and anxiety (3) Double depression – depressive and dysthymic disorder MOOD DISORDERS (AFFECTIVE DISORDERS), cont’d. 3. Major Depressive Disorder ( most severe form) a. Most common symptoms (1) Depressed mood (2) Anhedonia (3) Physical symptoms (4) Cognitive symptoms b. Course and recurrence (1) Most clear up without treatment (2) Onset mid-20s; 75% recurrent (3) Full recovery of double depression less likely c. Subgroups of major depressive disorder (1) Chronic (2) With atypical features (3) With melancholic features (4) With catatonic features (5) With seasonal pattern (SAD) (6) With postpartum onset MOOD DISORDERS (AFFECTIVE DISORDERS), cont’d. 4. Dysthymic Disorder and Other Types of Depression a. Duration for at least 2 years b. In children irritability rather than depression c. Feeling of inadequacy and brooding about past d. If not severe depressive disorder NOS e. Bereavement not disorder f. Pathological grief reaction MOOD DISORDERS (AFFECTIVE DISORDERS), cont’d. 5. Bipolar Disorder a. Mania and/or depression (1) Mixed episodes, both in same day (2) Major depression more common in women; bipolar equal (3) Bipolar starts in teens (4) More frequent in higher SES; greater genetic basis (5) Bipolar less often triggered by social stress b. Bipolar I (1) Severe, full-blown manic, 1 or more periods of maj. dep. (2) Two-thirds of bipolar patients c. Bipolar II (1) Maj. dep. episode, mild manic (hypomanic) (2) Not interfere with social functioning d. Cyclothymic disorder (1) Neither manic nor depression severe (2) 2 years in adults, 1 year in children MOOD DISORDERS (AFFECTIVE DISORDERS), cont’d. 6. Causes of Mood Disorders a. Medical conditions b. Genetic influences c. Neurobiological influences (1) Low level of norepinephrine (2) Neurotransmitter activity at synapse (3) Low levels of serotonin (4) Variation in CBF (5) Neurons fire too quickly in mania (6) Increased level of cortisol MOOD DISORDERS (AFFECTIVE DISORDERS), cont’d. 6. Causes of Mood Disorders, cont’d. d. Psychological causes (1) Intimate relationship (2) Attachment theories (3) Interpersonal theories (4) Role of reinforcement (5) Self-control model (6) Learned helplessness model (7) Beck’s cognitive triad (8) Stressors as triggers of depression MOOD DISORDERS (AFFECTIVE DISORDERS), cont’d. 7. Treatment of Mood Disorders a. Drug treatment (1) Antidepressants, MAOI, tricyclics, SSRI (2) For bipolar: Lithium carbonate, carbamazepine, valproate b. Physical treatment (1) ECT, light therapy c. Psychological treatment (1) Psychodynamic approaches (2) Behavioral approaches (3) Cognitive behavior therapy (4) Interpersonal therapy d. Combined treatments SUICIDE 1. Who Is Suicidal? a. Approx. 300,000 attempts yearly in U.S. b. More frequent among females (ratio: 3 to 1) c. More common in younger people d. 70-90% involve drug overdoses e. Parasuicidal behaviors common in early trauma 2. Completed Suicides – Who Is At Risk? a. Gunshot, hanging, carbon monoxide b. Strongly associated with mental disorder c. Psychological autopsies – depression or alcoholism d. Schizophrenic symptoms, especially among young men e. Cluster suicides common among Native American youth f. Being male, being older, European American, stressful life 3. Adolescent Suicide a. 2,000 teenagers per year; boys > girls b. Respond impulsively to acute stressor c. Cluster suicides d. 80% chronic mental illness e. 50% had relative attempted or committed SUICIDE, cont’d. 4. Causes of Suicide a. Biological factors (1) Impossible to determine if genetic loading is related (2) Unusually low concentration of 5-HIAA (3) Low CSF concentrations of homovanillic acid (HVCA) b. Environmental factors (1) Egoistic suicide – lonely, isolated people (2) Altruistic suicide – places social goal ahead of survival (3) Anomic suicide – feel lost or abandoned by society (4) Fatalistic suicide – prisoner or slave; severe social isolation c. Developmental factors (1) Intense, unresolved, internalized anger (2) Role of disturbed family relationships (3) Cognitive perspective – hopelessness SUICIDE, cont’d. 5. Suicide Prevention a. Three basic components (1) Assessing the risk of suicide (2) Helping cope with immediate crisis (3) Crisis intervention b. Treating suicidal tendencies (1) Antianxiety and antipsychotic medications (2) Cognitive behavior therapy (3) Suicide contract CHAPTER 10 SCHIZOPHRENIA Lecture Outline 1. What is schizophrenia? 2. Symptoms of schizophrenia 3. Types of schizophrenia 4. Causes of schizophrenia 5. Treatment of schizophrenia WHAT IS SCHIZOPHRENIA? a. A psychosis Can impair almost all aspects of psychological functioning Includes (1) Hallucinations (2) Delusions b. A fragmentation Basic psychological functioning is fragmented Attention, perception, thought, emotion, & beh. involved Person sees and hears things that are not there c. Evolving concept of schizophrenia Dementia praecox (Emil Kraeplin) Split (schizen) in the mind (phren) (Eugen Bleuler) Delusions and hallucinations “first rank” (Kurt Schneider) Synthesis achieved in DSM-III, remain in DSM-IV SYMPTOMS OF SCHIZOPHRENIA Positive Symptoms a. Delusions (1) Misinterpretations of normal perceptual experiences (2) Attempted explanations for experiences suffered b. Delusions classified by specific content (1) Somatic delusions – something wrong with body (2) Delusions of persecution – tormented or harassed (3) Delusions of reference – sounds, stimuli special