What are the research methods in psychopathology? - Chapter 4

There are many different research methods in psychology. This chapter will focus on what science is an on research methods in psychopathology.

What is science?

Science is trying to gain knowledge via observation. A theory is formed and then tested by systematically gathering data. A collection of propositions thought of to explain a class of observations is called a theory. A theory gives room for generation of more and specific hypotheses. Hypotheses are expectations about what should occur if a theory is true.

A good theory and good hypotheses are clearly and precisely formulated. The goal of testing theories or hypotheses is to disprove. A good formulated theory or hypothesis makes this possible. Subsequently, replication must be possible with each scientific observation.

What are the approaches to research on psychopathology?

When detailed information is recorded of one person at a time, we talk about a case study. A case study has disadvantages over other research methods: it lacks the control and objectivity. Despite these disadvantages, case studies still have an important role in psychopathology because:

• It can be used to give a detailed description of a clinical phenomenon.

• A case study can disprove a hypothesis.

• It can be used to generate hypotheses that can be tested through controlled research.

With the correlational method researchers try to find out if two variables co-relate. The variables are measured in a different way than in experimental research. Variables are measures as they exist in nature, whereas in experimental research they are manipulated. Researches mostly rely on this method when it is not ethical to manipulate variables.

The correlation coefficient is computed to determine the strength of the relationship between two variables. It can take any value between -1.00 and +1.00. If there is a strong and negative relationship the coefficient is close to -1.00. In contrast, if there is a strong and positive relationship the coefficient is close to +1.00. If the coefficient is close to 0.00, there does not seem to be a relationship between the two variables.

Both statistical and clinical significance should be considered. Statistical significance means that the observed correlation probably has not occured by chance. Clinical significance means that the relationship between the variables is large enough to matter.

There is a major disadvantage to the use of the correlation method. No conclusions can be drawn about the causation of the relationship. It is not known if one variable causes the other. This is called the directionality problem. You can use a longitudinal design to solve this problem. It is also possible that a third variable has caused the relationship between the two variables. This is known as the third-variable problem.

The study of the distribution of disorders in a population is called epidemiology. This kind of research focuses on three aspects of a disorder: prevalence, incidence and risk factors. Because the study of risk factors is often done without manipulating variables, the study is usually a correlational study.

Methods of correlation research in behavior and molecular genetics will be briefly discussed:

• In the family method the average number of genes shared within a family is known and therefor a study of genetic predisposition can be done with a family. The starting point in the family method is the person with the diagnosis, those people are called index cases or probands.
• In the twin method, twins are compared. Both kind of twins, monozygotic twins and dizygotic twins, are used. Monozygotic twins are interesting because they are genetically the same. Dizygotic twins are about 50% the same genetically. If a disorder can be inherited, the disorder should be seen more in monozygotic twins.
• In the adoptee's method, adopted children are raised by parents other than their biological parents. If a disorder is seen in adoptees, while their foster parents do not have the disorder, but their biological parents do, then there is convincing support for the heritability of the disorder. Environmental influences can be determined as well, when the foster parent has a disorder and the biological parent does not. This is called cross-fostering.

What is an experiment?

To determine a causal relationship between two variables the experiment is the best tool to use. Participants of an experiment will be randomly assigned to different conditions. An independent variable will be manipulated and a dependent variable will be measured. The conditions within the dependent variable differ from each other. This is called the experimental effect.

It is important that an experiment has good internal validity. Internal validity refers to the extent to which the experimental effect can be ascribed to the independent variable. To reach internal validity, it is important that the experiment at least has one control group. A control group does not get the experimental treatment. Random assignment is also important to reach internal validity, because it helps ensure that groups are similar.

Researchers want the results of their study also to be true for people outside of the study. The extent to which this is the case is called external validity. It is difficult to determine the external validity.

In a single-case experimental design, the experiment is conducted at one person instead of a group. This can have a high internal validity. The reversal design (ABAB design) is commonly used. In reversal design the participant’s behavior must be measured in a specific order:

1. The baseline: an initial time period (A).

2. The period when a treatment is introduced (B).

3. A reinstatement of the conditions of the period of the baseline (A).

4. A reintroduction of the treatment (B).

In this case, the period without treatment will function as the control condition.

What is Treatment Outcome Research?

When researchers want to know if a particular treatment works, they design a treatment outcome research. Such a study should at least include the following criteria:

• The sample being studied must be clearly defined.

• The treatment being offered must be clearly described.

• The study must include a control group.

• Random assignment.

• Reliable and valid outcome measures.

• The sample should be big enough for the statistical tests being used.

In randomized controlled trials (RCT) clients are randomly assigned to treatment group or control group. The independent variable is the received treatment and the clients’ outcome is the dependent variable. Psychologists want empirical based treatments (empirically supported treatments, ESTs).

The treatment condition is based on treatment manuals. This provides information about a specific treatment. The control group is important to compare the outcomes of the research to a baseline. Most of the times, a double-blind procedure is used. Sometimes physical or psychological improvement might be observed, because of the patients’ expectations instead of the active ingredient in a treatment. This is called the placebo effect. At last, it is important to look at the sample and their underlying problems.

RCTs are often designed to determine whether a treatment works under the purest of conditions, in other words they are designed to find out the efficacy of a treatment. Beside the efficacy, also the effectiveness of a treatment should be determined. The effectiveness is how well the treatment works in imperfect conditions, like the real world.

What are analogues in psychopathological research?

It is not always possible to use the experimental method due to ethical reasons. To still take advantage of the benefits of the experimental method, researchers can use an analogue experiment. In an analogue experiment, researchers try to create or observe a phenomenon related to the one they actually want to test. This phenomenon is then the analogue. Results with good internal validity can then be obtained, because a true experiment is conducted. The external validity is the only problem that remains.

How can you combine different findings of multiple studies?

When you replicate a study, you want the results to be the same as in the original study. Because of the publication bias, where negative findings are not published, researchers are not motivated to replicate a study. It needs to become more transparent. A meta-analysis was developed to solve this problem. This can be used to calculate an effect size. A criticism is that some meta-analysis includes studies that are of poor quality.

What is schizophrenia? - Chapter 9

The psychological disorder schizophrenia is characterized by disordered thinking, faulty perception and attention, a lack of emotional expressiveness and disturbances in behavior. The way someone thinks, feels and behaves are invaded by the symptoms of schizophrenia.

What are the clinical descriptions of schizophrenia?

In schizophrenia, the range of symptoms are extensive. These symptoms are often described in three broad domains:

1. Positive symptoms.

2. Negative symptoms.

3. Disorganization.

DSM-5 Criteria for Schizophrenia are:

• Two or more of the following symptoms for at least 1 month, and one symptom should be either 1, 2, or 3: (1) delusions; (2) hallucinations; (3) disorganized speech; (4) disorganized (or catatonic) behavior; (5) negative symptoms (diminished motivation or emotional expression).

• Functioning in work, relationships, or self-care has declined since onset.

• Signs of disorder for at least 6 months; or, if during a prodromal or residual phase, negative symptoms or two or more of symptoms 1-4 in less severe form.

Positive symptoms consist of excesses and distortions. These include hallucinations and delusions.

Beliefs that are contrary to reality and are firmly held in spite of disconfirming evidence are called delusions. Delusions are common positive symptoms in this disorder. Several forms are possible, including:

• Thought insertion: the believe that thoughts are not his or her own and that they have been placed in his / her mind by an external source.

• Thought broadcasting: the believe that thoughts of a person himself are broadcast or transmitted, so that others know what he is thinking.

• The believe that someone’s own feelings or behaviors are being controlled by an external force.

• Grandiose delusions: a person may have an exaggerated sense of his or her own importance, power, knowledge or identity.

• Ideas of reference: a person may incorporate unimportant events within a framework of a delusion and read personal significance into the trivial activities of others.

Hallucinations are the most dramatic distortions of perception. Hallucinations are sensory experiences in the absence of any relevant stimulation from the environment. They can be both auditory and visual, but auditory is more common.

Delusions and hallucinations do not only occur in people with schizophrenia, but also in people with other psychological disorders. Conducting thorough assessments is important to avoid misdiagnosing someone.

Behavioral deficits in motivation, pleasure, social closeness and emotion expression is what make up the negative symptoms in schizophrenia. These symptoms usually have a profound effect on the lives of people with this disorder.

A lack of motivation and a seeming absence of interest in or an inability to persist in what are usually routine activities is referred to as avolition or apathy. For certain life areas, but not all, people with schizophrenia may have trouble with motivation.

Asociality refers to severe impairments in social relationships. Anhedonia refers to a loss of interest in or a reported lessening of the experience of pleasure. There are two types:

1. Consummatory pleasure: the amount of pleasure experienced in the moment or in the presence of something pleasurable.

2. Anticipatory pleasure: the amount of expected pleasure from future events or activities.

Deficits for people with schizophrenia seem to be in anticipatory pleasure and not in consummatory pleasure.

A lack of outward expression of emotion is referred to as blunted affect. This concept refers not to the patient’s inner experience of emotion. A significant reduction in the amount of speech is referred to as alogia. If this symptom is present, the person does not talk much.

Two domains can represent the just described five different negative emotions:

1. Motivation and pleasure domain: involving motivation, emotional experience and sociality.

2. Expression domain: involving outward expression of emotion and vocalization.

Problems in organizing ideas and in speaking so that a listener can understand is called disorganized speech.

When a person is more successful in communicating with a listener but has difficulty sticking to one topic, the speech is disorganized by what is called loose association or derailment.

Disorganized speech is related to problems in executive functioning like problem solving, planning and making associations between thinking and feeling. It is also associated with the ability to perceive semantic information.

People with the symptom of disorganized behavior seem to lose the ability to organize their behavior and make it conform to community standards. Performing the tasks of everyday living seems to be difficult too.

Catatonia is one manifestation of disorganized behavior according to the DSM-5. Medications work effectively on the disturbed movements or postures of catatonia.

The chapter 'Schizophrenia apectrum and other psychotic disorders' in the DSM-5 includes schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, and delusional disorder.

What is the etiology of schizophrenia?

Schizophrenia has a genetic component as is supported by a good deal of research. The genetic factors involved may vary from person to person. Schizophrenia seems to be genetically heterogeneous.

The relatives of people with schizophrenia are at increased risk and when the genetic relationship becomes closer, the risk increases.

Twin studies show a less-than-100-percent concordance in MZ twins. This is important, because it tells us that genetic transmission does not only account for schizophrenia.

This type of research suggests that negative symptoms may have a stronger genetic component than do positive symptoms. Aspects of the environment could account for some portion of the increased risk.

In familial high-risk study, the study begins with one or two biological parents with schizophrenia and follows their children longitudinally in order to identify how many of the offspring may develop the disorder and what types of childhood neurobiological and behavioral factors may predict the onset of schizophrenia.

