What are the underlying concepts, procedures, and practices in psychopathology? - Chapter 1

What is maladaptive behaviour?

Maladaptive behaviour might involve behaving in a way that is a threat to the health and well-being of the individual and to others. We cannot define psychopathology solely in terms of maladaptive behaviour, as it is not the only criterion by which psychopathological conditions are defined. The problem by defining psychopathology solely in terms of maladaptive behaviour is that not all maladaptive behaviours can be labelled as psychopathology. For example, murders or terrorists show maladaptive behaviours, but they do not all have mental health problems. Moreover, some psychopathological disorders such as height phobia, water phobia, or snake phobia might have an adaptive function, as they could protect individuals from potentially life-threatening situations.

What are the biological models of psychopathology?

Genetics is the study of heredity and the inheriting of characteristics and is therefore often used to look at the role that heredity plays in psychopathology. Included methods are concordance studies, which look at different family members and the relation between a psychological disorder and the amount of shared genetic material, and twin studies, where monozygotic twins (identical genes) and dizygotic twins (50% shared genes) are used to examine if there is a genetic explanation for psychopathology. Many psychopathologies don't occur spontaneously due to a person's genes. Rather, they are a result of the combination of a genetic predisposition and some environmental influence. This is also known as the diathesis stress model, which suggests that problems develop from an interaction between the expression of our genes and the environment we experience. This model also supports the measure of heritability, which measures the degree to which some quality is explained by our genes, ranging from 0 to 1.

Freud believed that by the way children go through stages of development they could develop psychopathology. Failing to adjust to a particular stage of development could lead to the individual becoming fixed on this stage. The stages are:

• Oral stage: refers to the first 18 months of life where the child is dependent on the food from the mother. Failing to receive food could lead to 'oral stage characteristics', such as extreme dependence on others.
• Anal stage: (18 months to 3 years)
• Phallic stage: (3 to 5 years)
• Latency stage: (5-12 years)
• Genital stage: (12 years to adulthood)

How is psychopathology assessed and classified? - Chapter 2

What are the DSM and the DSM-5?

The American Psychiatric Association (APA) improved classification by developing the first Diagnostic and Statistical Manual (DSM) in 1952. The most recent classification system is the DSM-5, which is the most widely adopted psychopathology classification system.

The Four basic objectives of the DSM-5 are:

1. Sufficient criteria must be provided to achieve a correct differential diagnosis
2. It should discriminate between 'true' psychopathology from normal 'problems in living
3. Diagnostic criteria should allow the application by different clinicians in different settings
4. It should be theoretically neutral, therefore not favoring one theoretical approach over another one

It also provides the following information:

• Essential features of the disorder
• Associated features
• Diagnostic criteria
• Information on differential diagnosis

What are problems with the DSM-5?

The DSM-5 classifies psychopathology according to symptoms and not causes. Due to this classification by symptoms, it gives the impression of explaining symptoms, when it is just a different description of the symptoms. Labeling people according to criteria using the DSM-5 can attach stigma or be harmful. It can also lead to the view of disorders being discrete entities, while it has also been suggested that psychopathology may be viewed as rather dimensional. In practice, two or more distinct disorders co-occur, which is called comorbidity. This suggests that most disorders consist of symptoms of hybrid disorders (e.g., mixed anxiety-depressive disorder), rather than independent discrete disorders. Since comorbidity is so common, new terms have been introduced, such as a disorder spectrum. These are presented in a hierarchical structure, with individual discrete disorders as defined in the DSM-5 making up the bottom level of an overarching spectrum. Anxiety and depression are, in this new structure, part of the group of emotional disorders.

What is meant by reliability and validity of assessment methods?

To be sure that assessment methods provide objective information about clients, it is important to be sure about two things, namely reliability and validity. Reliability means that the method will still provide the same result when used by different clinicians on different occasions. Second, we need to be sure that the assessment has validity. This means that it actually measures what it claims to measure. For instance, if a test assesses anxiety, then scores on the test should correlate well with other ways of measuring anxiety.

What is cultural bias in assessment?

Many tests can be culturally biased and in return do not yield a correct picture of an individual's mental health. Not all ethnic groups score the same on assessment tests, consequently they are often given different diagnoses and popular ethnic stereotypes influence the medical and psychiatric practice. Also, clinicians often make judgments in unstructured interviews that are influenced by socioeconomic stereotypes.

What are the research methods in clinical psychology? - Chapter 3

What is research and what is meant with the scientific method?

Results of research should be replicable, meaning that other researchers can produce the exact same findings because collection of results has taken place under controlled conditions. If a scientific explanation gives suggestions of ways by which it can be tested or potentially falsified, it is testable. The scientific method relies on theories, which describe the cause-effect relationship in terms of sets of propositions. From there on a hypothesis can be created, which then explains the phenomenon and furthers investigation. Disconfirmed hypotheses are wrong or need to be changed.

What are correlational designs?

This type of research design allows a researcher to see if there is a relationship between two or more variables. Yet, this methodology does not provide a causal explanation of a relationship. The researcher needs to collect pairs of scores to perform a correlational analysis. Analysis can be done in computer programs such as The Statistical Package for the Social Sciences (SPSS). When computing correlation, the program will give the correlation coefficient r, which goes from +1.00 to -1.00, the former meaning a perfect positive correlation and the latter giving a perfect negative correlation. In a scatterplot the relationship between two variables can be displayed. Because of the differing nature of the relationships of the variables, the line of best fit differs with it. If the outcome of a study has a low probability of occurring by chance,

What are mediators and moderators?

In statistical analyses, mediators are a third variable between the relationship of the independent and dependent variable. For instance, in a correlational study, a mediator can be examined to find out whether this variable is mediating the relationship between two variables. For instance, males weigh more than females, but this is mediated by length. So, a mediator explains the relationship between two variables.

How can psychopathology be treated? - Chapter 4

What is the nature and function of psychopathology treatments?