reference to person (4) Delusions of control – foreign entity is controlling person (5) Thought withdrawal – thoughts are being stolen (6) Thought insertion – thoughts forced into head (7) Thought broadcasting – thoughts being transmitted to others (8) Delusions of grandeur – belief person is famous SYMPTOMS OF SCHIZOPHRENIA, cont’d. Positive Symptoms, cont’d. c. Hallucinations (1) Sensory experiences that seem real to person (2) Persons act as if experiences real (3) Unable to stop them (4) Persists no matter what person does (5) Auditory, tactile, visual, gustatory, olfactory d. Disordered thought processes (1) Disturbances in form of thought (2) Speech derailed (word salad, cognitive slippage, neologisms, perseveration) e. Disorders of behavior (1) Peculiar motor behavior (2) Catatonia (3) Disorganized behavior SYMPTOMS OF SCHIZOPHRENIA, cont’d. Negative Symptoms of Schizophrenia a. Deficit schizophrenia (1) Flat affect – 2/3 patients, emotionless masks, robotic voices (2) Alogia – failure to say anything in response to questions (3) Avolation – sit for hours on end (4) Avolation may be accompanied by anhedonia b. Schizophrenics do not find pain as aversive as other people do TYPES OF SCHIZOPHRENIA Five types: a. Paranoid type b. Disorganized type c. Catatonic type d. Undifferentiated type e. Residual type f. Future – simple deteriorative disorder Other classifications a. Process - reactive dimension b. Type I – Type II CAUSES OF SCHIZOPHRENIA a. Biological Causes (1) Genetic influence (2) Early physical trauma (3) Abnormal brain structures and functions (4) Higher levels of dopamine b. Psychological and sociocultural causes (1) Role of social class and urbanicity (2) Role of family environments (a) Schizophrenogenic mother (b) Double-bind hypothesis (3) Role of expressed emotion TREATMENTS OF SCHIZOPHRENIA a. Pharmacological treatment (1) Antipsychotics (neuroleptics) (2) Phenothiazines (block action of dopamine) (3) Cause serious side-effects (4) Clozapine (reduce positive and negative symptoms) b. Psychosocial treatment (1) Milieu programs to resocialize patients (2) Therapeutic communities or group homes (3) Self-management and social skills training (4) Family therapy Psychosocial CHAPTER 11 COGNITIVE DISORDERS Lecture Outline 1. Normal Aging 2. Cognitive Disorders of Aging 3. Amnestic Disorders and Delirium 4. Dementia 5. Alzheimer’s Disease 1. NORMAL AGING (a) Ageism (1) Prejudice against elderly (2) Stereotypes rely on misinformation (b) Keys to successful aging (1) Active, spiritual values, focusing on relationship (c) Sensory and motor function loss (1) Body flexibility, muscular strength and speed (2) Senses and balance (d) Metabolic changes (1) Decreases in respiratory, cardiac, liver, kidney function (2) Metabolize drugs slowly (e) Cognitive functioning (1) Average IQ scores decline a bit in late 50s, early 60s (2) Decrease in motor speed, info. processing, fine motor (3) Complaints of memory loss 2. COGNITIVE DISORDERS AND AGING a. Organic impairment of memory, language, consciousness, perception, intelligence (1) Amnestic disorders: memory loss without other impairment (I) Inability to learn new information (II) Inability to recall previously acquired information (2) Delirium: loses ability to focus, sustain, or shift attention (3) Dementia (senility) (I) Always memory loss plus one or more of (II) Aphasia - disturbance in language (III) Agnosia - inability to recognize or interpret objects (IV) Apraxia - inability to carry out motor activities (V) Executive functioning - loss of ability to plan, organ 3. AMNESTIC DISORDERS AND DELIRIUM Amnesic Disorders (1) Amnesia involves pure memory loss (I) If other cognitive failures; delirium or dementia (II) Effects of medical condition or substance (2) DSM-IV diagnosis (I) Serious, causing social, occupational problems (II) Marked decline from previous functioning (III) Must not occur only during delirium or dementia a. Anterograde amnesia - inability to learn new information b. Retrograde amnesia - inability to recall previously learned info. c. If damage to medial temporal structures, disturbance permanent d. Denial and apathy in severe amnesic disorders (I) Disoriented to time and place, own identity (II) Confabulation - making up materials to fill in gaps e. Long-term alcohol abusers develop due to vitamin deficiencies f. Important to distinguish from factitious disorder, malingering AMNESTIC DISORDERS AND DELIRIUM, cont’d. Delirium a. Altered or clouded awareness of environment (1) Difficulty sustaining, focusing, or shifting attention (2) Deficits in memory, perception, language, and disorientation b. Course (1) In children, onset rapid, usually with high fever (2) In elderly, awareness fluctuates days, deteriorates at night (3) During delirium, memory absent or false memory AMNESTIC DISORDERS AND DELIRIUM, cont’d. Delirium, cont’d. c. Characteristics (1) Warning signs similar to migraine (2) Some especially sensitive to smells or sounds (3) Mild perceptual distortions, changes in moods (4) May swing rapidly from one emotional extreme to another (5) Cannot judge passing time, maintain concentration (6) Autonomic nervous system arousal (7) Visual hallucinations, paranoid delusions common (8) Engage in perseveration (9) Capgras syndrome - delusion impostors posing as family (10) Complete recovery common once undelying cause treated d. Prevalence (1) High as 25% for