Molecular genetics researchers try to figure out what exactly constitutes the genetic predisposition. The predisposition is not transmitted by one gene. This kind of research has found that multiple common genes are related to both schizophrenia and bipolar disorder.

DTNBP1 is a gene associated with schizophrenia. COMT and BDNF are genes associated with the cognitive deficits associated with schizophrenia. COMT is related to cognitive control processes that rely on the prefrontal cortex. The genes are not associated with schizophrenia in other studies. Schizophrenia is related to a tremendous genetic heterogeneity and this may explain the above findings.

What is the role of neurotransmitters?

The dopamine theory states that schizophrenia is associated to excess activity of the neurotransmitter dopamine. This theory is based on the knowledge that drugs effective in treating schizophrenia reduce dopamine activity.

Though this turned out to be too simple to account for schizophrenia’s wide range of symptoms. Medications that block dopamine receptors, are effective for the treatment of the positive and disorganization symptoms. For the negative symptoms, the prefrontal cortex is thought to be especially relevant. Dopamine activity in this part of the brain seems to be low in people with the disorder. This underactivity of dopamine in the prefrontal cortex may contribute to the negative symptoms.

It is unlikely that only dopamine accounts for all the possible symptoms in schizophrenia.

Other neurotransmitters that seem to have a role in the disorder are serotonin, GABA and glutamate. Newer drugs for schizophrenia implicate neurotransmitters like serotonin. The dopamine disrupts the GABA transmission in the prefrontal cortex.

Ventricles are spaces in the brain filled with cerebrospinal fluid. The brain has four ventricles. A loss of brain cells is implied if one has larger fluid-filled spaces. Research shows that some people with the disorder have enlarged ventricles.

A variety of evidence suggests that the following is the case:

• Behaviors such as speech, decision making, emotion and goal-directed behavior are disrupted in schizophrenia. The prefrontal cortex plays a role in these behaviors.

• Reductions in gray matter and overall volume in the prefrontal cortex are found in MRI studies.

• Some neuropsychological tests are designed to tap functions supported by the prefrontal cortex. People with schizophrenia perform more poorly than people without the disorder on these tests.

• When performing neuropsychological tests tapping prefrontal functioning, people with schizophrenia show lower glucose metabolism in the prefrontal cortex, as is found in PET brain-imaging studies.

Studies indicate that what is lost in the prefrontal cortex is not neurons, but dendritic spines. This are small projections on the shafts of dendrites where nerve impulses are received from other neurons at the synapse. Communication among neurons is disrupted when some of these dendritic spines are lost.

Research has also found structural and functional abnormalities in the temporal cortex of people with schizophrenia. This includes areas such as the temporal gyrus, hippocampus, amygdala and anterior cingulate.

What is known about the connectivity in the brain?

People with schizophrenia tend to have less connectivity in the white matter. There is also less connectivity between the frontoparietal and default-mode networks. It helps in predicting who will respond to antipsychotic medication treatment.

A number of brain networks have been revealed by these connectivity methods. Clusters of brain regions that are connected to each other in that activation in these regions is reliably correlate when people perform certain kind of tasks or are at rest are referred to as brain networks.

What environmental and psychological factors may contribute to schizophrenia?

The following environmental factors possibly contribute to schizophrenia:

• Complications at birth.

• Maternal infections during pregnancy.

• Cannabis use among adolescents.

It seems that people with schizophrenia were especially vulnerable to daily stress.

The highest rates of schizophrenia are found in people with the lowest socioeconomic status (SES), but schizophrenia can be found among all levels of SES. Poverty, migration and urbanicity are associated with schizophrenia. There are also family-related factors, like having a schizophrenogenic mother. In conclusion, families with a higher expressed emotion (EE) are more likely to trigger a person with schizophrenia.

What are the developmental factors?

Retrospective studies looked at what people with schizophrenia were like before their first symptoms. Among the findings were:

• Lower IQs.

• Were more often delinquent.

• Were more often withdrawn.

• Boys were rated more disagreeable.

• Girls were rated more passive.

• Poorer motor skills.

• More expressions of negative emotions.

In a more recent prospective study, it was found that children who eventually developed the disorder had signs of a cognitive deficit beginning at the age of seven that remained stable through adolescence.

A study design that identifies people with early, attenuated signs of schizophrenia that nonetheless cause impairment is called a clinical high-risk study. Such a study found that those people who later developed a psychotic disorder had lower gray matter volumes than those who had not developed a psychotic disorder. Reduced gray matter volume may predate the onset of schizophrenia and other psychotic disorders.

Researchers from a similar longitudinal study identified several factors that predicted a greater chance of developing a psychotic disorder, including:

• Having a biological relative with schizophrenia.

• A recent decline in functioning.

• High levels of positive symptoms.

• High levels of social impairment.

What is the treatment for schizophrenia?

Treatment is often a combination of short-term hospital stays, medication, and psychosocial treatment.

Some people with schizophrenia lack insight into their impaired condition and refuse any treatment. This is a problem.

Drugs that are widely used in the treatment of schizophrenia are antipsychotic drugs. There are first-generation (reducing positive symptoms) and second-generation antipsychotic drugs (reducing positive and negative symptoms) e.g., clozapine and risperidone. Medications alone are not a completely effective treatment but do help a lot. Research keeps being done to find new and more effective drug therapies for schizophrenia.

Recommended is to treat schizophrenia with both medication and psychosocial interventions. Several of effective psychosocial interventions are:

• Social skills training: this training is designed to teach patients how to successfully manage a wide variety of interpersonal situations.

• Family therapies: these therapies have numerous characteristics in common: education about schizophrenia, information about antipsychotic medication, blame avoidance and reduction, communication and problem-solving skills within the family, social network expansion and hope.

• Cognitive behavior therapy.

• Cognitive remediation therapy: such therapies seek to improve basic cognitive functions. It is also called cognitive enhancement therapy (CET) and cognitive therapy.

• Psycho education.

• Residential treatment: people who do not need to be in the hospital but are not quite well enough to live on their own, can be placed in residential treatment homes.

What are substance use disorders? - Chapter 10

What are the criteria for substance use disorder?

People have used several substances in the hope of changing the mood, reducing pain or changing alter of consciousness . The root of substance use disorder is probably the pleasing effects of substances. The DSM-5 contains categories for specific substances in substance use disorder. Gambling disorder is also included in the DSM-5.

A severe substance use disorder is often referred to as addiction. Meeting 2-3 of the criteria is considered mild, meeting 4-5 is considered moderate and meeting 6 or more criteria is considered a severe substance use disorder.

Tolerance and withdrawal are most of the time part of a severe substance use disorder. Tolerance means either that a larger doses is needed to reach the same effect or that the effects become less using the same doses. When a person stops taking the drugs or reduces the amount, it is possible the person develops negative physical and psychological effects. This is called withdrawal.

Multiple factors can contribute to the development of substance use disorder, such as an individual’s neurobiology, social setting, culture and other environmental factors.

DSM-5 Criteria for Substance Use Disorder are:

Problematic pattern of use that impairs functioning. Two or more symptoms within a 1-year period:

• Failure to meet obligations.

• Repeated use in situations where it is physically dangerous.

• Repeated relationship problems.

• Continued use despite problems caused by the substance.

• Tolerance.

• Withdrawal.

• Substance taken for a longer time or in greater amounts than intended.

• Efforts to reduce or control use do not work.

• Much time spent trying to obtain the substance.

• Social life, hobbies or work activities given up or reduced.

• The craving to use the substance is strong.

What are the clinical descriptions of alcohol, tobacco, and marijuana use disorders?

When someone uses too much alcohol for too long, there is a risk at delirium tremens (Dts) when the person stops using it. It is a withdrawal symptom marked by fever, sweating, trembling, cognitive impairment and hallucinations.

Alcohol use disorder often comorbids with other drug use.

What is known about alcohol users?

College-age adults use alcohol most frequently. More men than women tend to have problems with alcohol. The consequences of binge drinking can be very serious (e.g. death). African American adolescents and adults are less likely to binge drink than European American and Hispanic adolescents and adults.

The disorder comorbids with several other psychological disorders. What the short-term effects of alcohol use are, depends on the amount of alcohol consumption, the person’s weight, presence of food in the stomach, and person’s body fat.

Alcohol interacts with multiple neural systems in the brain, leading to the effects that:

• It stimulates GABA-receptors.

• It increases levels of serotonin and dopamine.

• It inhibits glutamate receptors.

Prolonged alcohol abuse negatively effects almost every tissue and organ of the body.

The leading cause of intellectual disability among children is heavy alcohol consumption by a pregnant woman. Fetal alcohol syndrome (FAS) can be a consequence. In FAS, the growth of the fetus is slowed, and cranial, facial and limb anomalies can be produced.

Tobacco is addicting because of Nicotine. It activates the neural pathway that stimulates dopamine neurons in the mesolimbic area.

The most preventable cause of premature death is smoking. People with a psychological disorder are most likely to smoke in the USA.

Smoking is less prevalent among African American and Asian American adolescents than among European American and Hispanic adolescents.

Secondhand smoke is the smoke coming from the burning end of a cigarette. This smoke contains higher concentrations of ammonia, carbon monoxide, nicotine and tar than the smoke inhaled by the user. Some of the effects of secondhand smoking are:

• Lung damage.

• Babies are more likely to be born prematurely, to have lower birth weights and to have birth defects.

E-cigarettes are electronic cigarettes. They are made of plastic or metal. It contains liquid nicotine that is mixed with other chemicals. E-cigarettes are marketed as safe alternatives to cigarettes because they do not have the carbon monoxide and tar.

Very little research has been done on the safety of e-cigarettes.

Marijuana is made of the dried and crushed leaves and flowering tops of the hemp plant. The category name in the DSM-5 that includes marijuana is cannabis use disorder.

People who smoke marijuana often report feeling relaxed and sociable after use. The kind of effects are dependent on the dosage. Effects appear more or less after 30 minutes, as a consequence smoker tend to get much higher than intended. Marijuana use can interfere with cognitive functioning, as indicated by scientific evidence. If this is also the case when a smoker is not using at the moment, is not clear. Better research must be done to answer this question. Short-term physical consequences can be bloodshot and itchy eyes, dry mouth and throat, increased appetite, raised blood pressure, or reduced pressure within the eye. Lung structure and function can become impaired with long-term use of marijuana. Smokers can become tolerant to marijuana, but it is not clear whether a user will experience withdrawal symptoms when they stop using.

There is a lot of debate on whether marijuana use should become legal, because of its therapeutic benefits. Some states and countries have legalized marijuana.

What are opioids?

Opioids are addictive drugs that can relieve pain and induce sleep. These kinds of drugs include opium, morphine, heroin and codeine. Hydrocodone and oxycodone are pain medications that can be prescribed legally.