Treatments for psychopathology usually entail providing clients with relief from the distress, insight to their problems and self-awareness, acquisition of coping and problem-solving skills and identification and resolving of the causes of psychopathology. The palliative effect occurs when a form of treatment does not provide the client with insight into their problems and only reduces the severity of symptoms. The theoretical orientation and a therapist's training together with the nature of the psychopathology determine the treatment approach. Therapists take part in continuing professional development (CPD) to update their knowledge of recent developments in treatment techniques.

What are psychodynamic approaches?

The psychodynamic approach works with the assumption that an individual develops unconscious conflicts early in life. This approach tries to uncover these events. The therapist will work out strategies with the client for change by bringing these conflicts into conscious awareness through acknowledgment. Sigmund Freud (1856-1939) introduced the form of psychodynamic therapy called psychoanalysis, in which the therapist works with free association, dream interpretation and transference analysis to uncover the client's unconscious conflicts. For the client to call conflicts into awareness, to understand the source of the conflicts and to help the individual gain control over behavior, feelings and attitudes, psychoanalysts make use of these techniques:

• Free association: Any thoughts, feelings, or images that the client has in mind are verbalized.
• Transference: The therapist becomes a representative for an important person in the client's life, and thus any emotional responses or behaviors targeted towards that person are acted out on the therapist. This helps the client understand his feelings towards that person.
• Dream analysis: Dreams represent unconscious conflicts in a symbolic form.
• Interpretation: The information from all three sources is interpreted and ways of conflict solving are developed.

What is behavior therapy?

Behavior therapy uses objective knowledge to create a therapy approach. The approach is built on the principles of classical and operant conditioning. Earlier it was thought that psychological disorders came from faulty learning, in which pathological responses are learned. If psychological problems can be learned, then it should be possible to 'unlearn' them. From this idea the behavior analysis or behavior modification approach evolved, which uses the principles of operant conditioning, and the behavior therapy approach, which is based on principles of classical conditioning.

How is treatment evaluated?

Evaluating treatment is not as easy as it sounds, as one has to take into consideration that different approaches judge differently of what a successful therapy is and what characterizes that success. A therapy in that sense is effective if it was helpful to the client. Nevertheless, objective criteria to assess success of therapies are sought, because the aim is to provide the most effective support for clients and to determine how long-lived the effects of a therapy are and prevention of relapse.

What are meta-analyses?

The question of whether psychotherapy treatment is more effective than no treatment at all has been investigated by meta-analysis and results of a large-scale study reveal that psychotherapies indeed show greater effectiveness than not treating an individual at all. Yet, the types of psychotherapies did not differ in their effectiveness.

What are clinical practices? - Chapter 5

What is the recovery model?

Physical illnesses are easier to cure than mental health problems. The recovery model is a broad approach to treatment that recognizes the influence and importance of socio-economic status, work and education and social inclusion in helping to recover. It's a holistic approach. There are several key features of recovery:

• Heap
• A safe base
• Developing self-awareness
• Supportive relationships
• Empowerment and Inclusion
• Coping strategies;
• Phrase, developing a goal

What is the reflective practitioner model?

Despite the fact that not all clinical psychologists are happy with the scientist-practitioner label (because they use alternative philosophical approaches, for example), they are generally expected to use a reflective practitioner model in their work. This is a key competence in which one reflects on one's own experiences in working with a client and on the interaction with the client. The advantages of this are that it facilitates the development process to become an autonomous, qualified and self-managing professional, that it offers the opportunity to develop in the work and to reflect on the needs of each individual client and that it stimulates self-motivation and self-directed learning.

What are anxiety and stressor-related problems? - Chapter 6

An anxiety disorder is “an excessive or aroused state characterized by feelings of apprehension, uncertainty and fear” (Davey, 1993). An anxiety response might not be in proportion to a certain threat or may be a state experienced that is not triggered by any obvious threat and may disrupt the ability of an individual to live a normal life due to constant emotional distress. Six of the main anxiety disorders discussed in this chapter are: specific phobias, social anxiety disorder, panic disorder, generalized-anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). The diagnosis is based on subjective experience of anxiety that occurs so regularly that it disturbs every-day living.

What is comorbidity?

An individual experiences comorbidity if they experience several anxieties disorders whose symptoms overlap and this occurs quite frequently in anxiety-disorders. Diagnostic categories share common aspects:

• Physiological symptoms are present in panic disorder and in specific phobias
• Cognitive biases play a role in most anxiety disorders
• Dysfunctional perseveration plays a role in various prominent psychopathologies
• In many anxiety disorders certain early experiences are part of the aetiology

What are Specific Phobias and what is their prevalence?

An individual who reacts with unreasonable, excessive and persistent fear to a specific object or situation suffers from specific phobia. Even though the individual is aware of the irrationality of their fear, they have dysfunctional phobic beliefs that explain reasons for why they are afraid and react how they do. In therapy these beliefs can be challenged. Specific phobias are quite common, and recent surveys have suggested that 20% of all adults will experience some sort of diagnosable specific phobia in their life. Women have a lifetime prevalence of 16%, which is higher than the men's 7% lifetime prevalence.

Common phobias include animal phobias (snakes, spider, rats, mice, creepy-crawlies), social anxiety disorder, dental phobia, water phobia, height phobia, claustrophobia, and BII (blood, injury, inoculation fears). The DSM-5 divides these specific phobias into five groups by the source of the fear: 1) blood, injuries and injections 2) situational fears 3) animals 4) natural environment and 5) other phobias. There is a high comorbidity rate within each category. Different cultures bring along different clinical phobias, with 'fear-relevance' being determined by specific culture factors. This is the opposite of the biological view, which holds that there are universally feared stimuli and events created through evolution.

What is cognitive behaviour therapy (CBT)?

There is a 30% drop out rate in exposure and ritual prevention (ERP) due to the fear of exposure to what triggers OCD in the individual. In CBT, the dysfunctional beliefs such as responsibility appraisal, the over-importance of thoughts, and exaggerated perception of threat are challenged.