elderly in hospital (2) About 80% 0f elderly open-heart surgery patients AMNESTIC DISORDERS AND DELIRIUM, cont’d. Delirium, cont’d. e. Causes of Delirium Many physical causes: (1) Head trauma (2) Postoperative states (3) Using or withdrawal from drugs (4) Exposure to toxins (5) Epilepsy (6) Metabolic disturbances (7) Dehydration (8) Infections AMNESTIC DISORDERS AND DELIRIUM, cont’d. Delirium, cont’d. f. Treatment of Delirium (1) Most important goal - identify and correct underlying causes (2) Critical treatment delivered in supportive environment (3) Some require treatment for PTSD (4) Education of care givers to prevent institutionalization (5) Physical restraints avoided if possible (6) Rooms well lighted, familiar objects brought from home (7) Lowest effective doses of antipsychotics, sedatives, tranquilizers (8) Most important, dignity of patient appreciated, protected (9) Looping - humiliation - neg. reaction - more humiliation - treatments 4. DEMENTIA Most common causes (1) Alzheimer’s disease (2) Vascular illness, primarily strokes (3) Multiple conditions (4) Pick’s disease (a) Atrophy frontal lobes, neurons protein deposits (b) Early memory intact, changes in personality, mood (5) Lewy body dementia (a) Abnormal protein deposits, degeneration of neurons (b) Muscular rigidity, slow movements, paranoia (6) Dementia due to Parkinson’s disease (a) Reduced production of dopamine, Lewy bodies (b) Tremors in one or both hands, controlled by medication (7) Dementia due to Huntington’s disease (a) Prog. subcortical degeneration, motor disturbances (b) Facial grimaces, twitches, chorea, personality, memory (c) Hereditary - dominant gene on chromosome 4 (8) Dementia due to Creutzfeldt-Jakob disease (a) Infection from diseased tissue (“mad cow”), HIV, Syphilis (b) Rapid progression, death 1 year (9) Dementia due to head trauma, hypothyroidism, vitamin, MS 5. ALZHEIMER’S DISEASE Stages of Alzheimer’s Disease (1) Early Stages - increased forgetfulness, loss ability to cope (2) Middle Stages - great difficulties language, perception, new information (3) Later Stages - total inability to cope, average 8-12 yrs life expectancy Neuropathology and causes of Alzheimer’s Disease (1) Brain shows atrophy (2) “Hardest hit” language, learning, memory, limbic system (3) Primary sensory and motor cortex spared (4) Neurofibrillary tangles - clumps of protein fibres (5) Neuritic plaques - residue of dead neurons, cellular garbage (6) Death of brain cells caused by beta-amyloid-4 (abnorm. protein) (7) Gene on chromosome 19 (8) Head trauma, dementia puglistica (9) Coronary artery disease (10) Environmental toxins, aluminum, mercury, Ach (11) Low level education ALZHEIMER’S DISEASE, cont’d. Medical Treatments (1) Tacrine, slow breakdown of Ach, not for severe (2) Estrogen, promotes synapse formation, increases Ach synthesis (3) Derenyl, inhibits MAO-B which destroys dopamine (4) Vitamin E, prevents damage to neurons (5) Nimodipine, Ca channel blocker (6) Propentofyline, enhances blood flow, energy metabolism in brain (7) Prednisone, anti-inflammatory Psychosocial Interventions (1) Interventions may delay or slow its progress (2) Reducing head injuries, CV disease, high BP, stress, education (3) Management of behaviors (4) Training of care givers CHAPTER 12 PERSONALITY DISORDERS Lecture Outline 1. Characteristics of Personality Disorders 2. Diagnosing Personality Disorders 3. Dimensional Description of Personality Disorders 4. Types of Personality Disorders 5. Odd/Eccentric Personality Disorders (Paranoid, Schizoid, Schizotypal) 6. Dramatic/Emotional/Erratic Personality Disorders (Histrionic, Narcissistic, Borderline, Antisocial) 7. Anxious/Fearful Personality Disorders (Avoidant, Dependent, Obsessive-Compulsive) 8. Causes of Personality Disorders 9. Causes of Borderline Personality Disorders 10. Causes of Antisocial Personality Disorder 11. Treatment of Personality Disorders CHARACTERISTICS OF PERSONALITY DISORDERS a. Definition of personality (1) Unique pattern of consistency in behavior that distinguishes each person from each other (2) “Character is fate” (3) Personality trait – psychological attribute relatively stable over time, across different situations b. Definition of personality disorder (1) Enduring pattern of inner experience, behavior extremely inflexible, deviates markedly from expectations of a person’s culture (2) Important features (a) Ego-syntonic (b) Problems due to actions of others, uncooperative (c) More distressing for others; leave trail of disaster (d) 25-85% comorbid with another personality disorder (e) 27-65% comorbid with Axis I DIAGNOSING PERSONALITY DISORDER a. Personality Disorders and Axis I Disorders (1) DSM-IV places on Axis II (2) Difficult to distinguish Axis I and Axis II disorders (3) Axis I and Axis II disorders may simply coexist (4) One disorder likely to aggravate the other (5) One disorder predisposes person to develop another (6) Antisocial personality and substance abuse are similar (7) Avoidant personality and social phobia are similar (8) Criteria used to define disorders overlap (9) DSM-IV diagnosis assigned if meet number of criteria DIMENSIONAL DESCRIPTION OF PERSONALITY DISORDERS a. Big Five Model of Personality (1) Neuroticism – tendency to negative experience, disruptive behavior, distressing thinking (2) Extroversion – preference for social interaction, tendency to be active, talkative, optimistic, affectionate (3) Openness – interest in new experiences, receptivity to new activities, ideas; creative, curious, untraditional (4) Agreeable – compassionate, interest in others; trusting, tender-hearted, altruistic (5) Conscientious – well-organized dedication to work; ambitious, persistently strive to be achievers (6) Extreme scores sufficient to describe maladaptiveness b. Interpersonal Circumplex (1) More elaborate description of extroversion and agreeableness (2) Two basic dimensions: dominance/submission; love/hate (3) Interaction of two dimensions produces 8 personality styles ODD/ECCENTRIC PERSONALITY DISORDERS a. Paranoid Personality Disorder (1) Habitually suspicious, constantly on guard, mistrustful (2) Prone to anger and intense jealousy (3) Air of moral superiority (others are corrupt) b. Schizoid Personality Disorder (1) Indifference to social relationships; emotional blandness (2) No close friends; solitary activities and occupation (3) Emotional color bleached from life c. Schizotypal Personality Disorder (1) Socially isolated; shun close relationships (2) Act, dress, talk in odd ways (3) Socially anxious, apprehensive; stiff social reactions (4) Ideas of reference; paranoia, suspiciousness (5) Report talking to dead relatives; spirit inhabiting rooms DRAMATIC/EMOTIONAL/ERRATIC PERSONALITY DISORDERS a. Histrionic Personality Disorder (1) Attention-seeking; demands reassurances; dramatic emotions (2) All actions to make others notice (3) May develop attention-getting complaints (4) Admiration and drawn to authority figures b. Nacissistic Personality Disorder (1) Overinflated egos; sense of entitlement; exemptions to rules (2) If overlooked/criticized rage or humiliation (3) Preoccupied with own status; lack empathy; exploit (4) Poor candidates for psychotherapy c. Borderline Personality Disorder (BPD) (1) Destructive behavior (2) Impulsivity; instability in mood, image, relationship, behavior (3) During increased stress display psychotic symptoms (4) Unable to tolerate negative emotions (5) One of most severe disorders d. Antisocial Personality Disorder (APD) (1) Chronically callous and manipulative (2) Ignore social rules and laws, right of others (3) Impulsive, dishonest, irresponsible (4) Fail to learn from punishment (5) Lack remorse or guilt (6) Psychopathy and APD not synonymous (7) Begins prior to age 15 as CD ANXIOUS/FEARFUL PERSONALITY DISORDERS a. Avoidant Personality Disorder (1) Feeling of inadequacy (2) Fear of embarrassment, criticized, ridiculed (3) Avoid social situations (4) Avoid occupations requiring social interaction (5) Long for affection, acceptance; distressed if not (6) Inhibited, overly cautious; avoid spontaneity b. Dependent Personality Disorder (1) No decision without exorbitant advice, reassurance (2) Cling to others, excessive self-sacrifices for appreciation (3) Dread being alone; excessive dependency drives others away c. Obsessive-Compulsive Personality Disorder (1) Preoccupied with rules, details, organization (2) Prediction and safety (3) Perfectionist; make little or no progress (4) No delegation of tasks; fear standards not met (5) Inflexible about moral and ethical matters (6) Controlling, aloof in personal, romantic relationship CAUSES OF PERSONALITY DISORDERS a. Genetic Factors (1) Paranoid, schizoid higher among relatives with schizophrenia (2) Schizotypal stronger genetic contribution (MZ 33%) (3) Genetic predisposition in APD (4) Borderline, narcissistic, histrionic weak link (5) Avoidant, Dependent no link (6) OC possible genetic influence b. Psychodynamic Theories (1) No viable explanation (2) Object relations theory, early attachments c. Interpersonal Learning Theories (1) Desire to be with others who reinforce typical behaviors (2) Personalities shaped by experiences preferred, seek out (3) Disorders when relies too heavily on extreme (4) Encounters ruled by complementarity which is reciprocal (5) Dominance in one invites submission in other (6) Love/hate correspondence d. Evolutionary Theory (1) Minimization of pain and the maximization of pleasure (2) Passive accommodation or active modification (3) Advancing the self and/or caring for others CAUSES OF BORDERLINE PERSONALITY DISORDER a. Biological Contribution (1) Neurologically impaired kids show unstable mood, impulsivity (2) Translate into academic, social, emotional difficulties (3) High prevalence of affective disorders in relatives b. Psychoanalytic Factors (1) Lack of bonding, aggressive impulses (2) Independence undercut by fear of abandonment (3) Desire for closeness, fear of engulfed (4) Borderlines and mistreatment c. Early Childhood Trauma (1) Childhood neglect and abuse (2) 80% history of physical, sexual abuse CAUSES OF APD a. Childhood predisposition b. Biological predisposition c. Tendency to be underaroused d. Portions of cerebral cortex slow to develop e. Unusually low anxiety level f. Difficulty developing classical conditioning to fear g. Lack of development of conscience h. Family child rearing practices TREATMENT OF PERSONALITY DISORDERS a. Narcissistic Personality Disorder (1) Self-psychology by Heinz Kohut (2) Provide relationship meeting needs b. Avoidant Personality Disorder (1) CBT as for phobias (2) Systematic desensitization, social skills training c. BPD (1) Expressive psychotherapy of Otto Kernberg (2) Dialectal behavior therapy (Marsha Linehan) d. APD (1) Residential setting (2) Burnout