The effects produced by opioids are present because the drugs stimulate the neural receptors of the body’s own opioid system.

Users develop tolerance and show withdrawal symptoms; thus the drugs are addicting.

What are stimulants?

Stimulants increase alertness and motor activity by acting on the brain and the sympathetic nervous system.

The effects of amphetamines are produced by causing the release of norepinephrine and dopamine and by blocking the reuptake of these neurotransmitters. More and more of the drug is required to keep getting the same effect, because tolerance develops quickly.

Methamphetamine is the most abused kind of amphetamine. Men tend to abuse this stimulant drug more often than women. Tolerance and withdrawal are both present when someone is physiological dependent.

Neuroimaging studies have found damage in certain brain areas. It is not clear whether the drugs damaged these areas, or whether these areas were already damaged before the person started using.

Cocaine blocks the reuptake of dopamine in mesolimbic areas of the brain and does this rapidly. The effects can be the following:

• Pleasurable states.

• Increased sexual desire.

• Produced feelings of self-confidence.

• Produced feelings of well-being.

• Produced feelings of indefatigability.

Chronic use can cause heightened irritability, impaired social relationships, paranoid thinking, and/or disturbances in eating and sleeping.

What are hallucinogens, ecstasy and PCP?

The main effects of hallucinogens are hallucinations. Users often recognize the hallucinations as being caused by the drug. LSD is one of the hallucinogens. When the physiological effects of the drug have worn off, the person tend to have flashbacks. These are visual recurrences of perceptual experiences.

Ecstasy is made from methylenedioxymethamphetamine (MDMA) and is a hallucinogen-like substance. In the DSM-5 it is classified as “other hallucinogen use disorder”. The drug contributes mostly to both the release and reuptake of serotonin. It is not clear whether use of Ecstasy causes harm.

What is the etiology of substance use disorder?

For some people, becoming physiologically dependent on a substance is a developmental process:

1. It begins with a positive attitude toward a substance.

2. Start experimenting with using it.

3. Begin using it regularly.

4. Use it heavily.

5. Finally become dependent on it.

This process is not true for all cases of substance use disorders.

Factors that contribute to substance use disorders differ for the different moments in the above described process.

What are the genetic factors?

There is research evidence for a genetic contribution to drug and alcohol use disorders. No matter the drug, genetic and shared environmental risk factors seem to be the same.

For alcohol use disorder, the ability to tolerate large quantities of alcohol might be inherited.

What are the neurobiological factors?

Dopamine pathways in the brain are related to pleasure and reward. The effects of drugs often are rewarding and pleasurable feelings and this happens via the dopamine system by stimulating it.

An important area to figure out in the future is whether the “vulnerability model” is true or the “toxic effect model”. The first model proposes that people with problems in the dopamine system have increased vulnerability for becoming dependent on a substance. The second model proposes that problems in the dopamine system are the consequence of taking substances.

People often keep using drug to avoid the awful feelings of withdrawal.

There is a distinction between the value people give on short-term (immediate) versus long-term rewards. People with a substance use disorder often value the immediate reward more than a long-term reward.

What are the psychological factors?

In this paragraph, three other types of psychological factors that might contribute to substance use disorder will be discussed:

• The effects of drugs on mood.

• People’s expectations about the effects on behavior.

• Personality traits.

It is generally assumed that drug use is reinforced because it diminishes negative moods and enhances positive ones. Research support this idea, but only under certain circumstances.

It is more likely that people start using drugs, when they expect positive effects. This might explain why people use drugs, even though the drug does not really reduce tension.

Some personality traits appear to be important in predicting the development of substance use disorders are high levels of neuroticism, persistent desire for arousal, and/or cautious behavior, harm avoidance and conservative moral standards.

What are the sociocultural factors?

The likelihood of drinking heavily is influenced by cultural attitudes and patterns of drinking.

Another sociocultural factor is the ready availability of the substance. It seems that greater availability of a particular drug is related to greater use of that drug. Other contributing factors include family (e.g., unhappy marriage), social settings, and friends who use.

It is possible that a person who is likely to develop substance use disorder may create social surroundings that make it more likely to start using. Both a social influence model and a social selection model are explanations for how the social environment is related to substance use disorders.

What is the treatment of substance use disorder (alcohol)?

What is the treatment of alcohol use disorder? Detoxification is the first step in treatment for substance use disorders. Withdrawal can be difficult on both physical as psychological levels.

There are self-help groups around the world and the most widely known is Alcoholics Anonymous (AA).

For all kind of couples, behaviorally oriented marital therapy can achieve some reductions in problem drinking. It focuses on the skills covered in individual cognitive behavior therapy, the couple’s relationship and dealing with alcohol-related stressors together.

A form of cognitive behavior treatment is contingency management therapy. This therapy involves teaching people to reinforce behaviors inconsistent with drinking. The belief that environmental contingencies play an important role in encouraging drinking forms the basis of this therapy. Another form of cognitive behavior treatment that has been effective with alcohol and drug use disorders is relapse prevention.

Controlled drinking is based on two assumptions:

1. People have more potential control over their immoderate drinking than they normally believe.

2. Heightened awareness of the costs of drinking to excess as well as the benefits of abstaining can help.

What are the treatments for smoking?

If people around them quit smoking, people themselves are more likely to quit as well.

A physician telling an individual to stop smoking is probably the most widespread psychological treatment. This often happens, because of health issues.

Scheduled smoking is a treatment approach that seems to work. By getting smokers to agree to increase the time between cigarettes, nicotine intake will gradually reduce. That is the strategy behind scheduled smoking.

Some promise is shown in cognitive behavioral approaches that focus on coping skills and problem solving.

There are also nicotine replacement treatments (NRT). The goal in these treatments is to reduce the craving for nicotine by providing it in a different way. Examples of these are nicotine gum and nicotine patches.

What does the treatment of drug use disorder consist of?

Detoxification, withdrawal from the drug, is central to the treatment of people who use drugs.

Some somewhat helpful psychological treatments are:

• The antidepressant medication desipramine.

• Cognitive behavioral therapy (CBT) (more successful in the long term).

• Contingency management with vouchers (but more successful in the short-term).

• Motivational enhancement therapy.

• Self-help residential homes.

The administration of heroin substitutes or opiate antagonists are two widely used programs for heroin use disorder. With heroin substitutes, an individual takes drugs chemically similar to heroin that can replace the body’s craving for it. Opiate antagonists prevent the individual from experiencing the heroin high. This kind of treatment does not seem to be effective for cocaine use disorder.

What does the prevention of substance use disorder entail?

Developing ways to prevent young people from experimenting with tobacco has become a top priority, because all most everyone starts smoking before the age of 19. Promising are brief family interventions. Other effective strategies for reducing teenage smoking are:

• Increasing taxes on cigarettes.

• Restricting tobacco advertising.

• Public education campaigns.

• Creating smoke-free environments.

• Graphic images of the ill effects placed on packages.

There are also school-based programs aiming at preventing young people from starting to use tobacco, but not all of them are effective. They share some common components:

• Peer-pressure resistance training.

• Correction of beliefs and expectations.

• Inoculation against mass media messages.

• Peer leadership.

What are eating disorders? - Chapter 11

Eating disorders are likely to be stigmatized because of the cultural expectation from women.

What are the clinical descriptions of eating disorders?

Anorexia nervosa, bulimia nervosa and binge eating disorder will be discussed.

What is anorexia nervosa?

Anorexia Nervosa means loss of appetite due to emotional reasons. This is somewhat misleading, because they do not lose their appetite or interest in food.

People with this disorder tend to overestimate their own body size and see a thin figure as ideal.

More women than men meet the criteria for Anorexia Nervosa. It usually starts in the early to middle teenage years. An episode of dieting and the occurrence of a life stress often precede the onset of the disorder.

The disorder frequently comorbids with other psychological disorders.

These are some of the physical consequences of Anorexia Nervosa:

• Blood pressure often falls.

• The slowing of the heart rate.

• The development of kidney and gastrointestinal problems.

• Decline of bone mass.

• The drying out of the skin.

• Nails become brittle.

• The change of hormone levels.

• Mild anemia may occur.

• Some people lose hair from the scalp.

• Some people may develop lanugo.

Mostly after a few years, about 50-70 percent of the patients recover. Death rates are high, because of physical complications and suicide. DSM-5 Criteria for Anorexia Nervosa are:

• Restriction of food that leads to very low body weight; body weight is significantly below normal.

• Intense fear of weight gain or repeated behaviors that interfere with weight gain.

• Body image disturbance.

DSM-5 severity ratings for Anorexia Nervosa are:

• Mild: BMI range ≤ 17

• Moderate: BMI range 16 – 16.99

• Severe: BMI range 15 – 15.99

• Extreme: BMI range < 15

50-70% of the patients with anorexia nervosa recovers. Nevertheless, it is a life-threatening illness (death rates are 10 times higher).

What is bulimia nervosa?

Bulimia Nervosa is characterized by episodes of rapid consumption of a large amount of food, followed by compensatory behavior to prevent weight gain. Examples of such behaviors are vomiting, fasting and excessive exercise.

A binge is defined with two characteristics:

1. Eating an excessive amount of food.

2. Having a feeling of losing control overeating.

In contrast to anorexia, people with bulimia do not lose (a tremendous amount of) weight.

The binges often occur in secret and until the individual is uncomfortably full.

Studies show that a binge is likely to occur after a perceived negative social interaction.

People start inappropriate compensatory behavior due to feelings of discomfort, disgust and fear of weight gain after the binge.

The disorder comorbids with several other psychological disorders. It appears that each psychological disorder increases the risk of the other disorder.

Suicide is more common in comparison to the general population, but suicide rates are lower in comparison to people with anorexia nervosa.

DSM-5 Criteria for Bulimia Nervosa are:

• Recurrent episodes of binge eating.

• Recurrent compensatory behaviors to prevent weight gain, for example, vomiting.

• Body shape and weight are extremely important for self-evaluation.

DSM-5 severity ratings for Bulimia Nervosa are:

• Mild: 1 – 3 compensatory behaviors/week

• Moderate: 4 – 7 compensatory behaviors/week

• Severe: 8 – 13 compensatory behaviors/week

• Extreme: 14 or more compensatory behaviors/week

68-75% of the patients with bulimia nervosa recovers.

What is binge eating disorder?

Binge eating disorder is different from anorexia, because of the absence of weight loss. It differs from bulimia, because of the absence of compensatory behaviors. People with this disorder are often obese. A person is considered obese when having a BMI greater than 30.

Binge eating disorder comorbids with several other psychological disorders.

Risk factors for developing the disorder include low self-concept, depression, childhood obesity, critical comments about being overweight, weight-loss attempts in childhood, and childhood physical or sexual abuse. Physical consequences of the disorder include increased risk of type 2 diabetes, cardiovascular problems, chronic back pain, headaches, sleep problems, anxiety, depression, and irritable bowel syndrome.