What are depression and mood disorders? - Chapter 7

What are depression and mood disorders?

Everyone experiences periods of sadness from time to time. This can be the result of various reasons, especially losses and failures, but most of us are able to shake it off after a short period of time. However, for some getting rid of these depressing feelings is much harder, and these feelings will affect other domains of their live, making depression a mood disorder affecting emotional, motivational, behavioral, physical, and cognitive domains. Mania is the emotion opposite of depression, and it is bound by boundless, frenzied energy and feelings of euphoria.

Depression affects the emotional domain as depressed individuals often report negative emotional experiences such as hopelessness and sadness. Those suffering from depression show several motivational deficits, like the lack of interests in activities they used to enjoy, not taking initiative anymore and reporting that they simply don't care anymore. Behavioral symptoms seen in depression are sleeping for long periods of time, no interest in leaving the house and reporting lack of energy. Depression can even be seen in the posture and movements of people, as are other physical symptoms such as a wide variety of sleeping problems, headaches, indigestion, constipation and several others. The most disabling feature of depression are its cognitive symptoms. The negative thoughts that arise from depression are negative views of themselves, the world around them and their own future. These pessimistic thoughts can give rise to new problems, such as impaired thinking, concentrating and decision-making, possibly leading to feelings of worthlessness, shame and guilt. These thoughts can lead to suicidal thoughts, because they might think the world is better off without them. The two main types of depression are major depression and bipolar disorder.

What is Bipolar Disorder?

A person suffering from bipolar disorder has extreme mood swings. On one side of the spectrum, one experiences a state of depression, and on the other side there's the manic state, which is characterized by forced speech, extreme energy, short attention span, excessive talking and shifting from topic to topic. Someone in a manic state can become angry when 'confronted' with their state, and irritability is quite common. A manic state can last for days or weeks, and the onset can be quite quic

What is meant by nonsuicidal self-injury (NSSI)?

Direct and deliberate bodily harm without any suicidal intent is deliberate self-harm. It is now covered under the new DSM-5 category non-suicidal self-injury which describes intentional self-inflicted injury without suicidal intent. Deliberate self-harm is mostly seen in adolescents, and the motive is often when they are alone and experiencing negative feelings. It is often done as a means of soothing oneself or a way to seek help. Vulnerable groups include depressed adolescents, individuals with interpersonal crises (e.g., those suffering from substance abuse, eating disorders, psychosis) and those who have a history of previous self-harming. One of the few effective forms of preventing deliberate self-harm is with cognitive behavioral therapy and problem-solving therapy,

What are risk factors for suicide?

As mentioned before, the best predictor of self-harm or suicide, is a history of earlier self harm or attempted suicide. Yet these people only account for 20 to 30%, so other risk factor have been identified so we can more effectively prevent suicide. Risk factors are:

• A diagnosis of depression, borderline, panic disorder, schizophrenia, alcoholism, and substance abuse
• Hopelessness and low self-esteem
• Physical disability and poor physical health
• Low socio-economic status

What are Schizophrenia Spectrum Disorders? - Chapter 8

What is the nature of psychotic symptoms?

The first four of the five characteristics of a diagnosis of schizophrenia spectrum disorders listed in the DSM-5 are known as positive symptoms. These reflect an excess or distortion of normal functions, or extra feelings that are usually not present (e.g., delusions). The fifth characteristic represents negative symptoms, which are a loss or diminishment of normal functions (e.g., lack of emotional expression).

What are delusions?

Thoughts and beliefs that are firmly held, but yet false, are known as delusions. Delusions are usually misinterpretations of experiences or perceptions that become fixed and not likely to be changed, even when the individual is challenged with evidence of their conflicting thoughts. That delusions are often defended with logic makes clinicians suggest that delusions may result from an inability to integrate perceptual input with existing knowledge, when the rational thought processes are still intact.

There are six main types of delusion found in individuals experiencing psychosis:

1. Persecutory delusions (paranoia) are delusions in which the person believes they are being spied upon, persecuted or that they are in danger, usually due to some conspiracy
2. Grandiose delusions make the person believe that they are a person with fame or power or with exceptional abilities
3. Delusions of control are seen when individuals think their thoughts, actions or feelings are being controlled by some external force (e.g., aliens) and that these thoughts are controlled through some device controlling their brain
4. Delusions of reference result in the person believing that external events, normally seen as independent, are referring to them
5. Nihilistic delusions make the person think that either some part of the world or themselves does not exist anymore (e.g., they are dead) or that some major catastrophe will occur
6. Erotomaniac delusions are rare beliefs that a person (often of a higher social status) falls in love with them. This can result in stalking some celebrity.

What is disorganised thinking?

Disorganised thinking is usually noticeable in the individual's speech, with some common features recognizable when a person is experiencing psychotic symptoms. Most common is derailment or loose associations, seen when the individual is jumping quickly from topic to topic during a conversation. Answers to questions may be tangential, where the response is not quite or only slightly relevant to the question. Speech can become very unstructured and even incomprehensible when 'clanging' is exhibited, where the speech is based upon sound instead of concepts (e.g., rhyming or alliteration). More examples of incomprehensible speech are neologisms (made-up words) and word salads (very disorganized sentences where phrases have no link at all). The disorganization of speech in schizophrenia spectrum disorders seems to be due to the individual's difficulty inhibiting associations between thoughts and therefore jump from idea to idea, and that they have difficulty understanding the broader context of a conversation. This leads to a sometimes very detailed speech with many words and ideas and it being grammatically correct, but it will result in little substantive content, known as poverty of content.

What is the course of psychotic symptoms?

Development of psychotic symptoms is usually through the succession of three stages:

1. The prodromal stage
2. The active stage
3. The residual stage

What are Substance Use Disorders? - Chapter 9

A substance affecting one's physiological and psychological state when introduced to one's body is a drug. The effects of drugs vary from giving energy, relaxing, distorting perceptions, changing moods, or change ways of thinking. Some problems that result from the use of any kind of drug, are that they may have long-term negative effects, drugs can be both psychologically or physiologically addictive, and some move from less-harming drugs to more serious (illegal) substances. Lately a rise in the use of synthetic cathinones (bath salts) has been seen.