after age 40 CHAPTER 13 SUBSTANCE-RELATED DISORDERS Lecture Outline 1. Defining Substance-Related Disorders 2. DSM-IV Diagnosis of Substance-Related Disorders 3. Alcohol Use and Alcohol-Induced Disorders 4. Other Depressants 5. Stimulants 6. Opioids 7. Canabis and Hallucinogens DEFINING SUBSTANCE-RELATED DISORDERS 1. Psychoactive Drugs (a) Affect thinking, emotions, behavior (b) Widely available, used by many (c) Legally available through prescriptions (d) Illegal (cocaine, marijuana, LSD) 2. Substance Intoxication (a) Temporary, direct result of ingesting too much (b) Impaired judgment, mood, thinking, perception, motor (c) Personal distress (d) Legal problems 3. Drug Abuse (a) Level of use hazardous to health (b) Leads to significant impairment (c) Personal distress (d) Legal problems 4. Polysubstance Abuse (a) Abusing several drugs same time (b) Adverse consequences more important than number 5. Psychological Dependence (a) Addiction caused by excessive, frequent use (b) Leads to tolerance (larger doses same effect) (c) Withdrawal syndrome (physical symptoms) DSM-IV DIAGNOSIS OF SUBSTANCE-RELATED DISORDERS 1. Substance-induced disorders, e.g., alcohol intoxication 2. Substance-use disorders (repeated, frequent) (a) Problematic behaviors (b) Substance abuse (c) Maladaptive pattern of use, significant consequences (d) Maladaptive behavior, failure major obligations, legal, hazards 3. DSM-IV substance related disorders include (1) Alcohol (2) Amphetamine (stimulants) (3) Caffeine (4) Cannabis (marijuana) (5) Cocaine (6) Hallucinogens (e.g., LSD) (7) Inhalants (glue or spray paint) (8) Nicotine (9) Opioids (e.g., heroin) (10) Phencyclidine (PCP) (12) Sedatives, hypnotics, anxiolytics ALCOHOL USE AND ALCOHOL-INDUCED DISORDERS 1. Alcohol in the Body (a) Small amount ethanol immediately absorbed (b) Rest goes in small intestine (c) In liver converted to acetaldehyde, metabolized (d) Liver metabolizes 1/2 to 1 oz./hr (e) Tolerance when body’s capacity to metabolize increases (f) When liver can’t metabolize ethanol, acetaldehyde accumulate (g) Women metabolize less efficiently (h) Unmetabolized alcohol devastating effect on organs (1) Cirrhosis of liver (2) Cardiovascular disease (3) Anemia (10%) (4) Suppresses immune system (5) Hormones (testosterone, menstruation) (6) Crosses placental barrier (7) Brain and behavior ALCOHOL USE AND ALCOHOL-INDUCED DISORDERS, cont’d. 2. Patterns of Alcohol Abuse and Dependence (a) Alcoholism: pattern of heavy drinking (1) Worsens until loss of control (2) So dependent physical, mental health jeopardized (3) Social and occupational functioning impaired (b) Disorders associated with Alcohol Abuse and Dependence (1) Mood disorders, anxiety disorders, APD (2) Psychotic symptoms (3) DSM-IV lists 11 alcohol-induced disorders (4) Four explanations for comorbidity (a) Mental dis. precedes and causes the alcohol disord. (b) Alcohol disorder precedes and causes mental dis. (c) A common factor precipitates both disorders (d) Both disorders - exacerbates each other ALCOHOL USE AND ALCOHOL-INDUCED DISORDERS, cont’d. 3. Causes of Alcohol Disorder a. Genetic Factors (1) Runs in families, risk 7 times greater 1st degree (2) Higher concordance rate for MZ twins (3) Higher concordance rate in males (4) Adoption studies, prone b. Neurobiological Influences (1) EEG: sons higher-than-normal rates beta waves (2) Less EEG changes after consumption (3) Less enzyme monoamine oxidase (MAO) activity (4) Serotonin realted to alcohol craving c. Psychological Factors (1) Tension reduction hypothesis (2) Alcohol expectancies (3) Externalizing d. Sociocultural Factors (1) Loss of control, steady drinkers, Muslims (2) Parental, peer influences e. A Multifactor Model ALCOHOL USE AND ALCOHOL-INDUCED DISORDERS, cont’d. 4. Treatment and Prevention of Alcohol Use Disorders a. Minnesota Model b. Alcoholics Anonymous c. Marital and Family Therapy d. Behavioral Treatments e. Medication f. Controlled Drinking Treatments g. Relapse Prevention h. Brief Interventions I. Patient-Treatment Matching OTHER DEPRESSANTS 1. Barbiturates (e.g., Seconal, Tuinal, Nembutal) a. Odorless, white, crystalline (barbituric acid) b. Called “downs” or “downers” for insomnia c. Produces relaxation, mild euphoria d. High doses similar to alcohol intoxication e. Depresses respiration, BP, temp.; coma, death 2. Benzodiazepines (e.g., Valium, Librium, Xanax) a. Derived from benzoic acid b. Alleviate anxiety, panic disorder, muscle spasms c. Safer than barbiturates, still tragic death d. Dependence and withdrawal 3. Depressant Abuse and Dependence a. 15% prescriptions per year; 1% criteria abuse b. “Recreational” use by adolescents c. Polydrug d. High tolerance, withdrawal, middle class 4. Treatment a. Detoxification b. Individual, group, education STIMULANTS 1. Amphetamines (“uppers”, “speed”; Dexedrine) a. Elevation in dopamine b. Effect on nucleus accumbens (reward centre) c. Stimulates sympathetic branch of ANS d. Increases HR, BP, alertness; reduces mucus, appetite e. Recreational users inhale nasally, inject, smoke f. High doses hypervigilance, paranoia; crashing 2. Cocaine a. Decreases blood flow to brain and constrict b. vessels b. Treat migraine, asthma c. Low dose – mild stimulation; high – tremor, panic Treatment a. Cocaine Anonymous, 12-step program b. Azrin’s community reinforcement model c. Node-link mapping d. Medication (antidepressant, dopamine