DSM-5 Criteria for Binge Eating Disorder are:

• Recurrent binge eating episodes.

• Binge eating episodes include at least three of the following:

• Eating more quickly than usual.

• Eating until over full.

• Eating large amounts even if not hungry.

• Eating alone due to embarrassment about large food quantity.

• Feeling bad (e.g., disgusted, guilty, or depressed) after the binge.

• No compensatory behavior is present.

DSM-5 severity ratings for Binge Eating Disorder are:

• Mild: 1 -3 binges/week

• Moderate: 4 – 7 binges/week

• Severe: 8 – 13 binges/week

• Extreme: 14 or more binges/week

Research suggests that 25-82% recovers.

What is the etiology of eating disorders?

Several areas in life contribute to eating disorders.

What are the genetic factors?

Eating disorders running in families and the results of twin studies suggest genetic influence. Besides, research shows that key characteristics of eating disorders are heritable.

There is a lack of studies showing how genetic factors interact with the environment.

What are the neurobiological factors?

The hypothalamus has been proposed to play a role in anorexia, because it is a key brain center for regulating hunger and eating. People with anorexia indeed differ from the general population in the level of some hormones regulated by the hypothalamus. These hormonal differences occur as a result of self-starvation.

Opioids are release during starvation. Endogenous opioids reduce pain sensations, enhance mood and suppress appetite. The levels of endogenous opioids in people with anorexia may be increased due to starvation and resulting in a positively reinforcing positive mood state.

Among people with anorexia and bulimia low levels of serotonin metabolites have been found. Serotonin is a neurotransmitter related to eating and satiety.

It is known that brain activity of certain dopamine genes correlates with eating disorders, but it is not known whether or not this causes eating disorders.

What are the cognitive behavioral factors?

The fear of being fat and body-image disturbance are empasized as the motivating factors of reinforcing weight loss in cognitive behavioral theories of anorexia nervosa.

Dieting and weight loss can create the sense of self-control and therefore might be positively reinforced.

High scores on the restraint scale are linked to binge eating among people with eating disorders. Concerns about dieting and overeating are measured with the restraint scale.

Research suggests that the attention and memory of people with eating disorders are biased toward food and body image, because they pay more attention to food and body-image-relate things.

What are the sociocultural factors?

Sociocultural factors may play a role in eating disorders. This includes the preoccupation of society with thinness. The development of eating disorders is preceded by dieting among many people. The preoccupation with thinness is linked to these dieting efforts.

An increase in body dissatisfaction also precedes the development of the disorders. Body dissatisfaction often increases due to preoccupation with thinness and the media portrayals of thin women.

The stigma that comes with being overweight does not help either. People who are overweight are often seen as being unsuccessful and having little self-control, e.g.

In quite a few different countries has anorexia been observed. The intense fear of fat likely reflects an ideal of Westernized cultures though, because this fear seems to be less present in other cultures.

In industrialized countries, bulimia nervosa appears to be more common compared to non-industrialized countries.

Eating disorders are seen more often in:

• Women than men.

• White women than black women.

• Women of higher socioeconomic status (though less true today).

What are other factors contributing to the etiology of eating disorders?

When evaluating the personalities of people with anorexia and bulimia, one needs to keep in mind that severe restriction of food intake can have powerful effects on personality and behavior, as is shown in research. Among the changes are preoccupation with food, increased fatigue, poor concentration, lack of sexual interest, irritability, moodiness, and iInsomnia. According to research, the following personality characteristics may play a role:

• Perfectionism.

• Body dissatisfaction.

• A propensity to experience negative emotions.

Family characteristics that may play a role are not that clear yet. Maybe conflict in the family is important, but only from the perspective of the adolescent, not the parents.

What is the treatment of eating disorders?

Most of the times, hospitalization is necessary.

Are medications helpful?

Patients with bulimia often take antidepressants, because it often comorbids with depression. Some antidepressants are effective in reducing purging and binge eating. Medications does not seem to work for anorexia nervosa and binge eating disorder.

What is the psychological treatment of anorexia nervosa?

Therapy for anorexia nervosa has two goals:

1. The immediate goal is getting the patient to gain weight, to prevent medical complications and the possibility of death.

2. Long term maintenance of weight gain.

Cognitive behavior therapy (CBT) can be a part of the psychological treatment. Women who are older and have more severe symptoms seem to benefit the most from CBT.

Family therapy is often done in the treatment for anorexia, but more research is needed to demonstrate its effectiveness.

What is the psychological treatment of bulimia nervosa?

Cognitive behavior therapy is the most effective psychological treatment for bulimia nervosa. The overall goal in this therapy is to re-establish normal eating patterns, but it also involves changing a patient’s beliefs and thinking about thinness, being overweight, dieting, and restriction of food. For binge eating disorder is CBT also an effective treatment.

What are preventive interventions for eating disorders?

The following types of preventive interventions with children and adolescents have been developed and implemented:

• Psycho educational approaches.

• De-emphasizing sociocultural influences.

• Risk factor approach.

Prevention programs that are interactive rather than didactic are the most effective.

What are sexual disorders? - Chapter 12

Our fantasies and desires begin to qualify as abnormal when they affect us or others in unwanted or harmful ways.

The persistent disruptions in the ability to experience sexual arousal, desire, or orgasm or as pain associated with intercourse are termed as sexual dysfunctions.

Persistent and troubling attractions to unusual sexual activities or objects are termed as paraphilic disorders.

What are sexual norms and behavior?

What is seen as normal in human sexual behavior varies with time and place.

Cultures vary in their attitudes, and beliefs about sexuality. They also vary in their acceptance of variations in sexual behavior.

Genders tend to differ in sexuality in a few ways:

• Men tend to have a higher sex drive than women.

• Women feel more ashamed of any flaws in their appearance than men do.

• Sexuality seems to be more closely tied to relationship status for women than for men.

• Men are more likely to think in terms of power about their sexuality than do women.

It is not true to claim than women’s sole reason for having sex is to promote relationship closeness. They also have sex because of sexual attraction and physical gratification.

Some differences between the sexes are apparent, but it is not clear why this is the case. Is it because of culture? Biology?

The sexual response cycle was proposed by Masters and Johnson and was further developed by Kaplan. It consists of four phases:

1. Desire phase refers to sexual interest or desire.

2. Excitement phase, both men and women experience increased blood flow to the genitalia.

3. Orgasm phase, sexual pleasure peaks.

4. Resolution phase refers to the relaxation and sense of well-being that usually follows an orgasm.

In newer data, many women report that their desire and excitement co-occur and are not distinct. Other women report that their desire follows physiological arousal. Furthermore, for women subjective excitement may not mirror biological excitement. Subjective and biological excitement tend to be highly correlated for men, they need to be considered separately for women. Researchers know this because of doing research using a vaginal plethysmograph, which measures women’s physiological arousal.

What are the clinical descriptions of sexual dysfunctions?

The three categories of sexual dysfunctions in the DSM-5 are:

1. Those involving sexual desire, arousal, and interest.

2. Orgasmic disorders.

3. A disorder involving pain.

If a medical illness or another psychological disorder causes the problem, a diagnosis of sexual dysfunction is made.

The diagnosis will also not be made unless the symptoms cause distress or impairment.

It is often the case that if a person experiences problems in one phase of the sexual response cycle, he/she is likely to also experience problems in another phase.

Be aware that sexual problems in one individual may lead to sexual problems for the partner.

What are disorders involving sexual interest, desire and arousal?

Persistent deficits in sexual interest, biological or subjective arousal is referred to as female sexual interest/arousal disorder. Deficient or absent sexual fantasies and urges is referred to as male hypoactive sexual desire disorder. The failure to attain of maintain an erection through completion of the sexual activity is referred to as erectile disorder. These disorders are considered the most subjective.

DSM-5 Criteria for Female Sexual Interest/Arousal Disorder are (diminished, absent, or reduced frequency of at least three of the following):

• Interest in sexual activity.

• Erotic thoughts or fantasies.

• Initiation of sexual activity and responsiveness to partner’s attempts to initiate.

• Sexual excitement/pleasure during 75 percent of sexual encounters.

• Sexual interest/arousal elicited by any internal or external erotic cues.

• Genital or nongenital sensations during 75 percent of sexual encounters.

DSM-5 Criteria for Male Hypoactive Sexual Desire Disorder are:

• Sexual fantasies and desires, as judged by the clinician, are deficient or absent.

DSM-5 Criteria for Erectile Disorder are (on at least 75 percent of sexual occasions):

• Inability to attain an erection.

• Inability to maintain an erection for completion of sexual activity.

• Marked decrease in erectile rigidity interferes with penetration or pleasure.

What are orgasmic disorders?

Separate diagnoses for problems in achieving orgasm for women and men are included in the DSM-5. They will be named below.

DSM-5 Criteria for Female Orgasmic Disorder are (on at least 75 percent of sexual occasions):

• Marked delay, infrequency, or absence of orgasm.

• Markedly reduced intensity of orgasmic sensation.

DSM-5 Criteria for Premature Ejaculation:

• Tendency to ejaculate during partnered sexual activity within 1 minute of penile insertion on at least 75 percent of sexual occasions.

DSM-5 Criteria for Delayed Ejaculation:

• Marked delay, infrequency, or absence of orgasm on at least 75 percent of sexual occasions.

What are sexual pain disorders?

Persistent or recurrent pain during intercourse is the major symptom of genito-pelvic pain/penetration disorder. The disorder should not be caused by a medical problem.

DSM-5 Criteria for Genito-Pelvic Pain/Penetration Disorder:

Persistent or recurrent difficulties with at least one of the following:

• Inability to have vaginal/penetration during intercourse.

• Marked vulvar, vaginal or pelvic pain during vaginal penetration or intercourse attempts.

• Marked fear or anxiety about pain or penetration.

• Marked tensing of the pelvic floor muscles during attempted vaginal penetration.

What is the etiology of sexual dysfunctions?

Masters and Johnson proposed a theory of why sexual dysfunctions develop. According to their model, there are two immediate causes of sexual dysfunction: fears about performance and the adoption of a spectator role. They hypothesized that these causes had one or more historical antecedents.

In sexual dysfunctions, the following etiological variables appear to be key:

• Previous sexual abuse.

• Lack of sexual knowledge.

• Relationships problems.

• Psychological disorders.

• Negative cognitions about sexuality.

• Negative attitudes about sexuality.

What are the treatments for sexual dysfunctions?

Sex therapists often draw on a rich array of strategies to help their clients, because factors that promote healthy sexual functioning are complex. Couples therapy is an important therapy, because many sexual dysfunctions are embedded in a distressed relationship. Some (cognitive behavioral) approaches are:

• Anxiety reduction and psycho education.