What are the characteristics of specific Substance Use Disorders?

The specific substance uses disorders that we will look at are first alcohol and nicotine, which are then followed by substances increasing nervous system activity known as stimulants. Then we will discuss substances known as sedatives, which slow bodily activities and reduce pain and anxiety. Finally, hallucinogens, chemicals altering perception, are discussed.

Which factors contribute to regular use?

A main reason for using drugs is that they alter one's mood in some kind of way. Alcohol makes one relaxed and confident, nicotine is reported to make one calm and relaxed, stimulants affect the brain reward pathways making one feel euphoric and confident, and many other substances all have some pleasurable mood-altering effect. Most of these substances all work on the same dopamine VTA-NAc pathway in the limbic system, giving rise to a pleasurable effect. Alcohol's mood-altering effect appears to be an arousal-dampening effect, which means that not only the negative moods are reduced (which is often the reason why one uses alcohol), the positive moods are also reduced. Other studies have indicated that individuals intoxicated by alcohol have less cognitive resources available to interpret all on-going information, so attention is narrowed to process fewer cues in one's surrounding, and this process is known as alcohol myopia. Positive, lively situations will therefore lead to more focus on positive affect, but negative and lone drinking situations might lead to a bigger focus on negative emotions and thoughts. Drugs themselves are also powerful reinforcers conditioning the positive effects of drugs to a certain stimuli or cue which one associates with the drug. This leads to the user craving the drug when exposed to stimuli they associate with the positive effects of the drug, which leads to consuming more of the drug and higher rates of relapse. but negative and lone drinking situations might lead to a bigger focus on negative emotions and thoughts.

Individuals suffering from severe adjustment difficulties, seen in many psychiatric disorders, can resort to drug use as a method of self-medication. Self medicating is done in order to alleviate negative feelings with non-prescribed drugs, and self-medication supports the view that many psychological disorders are highly comorbid with substance use disorders. Self-medication is also frequently reported as the reason why one uses a substance. Evidence showed that some disorders pre-date substance use, but why users continue self-medicating despite their knowledge about the negative long-term effects has been suggested to be due to the following reasons: the intrinsic rewarding effects of the drug leads to physical dependence, the users life is so negative that the positive effects of the drug outweigh the negative effects, and a drug may not only reduce negative affect or pain, but can also help in social situations. However, if self-medicating is truly the reason for drug use, you would expect the drug preference to align with the disorder one suffers from, so anxious people would use more calming substances like alcohol, but evidence does not support this view.

The individual's expectations about a drug also significantly influence whether one uses a drug and continues its use. Culturally generated beliefs like alcohol improving sexual function (which is false) and alcohol increasing sociability is a predictor of whether or not an adolescent will use alcohol and in which quantities. Also, the belief whether or not a drug harms one can maintain regular use, as seen in smokers who often state that it may cause cancer in others but not themselves.

Cultural factors also influence whether experimental use transitions into regular use, and an example is whether or not it is socially normal to drink alcohol, which is the case in many countries. Culturally determined beliefs about substances also influence its use, like white Americans reporting less risks associated with drugs as Hispanics or African Americans. This group of white Americans was then found to use drugs significantly more.

How can Substance Use Disorders be treated?

Treating a substance use disorder is often hard to do, since many factors need to be accounted for. It is not only the dependence that should be challenged, but the individual’s environment also plays a big role whether or not an intervention will be successful. Factors like home situation, poverty and unemployment, if not addressed, can make the individual relapse much quicker.

What are Cognitive Behavioural Therapies (CBTs)?

Substance use disorders are known for their difficulty to treat over the long-term. Cognitive behavioral therapies are used to combat relapse and to deal with substance use disorder when it is comorbid with other psychiatric disorders. Relapse is often seen in up to 90% of individuals treated for their substance use. Preventing relapse and teaching people that relapse can be fought is therefore an important part of treatment. Two factors important in deciding whether or not a relapse will result in regular use are the person's beliefs about relapsing, and the emotional states that accompanied the relapse, like stress, anxiety, depression or frustration. Addressing these two factors are done with variants of CBT that for example challenge thoughts that one relapse is catastrophic and that they might as well get drunk anyway (known as abstinence violation beliefs). Addressing the second factor is done with cognitive behavioral therapies helping the client deal with negative emotions and stress. These are known as motivational-enhancement intervention (MET) and besides negative-mood management, they also provide communication training, problem-solving skills, social support or other relapse prevention methods.

What are eating disorders? - Chapter 10

What is Anorexia Nervosa?

Anorexia nervosa (AN) is an eating disorder primarily characterized by a refusal to maintain a minimal weight, a pathological fear of gaining weight, and a distorted body image in which clients persist in the belief that they are overweight. Ten times as many women as men have this disorder. The 12-month prevalence for women is around 0.4%.

The DSM-5 criteria for anorexia nervosa are:

• A significantly reduced caloric intake than the body requires, leading to a significantly underweight;
• Intense fear of gaining weight or getting fat;
• A disturbance in the way the patient views his own body, unnecessary influence of weight or body shape on the self-evaluation.
• An objective way to measure the severity of symptoms is with the body mass index (BMI). This can be used to measure whether an individual is in a healthy weight class by including both the height and the weight of a person.

The DSM-5 distinguishes between two different types of anorexia nervosa:

1. The restrictive type: in this type, self-starvation is not accompanied by, for example, vomiting.
2. The purging type: in this type, the patient regulates his weight with the help of purging: 'cleansing', for example by vomiting or using laxatives.

Anorexia is associated with various biological symptoms, due to its severe effect on the body. These include:

• Fatigue, cardiac arrhythmias, hypotension, low blood pressure and slow heart rate
• Dry skin and brittle hair
• Kidney problems and gastrointestinal problems
• Development of lanugo over the body
• Absence of menstrual cycles (amenorrhea)
• Hypothermia.