enhancer) STIMULANTS, cont’d. 3. Nicotine a. From leaves of tobacco plant b. In pure form deadly; resp. failure, paralysis, death c. No. 1 public health problem in USA d. Cancer, heart disease, resp. illness, childhood asthma e. Withdrawal symptoms Treatment a. Would-be quitters fail 3-4 times but succeed b. Gradual reduction before quitting cold turkey helpful c. Nicotine gum or patches reduce withdrawal d. New approach – gum with mecamylamine OPIODS (Morphine, Heroin, Codeine, Methadone) a. From seed pods of poppy b. Known as narcotics c. For pain relief, antidiarrheals, cough suppressants d. As antidepressants in intractable depression e. Endogenous opiates – endorphins, enkephalins f. Influence pain and appetite; positive mood Opioid Abuse and Dependence a. Heroin most commonly abused b. Heroic against pain; most addictive c. 60% inner city users affected with HIV d. Smoked, snorted, injection e. Intoxicated “spacey”, drunk, drowsy, disconnected, 6 hrs f. Intense withdrawal g. Excessive body excretions, pupils dilation, diarrhea, fever Treatment a. Medication central role b. Opioid antagonists in detoxification c. Other drugs to reduce craving d. Methadone substitute e. Supportive-expressive therapy f. Methadone combined with psychological CANNABIS AND HALLUCINOGENS 1. Cannabis a. Derived from hemp plant b. Marijuana (pot, weed, grass, boo) – leaves, tops c. Orally with food, brewing as tea d. Hashish, smoked, from dried resin from tops e. 5.5 million in U.S. use weekly f. Dilate blood vessels in eyes, dry mouth, appetite g. Sedating effect on CNS h. Motor, STM, reaction time impaired 2. Hallucinogens a. Psychedelics, objects shimmer, waver, halos b. Visual hallucinations c. Synesthesia (see sounds, feel colors) d. Depersonalization, paranoid, variable moods e. LSD (lysergic acid diethylamide) f. Flashbacks, little physical risk g. Others – mescaline, psilocybin, phencyclidine (PCP) Treatment a. 12-step-type support group developed b. LSD intoxication requires hospitalization c. Therapies focus on psychological dependence CHAPTER 14 SEXUAL AND GENDER IDENTITY DISORDERS Lecture Outline 1. Aspects of Human Sexuality 2. Gender Identity Disorders 3. Sexual Dysfunctions 4. Treatment of Sexual Dysfunctions 5. Paraphilias 6. Treatment of Paraphilias ASPECTS OF HUMAN SEXUALITY 1. Gender identity – person’s sense of being male or female 2. Gender role – behaviors expected of males or females in culture 3. Sexual orientation – person’s preference sexual behavior (a) Homosexual – sexual activity with member of same sex (b) Lesbianism – homosexual activities by females (c) Heterosexual – sexual activity members of opposite sex (d) Bisexual – sexual activity with members of both sexes (e) For some, restricted to touching, kissing, genital intercourse (f) Others, masturbation, oral sex, anal intercourse (g) Some have only one partner, some have many ASPECTS OF HUMAN SEXUALITY, cont’d. 4. Survey of Sexual Behavior a. National Health and Social Life Survey, 3000 Ss, aged 18-59 (1) 1.4% of women; 2.8% of men homosexual or bisexual (2) 60% of men; 40% of women masturbated in the past yr. (3) By age 22, 90% of Americans engaged in intercourse (4) Only 17% of Americans had more than one sex partner in past yr. (5) Only 5% of married admitted to having more than one partner b. Study of Sexual Fantasies (1) Mental images they find sexually arousing (2) Brain is body’s most important sex organ (3) Men think sex a lot; ½ say sexual fantasies daily, several times (4) Women few times a week of few times a month (5) Reliving prior experience; few “forbidden” ASPECTS OF HUMAN SEXUALITY, cont’d. 5. Biological Influences on Sexual Differentiation a. X and Y chromosomes b. Before birth – 8-12 weeks exact development c. At puberty – androgens (testosterone), estrogens (estradiol, progesterone) d. Congenital adrenal hyperplasis (1) Inherited disorder; adrenal glands produce excess androgen (2) Masculinizes external genitalia of females in fetal dev. (3) Demonstrate male behaviors; identity female e. Testicular Feminization (1) Affects male (2) Defective gene on Y; cannot absorb testosterone (3) Born with female external genitalia; raised as females (4) No uterus or ovaries; well-adjusted females ASPECTS OF HUMAN SEXUALITY, cont’d. 6. Sexual Orientation a. Sexual Orientation and Mental Health (1) Before 1973 homosexuality as personality disorder (2) In 1987 left out of DSM-IIIR; not in DSM-IV (3) More depression due to discrimination, rejection (4) Frequency: 64% non-Western, other 36% unapproved (5) 2.4% men exclusively homosexual, 2.6% bisexual b. Biological Factors in Development of Sexual Orientation (1) Most homosexuals have no choice (2) Moderate degree heritability/genetic (3) Slight neuroanatomical differences c. Development of Homosexuality: Psychological factors (1) Male growing up with dominant mother, weak father (2) Growing up with homosexual parents, child not same GENDER IDENTITY DISORDER 1. Confusion about dissatisfaction with biological gender a. Always involve two components (1) Persistent cross-gender identifications (2) Profound discomfort, disgust with sex organs (3) Persons sometimes termed transsexuals (4) Not hermaphrodites (both female and male sex organs) b. Prevalence: 3% for boys; < 1% for girls b. In children (1) Boys often described as beautiful or feminine (2) Show preference for cross-gender toys (3) Hide penis, tell parents hope will