• Procedures to change attitudes and thoughts.

• Communication training.

• Directed masturbation (for female orgasmic disorder)

• Other physical treatments.

• Medications.

There are also treatments for specific sexual dysfunctions. You can try relaxation therapy for genito-pelvic pain/penetration disorder, SSRIs for premature ejaculation and PDE-5 inhibitors (e.g., Viagra) for an erectile disorder.

What are the clinical descriptions of paraphiliac disorders?

Recurrent sexual attraction to unusual objects or sexual activities lasting at least six months are defined by the DSM-5 as paraphiliac disorders. These disorders are differentiated by the source of the arousal. The diagnoses are only to be considered when sexual attractions cause distress or impairment. The diagnoses should also only be considered when the person engages in sexual activities with a nonconsenting person.

What is a fetishistic disorder?

Reliance on an inanimate object or a nongenital body part for sexual arousal is the central feature of fetishistic disorder. The compulsive attraction is experienced as involuntary and irresistible by the individual with the disorder.

DSM-5 Criteria for Fetishistic Disorder:

• For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviors involving the use of nonliving objects or nongenital body parts.

• Causes significant distress or impairment in functioning.

• The sexually arousing objects are not limited to articles of clothing used in cross-dressing or to devices designed to provide tactile genital stimulation, such as a vibrator.

What are pedophilic disorders and incest?

Pedophilic is diagnosed, according to the DSM, when:

• Adults derive sexual gratification through sexual contact with prepubertal children.

• When their recurrent and intense desires for sexual contact with prepubertal children cause distress either for themselves or others.

Children who the person with this disorder knows are often the ones being molested.

With a penile plethysmograph one can measure the sexual arousal in response to pictures of young children. This measurement was one of the strongest predictors of repeated sexual offenses.

Sexual relations between close relatives for whom marriage is forbidden is called incest. This is listed in the DSM-5 as a subtype of pedophilic disorder. The abused person with incest is often in the puberty. This is in contrast to nonincestual pedophilic disorder, because people with this disorder are usually interested in prepubertal children.

DSM-5 Criteria for Pedophilic Disorder:

• For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviors involving sexual contact with a prepubescent child.

• Person has acted on these urges or the urges and fantasies cause marked distress or interpersonal problems.

• Person is at least 16 years old and 5 years older than the child.

What is voyeuristic disorder?

The intense and recurrent desire to obtain sexual gratification by watching unsuspecting other in a state of undress or having sexual relations is the key characteristic of voyeuristic disorder. Such fantasies are quite common in men, but more is needed for diagnosis. Risk seems to be an important element in this disorder.

DSM-5 Criteria for Voyeuristic Disorder:

• For at least 6 months, recurrent and intense sexually arousing fantasies, urges or behaviors involving the observation of unsuspecting others who are naked, disrobing or engaged in sexual activity.

• Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause marked distress or interpersonal problems.

What is exhibitionistic disorder?

Exposing one’s genitals to an unwilling stranger is the central feature in exhibitionistic disorder.

DSM-5 Criteria for Exhibitionistic Disorder:

• For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges or behaviors involving showing one’s genitals to an unsuspecting person.

• Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause clinically significant distress or interpersonal problems.

What is frotteuristic disorder?

Touching an unsuspecting person is the focus of sexual desire and urges in frotteuristic disorder.

DSM-5 Criteria for Frotteuristic Disorder:

• For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviors involving touching or rubbing against a nonconsenting person.

• Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause clinically significant distress or problems.

What are sexual sadism and masochism disorders?

Inflicting pain or psychological suffering on someone else is the focus of desire in sexual sadism disorder. Being the one subjected to pain or humiliation as the focus of desire is called sexual masochism disorder. The manifestations of this second disorders vary. The desires should lead to distress or impairment for diagnosis.

DSM-5 Criteria for Sexual Sadism Disorder:

• For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges or behaviors involving the physical or psychological suffering of another person.

• Causes clinically significant distress or impairment in functioning or the person has acted on these urges with a nonconsenting person.

DSM-5 Criteria for Sexual Masochism Disorder:

• For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges or behaviors involving the act of being humiliated, beaten, bound or made to suffer.

• Causes marked distress or impairment in functioning.

What is the etiology of paraphiliac disorders?

Almost all of the time, researches can only study paraphiliac disorders in men who are arrested for their sexual behavior, because many people do not want to talk about their paraphilias. The next literature is therefore mostly relevant for understanding sexual offenders.

A high number of sexual offenders report that they have been victims of sexual abuse themselves.

The disorders often occur in the context of alcohol use. The ability to inhibit impulses decreases because of alcohol. The sexual urges in the disorders can be seen as an impulsive act. The combination of the two is therefore a bad combination. Research shows that people with these disorders tend to have heightened impulsivity and poor emotion regulation.

What are the treatments for the paraphiliac disorders?

Because many sex offenders lack the motivation to change their illegal behavior, strategies to enhance their motivation are an important part of treatment. For countering the distorted thinking, cognitive procedures are often used. Other helpful treatments might be empathy training and relapse prevention.

Some drugs reduce testosterone levels. These drugs have been found to reduce sex drive and deviant sexual behaviors. Long-term use of these drugs have serious side effects though.

What are disorders of childhood? - Chapter 13

Childhood disorders are often a combination of genetic, neurobiological and environmental factors.

How does classification and diagnosis of childhood disorders work?

In the field of developmental psychopathology, it is important to consider what is typical for a particular age. What is normal for a five year old, can be abnormal for a sixteen year old.

Childhood disorders are often divided into two broad domains:

1. Externalizing disorders: these are characterized by more outward-directed behaviors.

2. Internalizing disorders: these are characterized by more inward-focused experiences and behaviors.

What are the externalizing disorders Attention-Deficit/Hyperactivity Disorder and conduct disorder?

ADHD and conduct disorder will be discussed in the following section.

What are the clinical descriptions, prevalence and prognosis of ADHD?

The diagnosis of ADHD may be appropriate when hyperactive behaviors are extreme for a particular developmental period, persistent across different situations and associated with significant impairments in functioning.

More children and adults may receive the diagnosis, because of two changes in the DSM:

1. The age of onset was changed from under 7 to under age 12.

2. Adults only need to show symptoms in five domains.

Three specifiers are included in the DSM-5 to indicate which symptoms predominate:

1. Predominantly inattentive.

2. Predominantly hyperactive-impulsive.

3. Combined.

The prevalence of ADHD has risen in the last ten years, a possible explanation is that many children may be getting the diagnosis when they do not have the disorder.

ADHD is much more common in boys than in girls. In comparison to girls without ADHD, girls with the disorder are more likely:

• To have a comorbid diagnosis of conduct disorder or oppositional defiant disorder.

• To be viewed more negatively by peers.

• To be more anxious and depressed (internalizing symptoms).

• To have symptoms of an eating disorder and substance abuse by adolescence.

• To have neuropsychological deficits.

• To have internalizing and externalizing psychopathology in early adulthood.

For many people, ADHD symptoms do not entirely go away, but may decline.

DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder (either A or B):

A. Six or more manifestations of inattention present for at least 6 months to a maladaptive degree and greater than what would be expected given a person’s developmental level, e.g., careless mistakes, not listening well, not following instructions, easily distracted, forgetful in daily activities.

B. Six or more manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive degree and greater than would be expected given a person’s developmental level, e.g., fidgeting, running about inappropriately (in adults restlessness), acting as if “driven by a motor", interrupting or intruding, incessant talking.

• Several of the above present before age 12.

• Present in two or more settings, e.g., at home, school or work.

• Significant impairment in social, academic, or occupational functioning.

• For people age 17 or older, only five signs of inattention and / or five signs of hyperactivity-impulsivity are needed to meet the diagnosis.

A lot of scientific evidence indicates that genetic factors play a role in ADHD. Heritability estimates are as high as 70 to 80 percent. A few genes are linked to ADHD:

• Dopamine receptor genes: DRD4 and DRD5.

• Dopamine transporter gene: DAT1.

• SNAP-25.

In comparison to children without the disorder, the brain structure, function and connectivity seems to be different for children with ADHD, especially in areas of the brain related to the neurotransmitter dopamine.

A number of perinatal and prenatal complications are neurobiological risk factors for the disorder, including low birth weight.

The idea that food additives impact hyperactive behavior has limited scientific support. The same is true for refined sugar.

Research findings suggest that smoking might not be a causal factor by itself, but that it is related to other maternal behavior and psychopathology that might increase the risk of the disorder.

Family interactions are important in interaction with neurobiological factors. The parent's own history of ADHD is also important.

Stimulant medications that are used to treat ADHD reduce disruptive behaviors and impulsivity and improve ability to focus attention. These drugs interact with the dopamine system in the brain.

The Multimodal Treatment of Children with ADHD (MTA) study is the best designed randomized control trial or treatments for this disorder. This study demonstrated that carefully prescribed and managed drugs is effective for children with ADHD but are not more beneficial than other treatments if it is prescribed in the way it is often prescribed. This is important, because of the side effects that this medication can have.

Some promising psychological treatments are parent training, changes in classroom management, and intensive behavioral therapies.

What is the clinical description, prevalence, and prognosis of conduct disorder?

Related to conduct disorder are intermittent explosive disorder (IED) and oppositional defiant disorder (ODD). IED involves recurrent verbal or physical aggressive outbursts that are far out of proportion to the circumstances. The difference with conduct disorder is that in IED the aggression is impulsive. With ODD, there is no agreement whether this disorder is distinct from conduct disorder, a precursor to it, or an earlier and milder manifestation of it. This disorder is diagnosed if a child does not meet the criteria for conduct disorder.

A specifier of conduct disorder in the DSM-5 is “limited prosocial emotions”, for children who have what are referred to as callous and unemotional traits (e.g., lack of empathy and guilt). Callous and unemotional traits in children are associated with more antisocial behavior and poorer response to treatment.

There seems to be two different courses of conduct problems. For some people the antisocial behavior starts very young and they keep showing this kind of behavior well into adulthood. Others are adolescence limited – meaning: they have typical childhoods, a lot of very antisocial behavior during adolescence, and have typical nonproblematic adulthood. Moffitt suggested to name the second group adolescent onset, because research shows that this group continued to have troubles with substance use, impulsivity, crime and overall mental health in their mid-20s.

DSM-5 Criteria for Conduct Disorder:

Repetitive and persistent behavior that violates the basic rights of others or conventional social norms as manifested by the presence of three or more of the following in the previous 12 months and at least one of them in the previous 6 months:

• Aggression to people and animals, e.g., bullying, initiating physical fights, physical cruelty to people or animals, forcing someone into sexual activity.

• Destruction of property, e.g., fire-setting, vandalism.

• Deceitfulness or theft, e.g., breaking into another’s house or car, conning, shoplifting.