Anorexia has high comorbidity with other psychiatric disorders, such as depression, OCD, and social anxiety disorder.

What is Bulimia Nervosa?

Bulimia nervosa (BN) is an eating disorder characterized by a fear of gaining weight and impaired body perception in which there are recurrent episodes of binge eating followed by periods of purging or fasting. The difference with the purging type of anorexia is that bulimia patients are not overweight or underweight. About 90% of bulimics are female. Life prevalence in women is between 1% and 3%.

The DSM-5 criteria for bulimia nervosa are:

• Repeated binge eating;
• Frequent inappropriate compensatory ways to avoid gaining weight, such as vomiting, fasting or exercising excessively;
• Binge eating and compensatory behaviors occur on average at least once a week for three months;
• Self-image is too much influenced by body shape and weight.
• The purging provides a liberating feeling after the unpleasant feeling that an individual gets from the uncontrolled eating.
• Bulimia has high comorbidity with other psychiatric disorders, including depression, SAD, and personality disorders.

What is Binge Eating Disorder (BED)?

Binge eating disorder (BED) is an eating disorder in which there are recurrent episodes of binge eating that are not followed by periods of purging or fasting as in bulimia. Therefore, patients are often overweight and have a lot to do with failure to lose weight. The difference with bulimia is often difficult and depends on how often the patient exhibits compensatory behavior. BED is also seen as a severe form of bulimia. The lifetime prevalence of BED is around 3%, about one and a half times as many women as men have the disorder.

The DSM-5 criteria for BED are:

• Repeated binge eating
• Binge eating is associated with at least three of the following:  eating faster than usual, eating until you are uncomfortably full, eating a lot when you are not hungry, eating alone because you feel embarrassed because of the amount and feel gross, depressed, or guilty after binge eating
• Suffering from binge eating
• The binge eating is not associated with inappropriate compensatory behaviors as seen in bulimia
• BED is associated with depression, impaired work-related and social functioning, low self-esteem, and bodily dissatisfaction

What are cultural differences regarding Eating Disorders?

Many studies suggest that cultural differences and changes are associated with differences in vulnerability to developing eating disorders and thus may represent risk factors. The emphasis placed on weight and body shape in Western cultures is an important contributor to the development of eating disorders. Thus, bulimia seems to arise only in individuals exposed to Western ideals.

White Latinas have thinner body ideals than black women. African American women are also more satisfied with their body shape, so these women are more likely to have bulimia than anorexia. Anorexia also occurs in parts of the world that are not or little exposed to Western influences. Thus, the refusal of food does not seem to be necessarily due to the presence of weight concerns and body dissatisfaction.

What are genetic factors?

Eating disorders have a genetic component, first degree relatives of individuals with anorexia and bulimia are more likely to have these disorders than relatives of people not diagnosed with these disorders. Twin studies show that the genetic component is about 40% to 60%.

Studies suggest that the genes that contribute to developing anorexia are different from those for bulimia. This is because bulimia appears to be culture-bound, but anorexia is not. It is therefore likely that there is a genetic component to self-starvation in anorexia, but more research is needed.

What are the psychological and dispositional factors?

Several studies have identified personality traits characteristic of individuals with eating disorders. These include:

• Perfectionism
• Shyness
• Neuroticism
• Low self-esteem
• High introspective awareness
• Negative or depressed affect
• Dependence and being unassertive.

What are sexual problems? - Chapter 11

How can pathological sexual problems be defined?

Because opinions are divided about what is and what is not acceptable behaviour, it is difficult to define what is 'normal'. However, there are two factors that are important in identifying psychopathology in sexual behavior and gender identity:

• A sexual activity or gender problem is suitable for treatment if it is frequent, chronic, distressing to the individual and affecting interpersonal relationships
• Some direct their sexual activity at individuals who do not participate in the activity or cannot legally consent to it (e.g., paedophilia)
• It is not required by the diagnostic criteria that the person experiences distress himself. It is difficult whether these kinds of categories should be labelled as psychopathology.

What are sexual dysfunctions?

Since the 1960s and 1970s, there has been more openness about sex and sexual activity. This opened up the opportunity to do more research into this.

There are four phases in the normal sexual cycle:

1. Desire
2. Arousal
3. Orgasm
4. Resolution

How can sexual dysfunctions be diagnosed?

Sexual dysfunctions are problems in the normal sexual cycle that prevent an individual from experiencing sexual pleasure. It is always important to include age in the diagnosis. Sexual activity and performance often decline with age. Other factors such as culture and religion should also be considered.

There are three disorders that occur in the first two stages of the sexual cycle: male hypoactive sexual desire disorder, erectile dysfunction, and female sexual interest/arousal disorder.

Male hypoactive sexual desire disorder is characterized by an absence or decreased interest in sexual activity or erotic/sexual thoughts. Prevalence is about 6% among young men and 41% among older men. DSM-5 criteria for this disorder are:

• Incessant or recurrent inadequate sexual/erotic thoughts or desires for sexual activity for at least six months, causing distress to the patient; and
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition.

Erectile dysfunction is characterized by an inability to maintain an erection during sexual activity. About 10% of men report erection problems and this increases to 20% in men over 50 years old. DSM-5 criteria for this disorder are:

• At least one of the following occurs in 75% of sexual activity for at least six months, causing patient distress: difficulty getting an erection during sexual activity, difficulty maintaining an erection to the end of sexual activity, and reduction in the stiffness of the erection.
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition.

The female sexual interest/arousal disorder is characterized by a combination of decreased sexual interest or arousal. DSM-5 criteria for this disorder are:

• Decrease or lack of interest in sexual arousal/openness, where at least three of the following are present for a period of at least six months, causing distress to the patient:
•  Lack of or decreased interest in sexual activity
•  Lack of or decreased interest in sexual/erotic thoughts or fantasies
• None or decreased initiation of sexual activity and no responsiveness of the partners to attempted sexual activity
• None or decreased arousal or pleasure during sexual activity for at least at least 75% of the time
• A lack of or diminished sexual interest in response to all internal and external sexual cues
• A lack of or diminished genital or non-genital sensations during sexual activity at least 75% of the time
• The sexual dysfunction is not better explained by non-sexual mental disorders or relationship problems or other stressors and is not due to the effects of medication/substances or any other medical condition

What are the risk factors for sexual dysfunctions?