go away (4) Girls wear male clothing, haircuts, use boyish names (5) Ostracized (kindergarten), relentless teasing (elementary) (6) Behavior suppressed by negative feedback (7) 80% reported being bisexual or homosexual c. In adults (1) Adult transsexuals two major categories (a) Homosexuals since childhood, seek help adopt (b) Male; heterosexual; married; gender dysphoria GENDER IDENTITY DISORDER, cont’d. 2. Causes of Gender Identity Disorder a. Richard Green - parental indifference key variable b. Fathers aloof and uninvolved in upbringing c. Girls whose mothers are distant at risk 3. Treatment of Gender Identity Disorder a. First receive treatment starting school b. Psychological Treatments (1) Goals – self-esteem, gender-appropriate behavior (2) Social, academic skills regardless of gender identity (3) Behavior therapy for child, parent training or both (4) Restrict time child spend with encouraging relatives c. Sex Reassignment Surgery (1) Transsexuals believe best intervention (2) Not candidates unless lived 1 yr. as desired gender (3) Extensive psychological evaluation (4) Female-to-male removal of breasts; penile surgery rare (5) Male-to-female removal of penis; creation of vagina; hormone; electrolysis SEXUAL DYSFUNCTIONS 1. The Sexual Response Cycle a. Sexual responsiveness 4-stage sequence (1) Desire – triggered by thoughts, fantasies, anticipation (2) Excitement – changes in sexual organs, skin, body (3) Orgasmic – sexual pleasure peaks, invol. rhythmic contr. (4) Resolution – disengorgement of blood in sexual organs b. Sexual dysfunctions – problem in a phase and/or pain 2. Factors affecting Sexual Responsiveness a. Neurological and vascular factors b. Attitude and beliefs c. Interpersonal factors d. DSM-IV four categories of disorders plus lifelong or acquired SEXUAL DESIRE DISORDERS 1. Hypoactive Sexual Desire Disorder (HSDD) (15-40%) a. Fantasies infrequent, interest in sexual activity nil b. Feels distressed, no medical or mental disorders c. Inhibitions during childhood carry over into adulthood d. Period of active desire stops when intense sexual attract. decline 2. Sexual Aversion Disorder (not common) a. One fears or disgusted by idea of sexual contact b. Some experience panic or revulsion of any kind of sexual beh. 3. Causal Factors a. Desire shaped by biological, cognitive, emotional factors b. Biological basis may be impaired, e.g., natural aging c. Testosterone, estrogen low; increase hormone d. Psychological causes more likely e. Anxiety; anger; depression (prior or current) SEXUAL AROUSAL DISORDERS 1. Female Sexual Arousal Disorder (FSAD) a. Problems attaining, maintaining, lubrication, genital swelling b. Woman distressed; no medical or mental problems c. History of sexual abuse may be factor d. Anxiety about sex major threat to adequate arousal 2. Male Erectile Disorder a. Most common and demoralizing sexual dysfunction b. 90% develop after normal functioning; 50% sometime in life c. 400,000 visits to G.P. every yr.; 10-20 million men in U.S. d. Most attributed to medical conditions, side effects medication 3. Biological Factors 4. Psychological Factors ORGASMIC DISORDERS 1. Female Orgasmic Disorder a. Experience normal desire, arousal but no orgasm b. 10% women never had orgasm c. Excessive alcohol and drug use impairs ability d. Age only psychological factor related to orgasmic function e. Depression, antidepressants; sociocultural, interpersonal 2. Male Orgasmic Disorder and Premature Ejaculation a. Inability to ejaculate or long delay b. Still orgasms with ejaculation when masturbate or in dreams c. Some report penises numb after erection, beginning intercourse d. Not retrograde ejaculation (ejaculate into bladder) e. Lack of arousal or conflict with partner f. Premature ejaculation 3. Sexual Pain Disorder a. Dyspareunia b. Viginismus TREATMENT OF SEXUAL DYSFUNCTIONS 1. Masters and Johnson 2. Treating Disorders of Sexual Desire a. Four-phases to become more aware of sexual sensations b. Quality of couple’s relationship c. Certain antidepressants, yohimbine hydrochloride d. Drug to increase heart rate, BP, blood flow to penis e. Gonadal hormone therapy 3. Treating Female Sexual Arousal Disorder (FSAD) a. Use vaginal lubricants; address relationship problems 4. Treating Male Erectile Failure a. Reduce performance anxiety; conflict resolution b. Learn to cope with disappointment c. If organic treat; penile prosthesis surgery 5. Treating Female Orgasmic Disorder 6. Treating Sexual Pain Disorder PARAPHILIAS 1. Forms of Paraphilia a. Fetishism b. Transvestic Fetishism c. Exhibitionism d. Voyeurism e. Frotteurism f. Sexual Masochism and Sadism g. Sadism and Rape h. Pedophilia i. Prevalence: 80,000 arrests/yr.; 500 acts/person j. Causes: biological factors, psychological factors k. Treatment of Paraphilias (1) Behavior methods (2) Multimodal treatment (3) Relapse prevention CHAPTER 16 PSYCHOTHERAPY Lecture Outline 1. What is Psychotherapy? 2. Methods of Psychotherapy a. Psychoanalysis b. Interpersonal Therapies c. Phenomenological/Experiential Therapies d. Client-Centred Therapy e. Gestalt Therapy f. Behavioral Therapies g. Cognitive Therapies 3. Evaluating Psychotherapy WHAT IS PSYCHOTHERAPY? 