• Serious violation of rules, e.g., staying out at night before age 13 in defiance of parental rules, truancy before age 13.

• Significant impairment in social, academic, or occupational functioning.

Heritability likely plays a part in conduct disorder, but evidence for genetic influences is mixed. The mixed findings are partly because the genetic influences in conduct disorder are shared with other psychological disorders.

Deficits in regions of the brain that support emotion are found in children with conduct disorder via neuroimaging studies. Abnormalities in the autonomic nervous system are linked to antisocial behavior in adolescents as indicated by other studies.

Neuropsychological deficits are also found:

• Poor verbal skills.

• Difficulty with executive functioning.

• Problems with memory.

Children with the disorder seem to be deficient in moral awareness, they lack remorse for their wrongdoing.

Causally related to aggressive behavior is rejection by peers.

In treating conduct disorder, some of the most promising approaches involve intervening early with the parents and families of the child. The most efficacious intervention is a behavioral program named parent management training (PMT). In PMT, parents are taught to modify their reactions to their children so that prosocial rather than antisocial behavior is consistently rewarded.

Multisystemic treatment (MST) is another promising treatment for serious juvenile offenders. The view that conduct problems are influenced by multiple factors within the family as well as between other social systems and the family forms the basis of MST. With MST, intensive and comprehensive therapy services are delivered to the community and targets the adolescent, the family, the schoo, and in some cases also the peer group.

The uniqueness with this therapy lies in emphasizing individual and family strengths, identifying the social context for the conduct problems, using present-focused and action-oriented interventions, and treatment is in “ecologically valid” settings, such as the home and the school.

What is known about depression and anxiety in children and adolescents?

To begin with depression in children. Children and adolescents ages 7 to 17 and adults both show the following symptoms in major depressive disorder:

• Depressed mood.

• Inability to experience pleasure.

• Fatigue.

• Concentration problems.

• Suicidal ideation.

Children and adolescents differ however in:

• Showing more guilt.

• Lower rates of early-morning wakefulness.

• Lower rates of early-morning depression.

• Lower rates of loss of appetite.

• Lower rates of weight loss.

Depression is more seen among girls than among boys, but this difference is not present before the age of 12.

Research results suggest that genetic factors play a role. Another predictor of the onset of depression in late adolescence and early adulthood is gene-environment interactions.

Results of a longitudinal study suggest that attributional style becomes style-like by early adolescence and serves as a cognitive diathesis for depression by the middle school years.

Some forms of treatments are possible:

• Antidepressants.

• Cognitive behavioral therapy.

• Selective prevention programs. This type of program targets particular youth based on family risk factors, environmental factors or personal factors.

What is anxiety in children?

Children’s functioning must be impaired before an anxiety disorder can be diagnosed. Children do not have to acknowledge that their fear is excessive or unreasonable, because children are not always capable of such judgments. This is different from the criteria for adults.

The constant worry in childhood that some harm will befall the parents or themselves when they are away from their parents is called separation anxiety disorder. This is often observed for the first time when the child goes to school.

Other types of anxiety disorders found in children are social anxiety disorder, symptoms of posttraumatic stress disorder, and obsessive compulsive disorder.

The heritability is 29-50%. Genetics play a role, but they do their work via the environment. Parenting practices play a small role, but parental control seems to play a role. Another factor is being bullied. The theories are most of the times the same for children and adults.

Treatment is for the most part the same as treatment for adults. It looks like CBT works for anxiety in children (with or without family). Coping Cat is one of the CBT methods that is used with children.

DSM-5 Criteria for Separation Anxiety Disorder:

Excessive anxiety that is not developmentally appropriate about being away from people to whom one is attached, with at least three symptoms that last for at least 4 weeks (for adults symptoms must last for 6 months or more):

• Repeated and excessive distress when separated.

• Excessive worry that something bad will happen to an attachment figure.

• Refusal or reluctance to go to school, work or elsewhere.

• Refusal or reluctance to sleep away from home.

• Nightmares about separation from attachment figure.

• Repeated physical complaints (e.g., headache, stomachache) when separated from attachment figure.

What is a specific learning disorder (dyslexia)?

When a person shows a problem in a specific area of academic, language, speech, or motor skills that is not because of intellectual disability or deficient educational opportunities, the person can have a condition called specific learning disorder.

Mental health professionals use the term learning disabilities to group together three categories that appear in the DSM:

1. Specific learning disorder.

2. Communication disorders.

3. Motor disorders.

DSM-5 Criteria for Specific Learning Disorder:

• Difficulties in learning basic academic skills (reading, mathematics, or writing) inconsistent with person’s age, schooling, and intelligence persisting for at least 6 months.

• Significant interference with academic achievement or activities of daily living.

The DSM-5 names dyslexia and dyscalculia as specifiers for the category specific learning disorder.

It is likely that there is a heritable component to dyslexia. The genes linked to typical reading abilities are also linked to dyslexia. These generalist genes are therefore important for understanding normal and abnormal reading abilities. Furthermore, research results suggest that the heritability of reading problems varies depending on parental education.

Dyslexia seems to involve problems in language processing as is observed in psychological, neuropsychological and neuroimaging studies. A lot of these processes fall under what is called phonological awareness.

What is intellectual disability?

For intellectual disability, the DSM-5 include three criteria:

1. Deficits in intellectual functioning.

2. Deficits in adaptive functioning.

3. An onset during development.

There is explicit recognition that an IQ score must be considered within the context of a more thorough assessment. Furthermore, adaptive functioning must be assessed across abroad range of domains. In the DSM-5, in comparison to the DSM-IV-TR, the severity is assessed in three domains:

1. Conceptual.

2. Social.

3. Practical.

For intellectual disabilities, most mental health professionals follow the guidelines of the American Association on Intellectual and Developmental Disabilities (AAIDD). The approach of the AAIDD is to identify the strengths and weaknesses of an individual on psychological, physical and environmental dimensions with the purpose of determining the kinds and degrees of support needed to enhance the individual’s functioning.

DSM-5 Criteria for Intellectual Disability:

• Intellectual deficits (e.g., in solving problems, reasoning, abstract thinking) determined by intelligence testing and broader clinical assessment.

• Significant deficits in adaptive functioning relative to the person’s age and cultural group in one or more of the following areas: communication, social participation, work or school, independence at home or in the community, requiring the need for support at school, work or independent life.

• Onset during child development.

The causes of intellectual disabilities that can be identified are typically neurobiological.

Having an extra copy of chromosome 21 is called trisomy 21. This is usually known as Down syndrome. Trisomy 21 is a chromosomal abnormality associated with intellectual disability.

Fragile X syndrome is another chromosomal abnormality that can cause intellectual disability. This syndrome involves a mutation in the fMR1 gene on the X chromosome.

Recessive-gene diseases can cause intellectual disability. Many of these diseases have been identified. Phenylketonuria (PKU) is an example of a recessive-gene disease.

If there are maternal infectious diseases, the foetus is at increased risk of intellectual disabilities. Examples of such diseases are:

• HIV.

• Herpes simplex.

• Toxoplasmosis.

• Cytomegalovirus.

• Rubella.

Some environmental pollutants, such as mercury, are implicate in intellectual disability by damaging the brain. Another example is lead. Some treatments of intellectual disability are available:

• Residential treatment. These are there for those who need extra support to function effectively in the community.

• Behavioral treatments. Behavioral techniques have been developed to improve the level of functioning.

• Cognitive treatments. Using strategies in solving problems are often a difficulty for a lot of children with intellectual disability. Self-instructional training has been designed to teach them to guide their problem-solving efforts through speech.

• Computer-assisted instruction. Some benefits of computer-assisted instruction are that computers can help to maintain the attention of distractible students because of visual and auditory components. Additionally, it can ensure successful experiences, because the level of the material can be geared to the person using the computer. Lastly, the need for numerous repetitions of material can be met.

What are the clinical descriptions, prevalence, and prognosis of autism spectrum disorder?

Profound problems with the social world are often found in children with autism spectrum disorder (ASD). Children with ASD do not participate in joint attention. Joint attention is when two people have to pay attention to each other while interacting.

DSM-5 Criteria for Autism Spectrum Disorder:

A. Deficits in social communication and social interactions as exhibited by the following:

• Deficits in social or emotional reciprocity such as not approaching others, not having a back-and-forth conversation, reduced sharing of interests and emotions.

• Deficits in nonverbal behaviors such as eye contact, facial expressions, body language.

• Deficit in development of peer relationships appropriate to developmental level.

B. Restricted, repetitive behavior patterns, interests, or activities exhibited by at least two of the following:

• Stereotyped or repetitive speech, motor movements, or use of objects.

• Excessive adherence to routines, rituals in verbal or nonverbal behavior, or extreme resistance to change.

• Very restricted interests that are abnormal in focus, such as preoccupation with parts of objects.

• Hyper- or hyporeactivity to sensory input or unusual interest in sensory environment, such as fascination with lights or spinning objects.

C. Onset in early childhood.

D. Symptoms limit and impair functioning.

Children with ASH spend less time looking at the faces of other people. Studies with fMRI show that these children do not show activation in the areas of the brain most often linked to identifying faces and emotion. Some of these areas are:

• Fusiform gyrus.

• Other regions in the temporal loves.

• Amygdala.

Children with this disorder have some communication deficits:

• Babbling is less frequent in infants with ASD.

• Echolalia: what the child heard another person say, is echoed.

• Pronoun reversal.

Changes in the daily routine or surroundings can extremely upset the child with ASD.

Children with this disorder might become obsessed with something. An example of this obsessive behaviour is continuously lining up toys.

They may also show stereotypical behavior, like peculiar ritualistic hand movements and other rhythmic movements. These activities are often described as self-stimulatory.

Some children with the disorder can become obsessed with and form strong attachments to simple inanimate objects and to more complex mechanical objects.

ASD often comorbids with intellectual disability and anxiety. Children with ASD who learn to speak before the age of 6 are most likely to have the best outcomes.

Research results suggest a genetic component for the disorder, and the heritability estimates are around .80. Twin studies and family studies suggest that ASD is associated genetically with a broader spectrum of deficits in communication and social interaction.

Children with ASD seem to have a larger brain than children and adults without ASD. This might indicate that neurons are not being pruned correctly and pruning of neurons is an important part of brain maturation. The areas of the brain that are larger include the frontal, temporal and cerebellar and these have been associated with language, social and emotional functions.

Psychological treatments of ASD seem to be the most promising. These include intensive behavioral interventions and work with parents. Several medication treatments have been used, but these have proved to be less effective than behavioral interventions.

Medication is less effective than psychological treatments. The most used medication in treating ASD is psychotic medication (like haloperidol).