Menopause is an important risk factor for female sexual interest/arousal disorder. Aging, depression, smoking and medical conditions such as diabetes and cardiovascular and genitourinary disorders are risk factors for dysfunction in men. Education also has an influence: men who are more educated are more likely to have early ejaculation and less educated men are more likely to have erectile dysfunction. Childhood abuse is also a risk factor for sexual dysfunction. Finally, sexual dysfunction is more common in women than in men (43% versus 31%).

What is Pedophilia?

Pedophilia is the sexual attraction to children normally 13 years or younger. The DSM-5 criteria for this disorder are:

• Sustained strong sexual arousal from fantasies, needs, and behaviors that include sexual activity with children 13 years of age or younger
• The patient has acted according to these needs in non-consenting individuals or the needs cause distress or impairment in social, occupational, and other areas
• The patient is at least 16 years old and at least 5 years older than the child involved
• The patient is not in late adolescence in a sexual relationship with a 12- or 13-year-old child.

What are Personality Disorders? - Chapter 12

What is the categorical approach to Personality Disorders in DSM-IV-TR and DSM-5?

A personality disorder (PD) is a disorder characterized by persistent, inflexible, maladaptive thought patterns and behaviors that develop in adolescence or early adulthood and significantly impair functioning.

The DSM-IV-TR organized personality disorders into three categories: (1) Odd/Eccentric Personality Disorders, (2) Dramatic/Emotional Personality Disorders, and (3) Fearful/Anxious Personality Disorders.

What are Odd/Eccentric Personality Disorders (Cluster A)?

The eccentric personality disorder cluster contains three subtypes:

1. Paranoid PD
2. Schizoid PD
3. Schizotypal PD

The dramatic/emotional personality disorder cluster contains four subtypes:

1. Antisocial PD
2. Borderline PD
3. Narcissistic PD
4. Histrionic PD

What are Anxious/Fearful Personality Disorders (Cluster C)?

The anxious personality disorder cluster contains three subtypes:

1. Avoidant PD
2. Dependent PD
3. Obsessive Compulsive PD

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy is a client-centred therapy that seeks to provide clients with an understanding of their dysfunctional ways of thinking about the world that is particularly successful in borderline personality disorders. There are four phases:

1. Identifying dangerous and impulsive behaviors and helping the client deal with these behaviors
2. Helping the client to moderate extreme emotions
3. Improving the client's self-confidence and coaching the client in dealing with relationships
4. Promoting positive emotions

What is Somatic Symptom Disorder? - Chapter 13

How can Somatic Symptom Disorder be characterized and diagnosed?

Somatic symptom disorders are characterized by psychological problems that manifest as physiological distress or psychological distress caused by physiological symptoms or characteristics. The DSM-5 criteria are:

• Demonstrate at least one somatic symptom for at least six months that causes distress or disruption in daily life
• Unwarranted thoughts, feelings, or behaviors related to the somatic symptoms or associated with health concerns, manifested in at least one of the following:

1. Disproportionate and persistent thoughts about how serious the symptoms are
2. Constant high levels of anxiety about the symptoms or health in general
3. Devoting unnecessary amounts of time and energy to the symptoms or health concerns.

What is Illness Anxiety Disorder?

Individuals with an anxiety disorder have a preoccupation with fear of having a serious illness through misinterpretation of physical signs and symptoms. This disorder was first known as hypochondriasis, but the criteria for this were different (DSM-IV-TR). Approximately 75% of people diagnosed with hypochondriasis are re-diagnosed with an anxiety disorder based on the DSM-5. The DSM-5 criteria for this disorder are:

• Obsession with having a serious illness
• Somatic symptoms are mild or absent
• High level of anxiety about health and easily worried about health
• Performs excessive health checks or shows maladaptive avoidance
• The illness preoccupation has been present for at least six months
• The symptoms are not better explained by another mental disorder.

What is Conversion Disorder?

In conversion disorder, psychological symptoms or impairments affect voluntary motor and sensory functions, which would indicate an underlying medical or neurological condition. The DSM-5 criteria for this disorder are:

• At least one symptom of altered voluntary and sensory function;
• Evidence of incompatibility between the symptoms and known neurological or medical conditions;
• The symptoms are not better explained by another mental disorder; and
• The symptoms cause distress or impairment in key areas of function.

What is Factitious Disorder?

A factitious disorder is a set of physical or psychological symptoms that are deliberately produced to assume a disease role. DSM-5 criteria for this disorder are:

• Making up physical or psychological symptoms or signs of an injury or illness
• presenting oneself to others as ill or injured
• The cheating is obvious, despite no clear reward
• The behavior is not better explained by another mental disorder, such as delusional disorder.

What are risk factors for somatic symptom disorders?

Important risk factors are trauma or abuse or periods of severe stress and anxiety. For example, childhood trauma increases the vulnerability for developing conversion disorder. Family factors such as parents with somatization characteristics and insecure attachment are also risk factors for developing somatic symptom disorders. However, all the factors mentioned are risk factors in all kinds of different forms of psychopathology.

What are Dissociative Experiences? - Chapter 14

What is Dissociative Amnesia?

Dissociative amnesia is the inability to remember important personal information, which is usually of a stressful or traumatic nature. The DSM-5 criteria for this disorder are:

• Failure to remember important personal information, often related to traumatic or stressful events, other than normal forgetting. This stresses or limits the individual in key areas of function
• The symptoms are not the result of substance use or any other neurological or medical condition
• The disorder is not better explained by other mental disorders, such as dissociative identity disorder, PTSD, or acute stress disorder.