1. Treatment of behavior disorders using psychological methods 2. Change behaviors, thoughts, emotions; feel and function better 3. Therapists can be psychiatrists, psychologists, C.S.W., training 4. Ability to listen with understanding and sensitivity, non-judgmental 5. All walks of life; gender, class, education, culture 6. Problems bought to therapy in order of frequency a. Anxiety and depression b. Interpersonal problems c. Marital problems d. School difficulties e. Physical complaints f. Job-related difficulties g. Substance abuse h. Psychotic conditions i. Mental retardation METHODS OF PSYCHOTHERAPY 1. Psychoanalysis a. Help understand unconscious reasons maladaptive behaviors b. Long-term; insight, work through c. Free association d. Interpretation of dreams, every day behavior e. Analysis of resistance, transference; countertransference f. Variations on psychoanalysis METHODS OF PSYCHOTHERAPY, cont’d. 2. Interpersonal Therapies a. Harry Stack Sullivan: disturbances in interpersonal relationships, developed out of early interactions b. Mental disorders consist of “rigid, constricted and extreme patterns of interpersonal behaviors” c. Maladaptive behaviors perpetuated by provoking others to behave in ways that reinforce these behaviors d. Major goal to counteract clients’ ploys e. Help understand how conflicts perpetuated by displaying exaggerated dependence, hostility f. Teach style learned in childhood, now maladaptive g. Teach more flexible, positive ways h. Reduce feelings of dependency and increase self-esteem METHODS OF PSYCHOTHERAPY, cont’d. 3. Phenomenological/Experiential Therapies a. Vary considerably; share five distinguishing features b. Meaning of life not intrinsic; constructed by perceiver; Gestalt c. When full potentials reached, find own solutions; humanistic d. Therapeutic relationship primary vehicle e. Focus on immediate, moment-to-moment experiences creates positive perception f. Equals, responsible individuals, expert on own experiences, ultimately can make own decisions g. Emphasize importance of experiencing, exploring emotions that are confusing or painful h. Empty chair technique METHODS OF PSYCHOTHERAPY, cont’d. 4. Client-Centred Therapy a. Pioneered by Carl Rogers b. Self-actualization thwarted by judgements imposed by others c. Judgements create conditions of worth d. Therapist must communicate three related attitudes (1) Convey unconditional positive regard (2) Strive for empathic understanding (3) Genuine in relating to client; all actions, feelings congruent METHODS OF PSYCHOTHERAPY, cont’d. 5. Gestalt Therapy a. Developed by Fritz Perls b. Gaps or distortions in awareness of genuine feelings c. Difficult to directly experience and express emotions d. Develop manipulative social games or phoney roles; the more energy, the more unhappy e. Ploys lead people to believe not responsible for behavior f. Eventually feel powerless; experience perceived helplessness g. Want therapist to solve problems h. Gestalt therapy focuses on helping client (1) Become aware of feelings and need disowned (2) Recognize feelings and need as genuine and part of self (3) Therapist more active and confrontative than client-cent. (4) Talking gets nowhere; must reexperience old feelings (5) Role-play significant people in lives (6) Empty chair dialogue hallmark (7) Client asked to become body part (8) Client asked to enact own manipulations (9) Method helps become aware of genuine feelings (10) Reduce emotional upset (11) After session, lowered BP, reduced anger METHODS OF PSYCHOTHERAPY, cont’d. 6. Behavior Therapy a. B.F. Skinner views disordered behaviors learned b. Decrease maladaptive, develop more adaptive behaviors c. Replace self-defeating thoughts with rational d. Focus on here and now e. Improve social skills, reduce phobias f. Practicing self-rewarding thoughts to improve performance g. Behavior therapy procedures (1) Systematic desensitization (2) Exposure treatments (3) Social skills training (4) Modeling (5) Contingency management (6) Biofeedback (7) Aversion therapy (8) Cognitive therapies EVALUATING PSYCHOTHERAPY 1. Methods of evaluating psychotherapy a. Experimental group designs b. Placebo groups c. Within-subject designs 2. The Validity of Experiments in Psychotherapy a. Ideal experiment designed for high internal validity b. Internal validity – results due to independent variable c. Try to have high external and statistical validity d. External validity – results can be generalized e. Statistical validity – enough Ss to allow statistical analyses 3. Research on the Outcome of Psychotherapy 4. Conclusions About Psychotherapy’s Effectiveness a. Consumer Reports Survey, 7000 readers answered questions b. 90% felt better after treatment c. No particular approach better than other d. No difference in therapists e. Benefits after 6 to 8 sessions f. Cognitive, behavioral advantage over traditional ABNORMAL PSYCHOLOGY 385 UNIVERSITY OF CALGARY Introduction 1 CHAPTER 1 – Making Sense of Abnormality 28 CHAPTER 2 – Assessment and Diagnosis 43 CHAPTER 3 – Disorders of Infancy, Childhood and Adolescence 62 CHAPTER 4 – Developmental Disorders and Learning Disabilities 76 CHAPTER 5 – Stress, Sleep and Adjustment Disorders 97 CHAPTER 6 – Psychological Factors and Health 108 CHAPTER 7 – Anxiety Disorders 119 CHAPTER 8 – Dissociative and Somatoform Disorders 128 CHAPTER 9 – Mood Disorders and Suicide 139 CHAPTER 10 – Schizophrenia 147 CHAPTER 11 – Cognitive Disorders 158 CHAPTER 12 – Personality Disorders 169 CHAPTER 13 – Substance-Related Disorders 181 CHAPTER 14 –Sexual and Gender Idenity Disorders 194 CHAPTER 16 – Psychotherapy 203