What are personality disorders? - Chapter 15

Personality disorders are defined as persisting problems with forming a stable positive identity and sustaining close and constructive relationships. From time to time we all behave, think and feel in ways that are similar to symptoms of personality disorders, but an actual personality disorder is defined by the persistent, pervasive and maladaptive ways in which these traits are expressed. Given how many areas of our life are shaped by personality traits, it stands to reason that the extreme and inflexible traits found in personality disorders create problems in multiple domains. People with these disorders experience difficulties with their identity and their relationships, and these problems are sustained for years.

What is the DSM-5 approach to classification?

Three clusters are used in the DSM-5 to classify the ten different personality disorders:

1. Cluster A: odd or eccentric behavior.

2. Cluster B: dramatic, emotional or erratic behavior.

3. Cluster C: anxious of fearful behavior.

DSM-5 Criteria for General Personality Disorder:

• Inflexible pattern of inner experience and behavior (not related to culture)
• This pattern causes significant distress, is inflexible and is pervasive
• The onset is early adulthood
• The symptoms cannot be explained by another mental disorder

Personality disorders often have comorbidity with other psychological disorders. When comorbidity is the case, more severe symptoms are seen, as well as poorer social functioning and worse treatment outcome.

Research outcomes support the use of structured diagnostic interviews due to the enhancement of diagnostic accuracy and reliability. Many clinicians still prefer to use their own unstructured assessments. Interviewing a person close to the patient may improve the accuracy of diagnosis. Therefore, it is important for clinicians to consider this option.

There are a few problems with the DSM-5 approach to personality disorders.

Results of multiple researches suggests that personality disorders may not be as stable over time as the DSM-5 suggests:

• Many people still have some symptoms after remission, but not enough to meet the criteria for diagnosis.

• Even after remission, many problems with functioning exist.

• The possibility of relapse stays high.

Personality disorders have comorbidity with each other, and this makes classifying them difficult. The different personality also have similar kinds of concerns. The DSM-5 committee on Personality and Personality Disorders recommend a different approach to personality disorders due to the lack of test-retest stability and the high rates of comorbidity in classifying these disorders.

What is the alternative to the DSM-5 model for personality disorders?

The committee recommends reducing the number of personality disorders, putting personality trait dimensions together and diagnosing these disorders on the basis of extreme scores on personality trait dimensions.

In this model, diagnoses will be made when an individual shows persistent and pervasive impairments in self and interpersonal aspects of functioning from early adulthood. If this is the case, the clinician decides which personality disorders fits best by using the individual’s profile of personality domain and facet scores.

Some of the key advantages of this model are:

• People with the same personality disorder can vary a lot from each other in their personality traits and in the severity of their symptoms. By using the alternative model, clinicians can determine which traits are of most concern for a given client.

• Personality disorder diagnoses tend to be less stable over time than personality trait ratings.

• Many aspects of psychological adjustment and physical outcomes are related to personality trait dimensions.

• Clinicians find the alternative system more descriptive of clinical problems.

What are common risk factors across the personality disorders?

The book discusses two major studies on the ten personality disorders. The first study was designed to assess the links between the disorders and childhood adversity. The results showed that the disorders were strongly linked to childhood adversity.

The second study was designed to estimate the heritability. These estimates were at least moderately high for the disorders, which suggests that biology plays an important role in the onset of the disorders. Meaning that caution is necessary while thinking about parenting and early environment. Many parents probably experience at least mild personality problems themselves.

What is the clinical description and etiology of the odd/eccentric cluster?

To begin with the paranoid personality disorder. People with this disorder are suspicious of others. The disorder is different from paranoid schizophrenia, because not all symptoms of schizophrenia are present, and the impairment of social and occupational functioning is less severe. Full-blown delusions are also not present and that makes this disorder different from delusional disorder.

The DSM-5 Criteria for Paranoid Personality Disorder, presence of 4 or more of the following signs of distrust and suspiciousness from early adulthood across many contexts:

• Unjustified suspiciousness of being harmed, deceived or exploited.

• Unwarranted doubts about the loyalty or trustworthiness of friends or associates.

• Reluctance to confide in others because of suspiciousness.

• The tendency to read hidden meanings into the benign actions of others.

• Bears grudges for perceived wrongs.

• Angry reactions to perceived attacks on character or reputation.

• Unwarranted suspiciousness of the partner’s fidelity.

What is schizoid personality disorder?

The DSM-5 Criteria for Schizoid Personality Disorder:

Presence of 4 or more of the following signs of aloofness and flat affect from early adulthood across many contexts:

• Lack of desire for or enjoyment of close relationships.

• Almost always prefers solitude to companionship.

• Little interest in sex.

• Few or no pleasurable activities.

• Lack of friends.

• Indifference to praise or criticism.

• Flat affect, emotional detachment, or coldness.

What is schizotypal personality disorder?

Defining aspects of this disorder include eccentric thoughts and behavior, interpersonal detachment and suspiciousness.

The DSM-5 Criteria for Schizotypal Personality Disorder:

• Presence of 5 or more of the following signs of unusual thinking, eccentric behavior, and interpersonal deficits from early adulthood across many contexts:

• Ideas of reference.

• Odd beliefs or magical thinking.

• Unusual perceptions.

• Odd thought and speech.

• Suspiciousness or paranoia.

• Inappropriate or restricted affect.

• Odd or eccentric behavior or appearance.

• Lack of close friends.

• Social anxiety and interpersonal fears that do not diminish with familiarity.

What is the clinical description of the dramatic/erratic cluster?

The terms antisocial personality disorder and psychopathy are often used interchangeably by the public, but the disorders do differ from each other.

What is antisocial personality disorder?

The DSM-5 criteria for antisocial personality disorder are shown below. Men are five times more likely to meet these criteria than women. The disorder often co-occurs with substance abuse.

The DSM-5 Criteria Antisocial Personality Disorder:

• Age at least 18.

• Evidence of conduct disorder before age 15.

• Pervasive pattern of disregard for the rights of others since the age of 15 as shown by at least three of the following: repeated law breaking, deceitfulness (lying), impulsivity, irritability and aggressiveness, reckless disregard for own safety and that of others, irresponsibility as seen in unreliable employment or financial history, and lack of remorse.

What is psychopathy?

An important aspect of psychopathy is poverty of emotions, both positive and negative.

The Psychopathy Checklist-Revised (PCL-R) is the most used scale to assess psychopathy. It consists of a 20-item scale and the ratings are made based on an interview and review of mental health charts and of criminal records.

Two big differences between the criteria for APD and psychopathy are:

• The scale of the PCL-R differs from the DSM-5 criteria for APD in including more affective symptoms.

• The DSM-5 criteria for APD have the requirement that a person develop symptoms before the age of 15. This is not the case with PCL-R.

The consequence of these differences is a different population of patients.

How do genes and the social environment act for the stated disorders?

A lot of studies give evidence for the role of the social environment as key factor in APD. There is little question that adversity during childhood can set the stage for the development of this disorder. These childhood adversities might be especially negative for those who are genetically vulnerable to APD.

What are the psychological risks?

Learning from experience seems impossible for people with psychopathy. Many studies link psychopathy to deficits in the experience of fear and threat. Because of this idea, the behavioral model suggests that the rule breaking of clients stems from deficits in developing conditioned fear responses. The unresponsiveness to threats might become even stronger when a reward can be gained.

Some regions of the prefrontal cortex are involved in attending to negative information during goal pursuit. Antisocial behavior is linked to deficits in these regions.

Empathy is defined as the capacity to share the emotional reactions of others. To some researchers the lack of empathy could be the key reason people with psychopathy exploit others.

What is Borderline Personality Disorder?

Key aspects of Borderline personality disorder (BPD) are impulsivity and instability in relationships and mood. BPD is very common in clinical settings, it is difficult to treat, and it is associated with recurrent periods of suicidality.

Posttraumatic stress disorder, mood disorders, substance-related disorders and eating disorders often co-occur with BPD.

The DSM-5 Criteria Borderline Personality Disorder:

Presence of five or more of the following signs of instability in relationships, self-image, and impulsivity from early adulthood across many contexts:

• Frantic efforts to avoid abandonment.

• Unstable sense of self.

• Unstable interpersonal relationships in which others are either idealized or devalued.

• Self-damaging, impulsive behaviors in at least two areas, such as spending, sex, substance abuse, reckless driving, and binge eating.

• Recurrent suicidal behavior, gestures, or self-injurious behavior.

• Marked mood reactivity.

• Chronic feelings of emptiness.

• Recurrent bouts of intense or poorly controlled anger.

• During stress, a tendency to experience transient paranoid thoughts and dissociative symptoms.

A lot of risk factors may contribute to the onset of BPD. Beginning with the neurobiological factors. BPD patients show an increased activation of the amygdala to emotional pictures, which is relevant to the emotion dysregulation. Patients show deficits in the prefrontal cortex and this might contribute to impulsivity when emotions are present. They also show a disrupted connectivity between the amygdala and the prefrontal cortex.

Secondly, the interaction with parents. High estimates of heritability are seen in the BPD population, besides high rates of childhood abuse or neglect. It is not clear yet, which of these two factors sets the disorder in motion. Most of the patients with BPD grow up in a family without learning how to control their emotions.

Linehan’s Diathesis-Stress Theory proposes that BPD develops when people are bad at controlling their emotions due to their biological makeup, in combination with growing up in an invalidating family environment.

What is Histronic Personality Disorder?

Overly dramatic and attention-seeking behavior are the key aspects in Histronic Personality Disorder.

The DSM-5 Criteria Histronic Personality Disorder:

• Presence of five or more of the following signs of excessive emotionality and attention seeking from early adulthood across many contexts:

• Strong need to be the center of attention.

• Inappropriate sexually seductive behavior.

• Rapidly shifting and shallow expression of emotions.

• Use of physical appearance to draw attention to self.

• Speech that is excessively impressionistic and lacking in detail.

• Exaggerated, theatrical emotional expression.

• Overly suggestible.

• Misreads relationships as more intimate than they are.

What is Narcissistic Personality Disorder?

Key aspects of the Narcissistic Personality Disorder are a grandiose view of their own qualities and being preoccupied with fantasies of great success.

The DSM-5 Criteria Narcissistic Personality Disorder, consists of the presence of five or more of the following signs of grandiosity, need for admiration and lack of empathy from early adulthood across many contexts:

• Grandiose view of one’s importance.

• Preoccupation with one’s success, brilliance, beauty.

• Belief that one is special and can be understood only by other high-status people.

• Extreme need for admiration.

• Strong sense of entitlement.

• Tendency to exploit others.

• Lack of empathy.

• Envious of others.

• Arrogant behavior or attitudes.

It has been hypothesized by Millon that parents who are overly indulgent foster children’s belief that they are special and that their expressions of their specialness, behaviorally, will be tolerate by others.

Kohut hypothesized that the inflated self-worth and denigration of others can be seen as defenses against feelings of shame.