What is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is characterized by the display of two or more identities or personality states that take turns regulating behavior (previously known as multiple personality disorder). The DSM-5 criteria for this disorder are:

• Confusion of identity, characterized by at least two different personality states, which is seen in some cultures as being possessed
• Recurrent interruptions in remembering everyday events, personal information, or traumatic events, other than normal forgetting
• The symptoms cause distress or impairment in key areas of function
• The disruption is not a normal part of generally accepted cultural or religious practices
• The symptoms are not the result of substance use or any other neurological or medical condition.

What are the biological explanations?

At first glance, it seems logical that neurological disturbances would underlie dissociative disorders, but this does not seem to be the case. The amnesia is selective and usually transient. The brain abnormalities should therefore be selective and transient. A candidate where this appears to be the case is undiagnosed epilepsy (a disorder of the nervous system characterized by mild, episodic loss of attention or drowsiness or by severe convulsions with loss of consciousness). Epileptic seizures seem to be associated with DID, among other things, but this is unlikely to explain dissociative symptoms. An alternative explanation is that there are abnormalities in the hippocampus, where various elements of autobiographical memory converge.

How can dissociative disorders be treated?

The main focuses in the treatment of dissociative disorders are reducing selective amnesia and helping the client get used to recovered memories if they are painful or traumatic and helping clients merge the alter identities into one identity. However, there are some issues that therapists run into:

• Some dissociative disorders are rare, making therapeutic techniques relatively underdeveloped and effectiveness unknown
• Some dissociative disorders sometimes resolve spontaneously, where it is not clear whether the therapeutic methods used are effective or not
• Dealing with recovered memories is often traumatic for the client because the traumatic events are relived (abreaction), which can lead the client into an emotional crisis
• Directive therapeutic styles can lead to the recovery of erroneous memories, which can have negative consequences for the client and the family
• Integrating alter identities into one identity is a very difficult process, clients find the identities a nice way to explain their behavior to others and to absolve the host identity of responsibility
• Dissociative disorders are often comorbid with many other psychiatric disorders, addressing these issues as well is a requirement in therapy

What are Neurocognitive Disorders? - Chapter 15

What are the cognitive impairments in neurocognitive disorders?

Amnesia is common in neurocognitive disorders. Anterograde amnesia or anterograde memory dysfunction is amnesia for information acquired after the onset of the amnesia. The first indications of neurocognitive problems are when the individual shows signs of a lack of attention, being easily distracted, and being slower in performing well-learned activities. In addition, it may be difficult to follow a conversation and more time may be needed to make a decision.

Language impairments are collectively known as aphasia: speech impairments that result in difficulty producing or understanding speech. This can take several forms:

• An inability to understand speech or repeat speech accurately and correctly
• Fluent aphasia: the production of incoherent, messy speech
• Non-fluent aphasia: An inability to initiate or respond to speech other than a few simple words

How does assessment in clinical neuropsychology take place?

Assessment is important for a number of reasons:

• To determine the nature of impairments and the location of related tissue damage in the brain
• To obtain information about the onset, type, severity and progression of symptoms
• To distinguish between neurological impairments that have an organic basis and psychiatric symptoms that do not
• To identify the focus for rehabilitation programs and to test progress in these programs

How are Neurocognitive Disorders diagnosed?

Diagnosis can be tricky because the impairments found in neurocognitive disorders are often symptoms of other psychological disorders as well. In addition, experiencing cognitive limitations in the early stages often leads to the development of psychological problems, such as depression.

The symptoms of neurological disorders overlap. For example, damage to specific areas due to closed head injury can cause cognitive impairments that are also found in more general degenerative disorders. Closed head injury is a concussion or head trauma, the symptoms include loss of consciousness after the trauma, confusion, headache, nausea or vomiting, blurred vision, loss of short-term memory and perseveration.

What types of major neurocognitive disorder are there?

There can be several causes for neurocognitive disorders, such as cerebral infection, traumatic brain injury, cerebrovascular events (CVAs) and degenerative disorders. One of the viruses that can infect the brain is the human immunodeficiency virus type 1 (HIV-1). The DSM-5 criteria for a neurocognitive disorder due to HIV infection are:

• Criteria for major or mild neurocognitive impairment are met
• The patient is infected with HIV
• The disorder is not better explained by non-HIV conditions including secondary brain diseases
• The disturbance is not due to another medical condition and is not better explained by another medical condition

What is deep brain stimulation?

Deep brain stimulation is a form of treatment for Parkinson's that uses a surgically inserted battery-operated device (a neurostimulator). This device delivers electrical stimulation to the ventral intermediate nucleus of the thalamus or the subthalamic nucleus area in the basal ganglia. This ensures the improvement of physical skills.

What are childhood and adolescent psychological problems? - Chapter 16

What difficulties are associated with the identification and diagnosis of childhood and adolescent psychological problems?

There are some difficulties in psychopathology in childhood and adolescence that are not present in adults. First, behavioural and psychological problems must be seen in the context of the child as a developing organism. Bedwetting is normal up to a certain age, but it is from about 5 years old. Second, children have weak self-knowledge due to their immaturity. They can sense that something is not right, but not name it.

The psychological problems in children can be divided into two domains: externalizing disorders and internalizing disorders. Externalizing disorders are characterized by outward behaviour problems, such as aggressiveness, hyperactivity, or impulsiveness. Internalizing disorders are characterized by inward-looking and withdrawn behaviours and may represent depression, anxiety, and active attempts at social withdrawal.

It is important to consider what is normal at a given age when determining clinically relevant behavior in children. Diagnosis often depends on the individual's ability to communicate problems and their consequences to the counsellor. Children often find it difficult to communicate feelings and often have weak self-knowledge. Differences in cultural norms also influence whether behaviors are seen as problematic or not. In childhood and early adolescence, developments are very fast, which means that psychological problems can escalate quickly and dramatically. Therefore, problems should be identified as soon and early as possible to minimize psychological damage.

How Is ADHD Diagnosed?