Morf and Rhodewalt developed the Social-Cognitive Model of this disorder and is built around two basic ideas:

1. The self-esteem of people with this disorder is fragile.

2. The importance of interpersonal interactions lies with the need for bolstering self-esteem instead of gaining closeness.

Research findings show evidence for these ideas. Their fragile self-esteem seems to make them brag often and denigrate others who performed better on a task that is of importance to their self-esteem.

What is the clinical description of the anxious/fearful cluster?

People with an Avoidant Personality Disorder will avoid jobs or relationships to protect themselves from negative feedback, because they are very fearful of criticism, rejection and disapproval.

This disorder often comorbid with social anxiety disorder. The genetic makeup of these disorders appears to overlap.

The DSM-5 Criteria Avoidant Personality Disorder:

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as shown by four or more of the following from early adulthood across many contexts:

• Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval.

• Unwilling to get involved with people unless certain of being liked.

• Restrained in intimate relationships because of the fear of being shamed of ridiculed.

• Preoccupation with being criticized or rejected.

• Inhibited in new interpersonal situations because of feelings of inadequacy.

• Views self as socially inept, unappealing or inferior.

• Unusually reluctant to try new activities because they may prove embarrassing.

What is Dependent Personality Disorder?

The key aspect of dependent personality disorder is an excessive reliance on others. The DSM-5 criteria make people with disorder seem like as being very passive, but this might not always be the case according to research.

Findings of other research suggests that this disorder is linked to an overprotective and authoritarian style of parenting. This type of parenting may reinforce children for dependency by being overprotective and being authoritarian may limit the opportunity to develop feelings of self-efficacy.

The DSM-5 Criteria Dependent Personality Disorder consists of an excessive need to be taken care of, as shown by the presence of at least five of the following from early adulthood across many contexts:

• Difficulty making decisions without excessive advice and reassurance from others.

• Need for others to take responsibility for most major areas of life.

• Difficulty disagreeing with others for fear of losing their support.

• Difficulty doing things on own or starting projects because of lack of self-confidence.

• Doing unpleasant things as a way to obtain the approval and support of others.

• Feelings of helplessness when alone because of fears of being unable to care for self.

• Urgently seeking new relationship when one ends.

• Preoccupation with fears of having to take care of self.

What is Obsessive-Compulsive Personality Disorder?

Key aspects of the obsessive-compulsive personality disorder are perfectionism, preoccupation with details, rules and schedules. People with this disorder often fail to finish projects due to paying too much attention to detail.

This personality disorder does not entail obsessions and compulsions as is the case for obsessive-compulsive disorder. Therefore, the two are different, despite the similarity in names.

The DSM-5 Criteria Obsessive-Compulsive Personality Disorder consists of an antense need for order, perfection, and control, as shown by the presence of at least four of the following from early adulthood across many contexts:

• Preoccupation with rules, details and organization to the extent that the point of an activity is lost.

• Extreme perfectionism interferes with task completion.

• Excessive devotion to work to the exclusion of leisure and friendships.

• Inflexibility about morals and values.

• Difficulty discarding worthless items.

• Reluctance to delegate unless others conform to one’s standards.

• Miserliness.

• Rigidity and stubbornness.

• Social anxiety and interpersonal fears that do not diminish with familiarity.

What is the treatment for personality disorders?

There are several general approaches. Psychotherapy is often the first choice for the treatment of personality disorders. Most of the time this is supplemented with medications.

Psychodynamic therapy tries to help the patient become aware of how early childhood experiences drive their current behavior. This therapy is based on the psychodynamic theory that suggests that childhood problems are the root of the disorders.

According to the cognitive theory negative cognitive beliefs are central to the personality disorders. For this reason, therapists try with cognitive therapy to help a person become more aware of those beliefs and then try to change them.

What is the treatment for schizotypal personality disorder and avoidant personality disorder?

A lot of the etiology of the schizotypal personality disorder is the same as with schizophrenia and the etiology of the avoidant personality disorder is the same as the etiology of social anxiety disorder. So, most of the times antipsychotic drugs are used. CBT could help as well.

What is the treatment for borderline personality disorder?

The focus here will be on transference-focused, mentalization and dialectical behavior therapy, because a lot of research supports the advantages of this approach.

The relationship with the therapist is important in the transference-focused therapy. After the interactions with the therapist, the client can generalize the information to their daily life. Mentalization therapy focuses on self-reflection about their own feelings.

The dialectical behavior therapy combines multiple strategies and techniques. It is a combination of client-centered empathy and acceptance with cognitive behavioral problem solving, emotion-regulation techniques, and social skills training.

What is the diagnostic process? - Chapter 1 - Bijttebier - 2019 - Article

Clinical psychodiagnositcs is an exclusive specialism of the clinical psychologist. The clinical psychologist tended to present himself as a therapist rather than a diagnostician. Analyzing problems, searching for explanations and trying to solve these problems is human nature. But clinical psychodiagnostics is a professional activity that is based on three elements: theory development, operationalization and the application of the relevant diagnostic methods. In this chapter we will explain the consecutive steps in the psychodiagnostic process and will outline five basic questions that form the foundation for most of the questions that are posed by clients, referrers and diagnosticians.

What are the steps in the diagnostic process?

A clinical psychodiagnostic examination begins with the client's referral to the diagnostician, but it may occasionally also begin with the client's direct question to the diagnostician. The diagnostician analyzes both the client's request for help and the referrer's request. This need not be the same. On the basis of this analysis you can make several questions regarding the request and request for help. On the basis of these questions, the diagnostician will construct a diagnostic scenario that contains a provisional theory about the client, which describes what the problems are and how they can be explained. Testing this theory requires five diagnostic measures:

1. Converting the provisional theory into concrete hypotheses
2. Selecting a specific set of research tools, which can either support or reject the formulated hypotheses
3. Making predictions about the results or outcomes from this set of tools, in order to give a clear indication as to when the hypotheses should be accepted or rejected
4. Applying and processing instruments
5. On the basis of the results that have been obtained, giving reasons for why the hypotheses have either been accepted or rejected

What are the five basic questions in clinical psychodiagnostics?

There are five basic questions that form the basis for most of the questions that are posed by clients, referrers and diagnosticians:

1. Recognition: What are the problems, what works and what doesn't?
2. Explanation: Why do certain problems exist and perpetuates them?
3. Prediction: How will the client's problems subsequently develop in the future?
4. Indication: How can the problem be resolved?
5. Evaluation: Have the problems been adequately resolved as a result of the intervention?

What does recognition mean?

In order to obtain a better understanding of the client's problem, the diagnostician identifies both the complaints and adequate behavior of the client is his/her environment. The distinction made between classification and diagnostic formulation is also relevant; in the case of classification, the clinical picture is assigned to a class of problems. This can be done according to an all-or-nothing principle or a more-or-less principle. Diagnostic formulation on the other hand focuses on the individual and his own unique clinical picture.

There is a clinical practice's preference for making a psychiatric diagnosis on the basis of the DSM categories, an approach is advocated here in which recognition not only leads to categorizing problem behavior in terms of disorders, but also to describing the individual on the basis of specific characteristics, dimensions and specific methods for functioning. But classification leads to 'labeling', which is limited and often forms the basis for establishing co-morbidity.

What is the explanation?

An explanation answers the question of why there is a problem or a behavioral problem. It includes (1) the main problem or problem component, (2) the conditions that explain the problem's occurrence, and (3) the causal relationship between point 1 and 2. Explanations can be classified according to:

• The locus, the person or situation
• The nature of control
• Synchronous and diachronous explanatory conditions
• Induced and persistent conditions

Four possible types of explanations for problem behavior are given for these conditions and it is important that the diagnostician has knowledge of these options, so that he continues to make allowances for more than one type of explanations.

What does prediction mean?

Prediction involves making a statement about the problem behavior in the future. It is a chance statement, and this chance plays an important role in determining the treatment proposal. Predictions often pertains to a relation between a predictor and a criterion. The predictor is the present behavior and the criterion is the future behavior.

In case of prediction, the margins of error are often so large that the high expectations of legal and other societal contexts cannot be met. One disadvantage of this kind of predictions (permanent damage after trauma, divorce custody problems etc.) is that they may be antitherapeutic, because they document a situation without taking into account the possibility of future changes.

What is the indication?

The indication focuses on the question of whether the client requires treatment and, if so, which caregiver and assistance are the most suitable for the particular client and problems. Before we can proceed to the indication, the steps for explanation and prediction must be completed. There are also three additional elements:

1. Knowledge of treatments and therapists
2. Knowledge of the relative usefulness of treatments
3. Knowledge of the client's acceptance of the indication

What is the evaluation?

Evaluation of the assertions about diagnosis and/or intervention takes place on the basis of both the progress of the therapeutic process and the results of the treatment.

What is the diagnostic cycle?

One way to regulate and discipline the diagnostic process is to structure it according to the empirical cycle of scientific research. This cycle is a model for answering questions in a scientifically justified manner, and consists of observation, induction, deduction, testing and evaluation.

1. Observation involves collecting and classifying empirical materials, which provide the basis for forming thoughts about the creation and persistence of problem behavior
2. Induction includes the formulation of theory and hypotheses about the behavior
3. During the deduction phase, testable predictions are derived from these hypotheses
4. During the testing phase, new materials are used to determine whether the predictions are correct or incorrect
5. The results are shown in evaluation.

What is the diagnostic process: from application to report?

The referrer's request does not necessarily coincide with the client's request for help. The referrer actually needs recognition, an explanation, a prediction or a recommendation with regard to the treatment.

The analysis of the application is followed by a reflection phase, in which due weight is given to each of the various pieces of information.

In a diagnostic scenario, the diagnostician organizes all the requester's and client's questions from the application phase and all the questions that may have occurred to him and his knowledge of the problem. He then proposes a tentative theory about the client's problematic behavior.

What holds the diagnostic examination?

1. Hypothesis formulation. The diagnostician formulates a number of hypotheses based on the diagnostic scenario. A hypothesis is an assumption about a correlation in reality, which is formulated in such a way that concrete, verifiable predictions may be derived from it. The hypotheses are formulated in such a way that the relationship between the hypotheses is clear.
2. The selection of examination tools. Theory development and operationalization of the problem behavior is followed by the search for appropriate examination tools.
3. Formulation of testable predictions. Once the examination tools have been selected, the criteria, against which the client will be examined, will need to be established.
4. Administration and scoring. The administration and scoring of diagnostic tools provide both qualitative and quantitative information.
5. Argumentation. The administration and scoring results are linked back to the hypotheses and predictions. The diagnostician takes into account the psychometric quality of the tools and the specific nature of the sources and consequently assigns the appropriate weight to each of them.
6. Report. The report is for the referrer and contains the results of the diagnostic examination. The initial aim of the report is to substantiate the conclusions from the examination.