Most children show both inattention and hyperactivity (combined presentation), but sometimes one is dominant. Therefore, there are two diagnostic subtypes, namely ADHD-predominantly inattentive and ADHD-predominantly hyperactivity/impulsivity. The DSM-5 criteria for ADHD are:

A persistent pattern of inattention and/or hyperactivity and impulsivity, interfering with normal functioning or development. For inattention, at least six of the following are present for at least six months: (1) not paying careful attention to details or carelessly making mistakes, (2) difficulty sustaining attention in activities, (3) not listening when spoken to becomes, (4) ignores instructions, (5) has difficulty organizing, (6) dislikes or avoids tasks that require sustained effort, (7) loses things necessary to complete tasks, (8) is easily distracted , (9) is forgetful in daily activities. For hyperactivity and impulsivity, at least six of the following have been present for at least six months: (1) high level of agitation,

• The symptoms were present before age 12
• The symptoms are present in at least two situations
• The symptoms reduce the quality of educational, social, or occupational skills
• The symptoms do not occur during schizophrenia or any other psychotic disorder and are not better explained by another mental disorder
• ADHD has a high comorbidity with oppositional defiant disorder and conduct disorder

What is Conduct Disorder?

Conduct disorder is a pattern of behavior in which the child shows various behavior problems, including fighting, lying, running away from home, vandalism and truancy.

How is conduct disorder diagnosed?

The DSM-5 criteria for conduct disorder are:

A persistent pattern of behavior that violates other people's rights or social norms, manifested by at least three of the following for at least 12 months:

• Bullying or threatening others
• Starting a fight
• Using of a weapon to inflict serious physical harm
• Physical cruelty to others
• Physical cruelty to animals
• Robbing or other similar offenses
• Forcing others to engage in sexual activity
• Setting fire to destroying or seriously damaging property
• Intentionally destroying another's property
• Breaking into cars or houses
• Lying to get things
• Shoplifting or similar
• Staying out at night despite parental intervention, which starts before the age of 13
• Running away from home at least twice or once for a longer period of time, (15) often misses school starting before age 13
• The disruptions cause significant impairment in social, academic, and occupational functioning
• If the patient is over 18: the condition is not better explained by antisocial personality disorder

What are the characteristics of anxiety problems?

Separation anxiety is the intense fear of being separated from parents or caregivers. The prevalence is about 4% for children aged 6-12 months and has a 12-month prevalence of 1.6% for adolescents. The DSM-5 criteria for separation anxiety are:

Excessive fear of separation from those to whom the individual is attached, manifested by at least three of the following:

• Disproportionate distress when separation from home or attachment figures is experienced or anticipated
• Ongoing and unnecessary care about losing attachment figures or possible things that could happen to them
• Persistent and unnecessary worry about unexpected events that may cause separation from attachment figures
• Persistent aversion to going out or going far away from home because of fear of separation
• Persistent and unnecessary fear of being left alone or without the attachment figures
• Persistent aversion to sleeping alone or sleeping far away from home
• Repeated nightmares about separation
• Complaints about physical symptoms such as headaches or nausea upon separation from attachment figures or in anticipation thereof.
• The fear is present for at least four weeks in children and six months in adults
• The disruption causes significant impairment in key areas of functionality
• The disturbance is not better explained by another mental disorder.

What is the aetiology of depression in childhood and adolescence?

There are several risk factors for developing depression:

• Dispositional factors and existing psychological problems
• Stressful experiences
• Weak coping skills
• Weak social support
• Problems in physical health
• Weak learning performance

What drug treatments are there?

SSRIs were first used to treat depression, but this has been shown to increase the risk of suicide. However, new studies call for this to be reconsidered, as the benefits would outweigh the risks. Fluoxetine is used in the treatment of anxiety disorders. However, there are several reasons why drug treatment in children should be treated with caution:

• Complete resolution of symptoms is rarely achieved, especially in the treatment of depression with SSRIs
• SSRIs have unpleasant side effects, such as nausea, headache and insomnia
• Safety and effectiveness have not been proven, as studies vary widely in methodology
• Doubts about the safety of various antidepressant drugs in children exist in both the US and the UK, to the extent that official warnings have been issued against their use.

With regard to ADHD, more is known about drug treatments. Ritalin (methylphenidate) is the most commonly used form of stimulant medication to treat hyperactive children. The exact effect is not known, but it probably acts on the neurotransmitters noradrenaline and dopamine in areas of the brain that regulate attention and behavior. Disadvantages of Ritalin are that the long-term effects are not known that there are various side effects (such as sleeping problems and memory loss), and that it is an amphetamine, which means that it can also be abused.

What about Neurodevelopmental Disability and Diversity? - Chapter 17

How are Neurodevelopmental Disabilities and Diversities categorized and labelled?

Neurodevelopmental disorders are apparent in early development and affect intellectual, social and motor development. Three categories will be discussed: specific learning problems, intellectual disabilities and autistic spectrum disorders.

Learning disabilities is an umbrella term for the three main categories as mentioned above. In the DSM-IV-TR, the term mental retardation was used to refer to an IQ of 70 or less.

What are Specific Learning Disorders?

The DSM-5 divides specific learning problems into two broad categories, namely specific learning disorders, and communication disorders.

A specific learning problem is a diagnostic category that includes disorders such as dyslexia and communication disorders. There is high comorbidity between specific learning disabilities and bipolar disorder, ADHD and autism. The DSM-5 criteria for a specific learning disability are: Deficits in learning and using academic skills, reflected in at least one of the following for at least six months:

• Inaccurate or slow reading with difficulty
• Difficulty understanding what words read mean 
• Spelling problems
• Difficulty with expression through writing
• Difficulty understanding numbers
• Difficulty with mathematical reasoning
• The academic skills affected are substantially below what would be expected based on the patient's age
• The difficulties are not better explained by intellectual impairment, visual impairment, hearing impairment, or other mental or neurological impairment

What is Dyslexia?

Dyslexia is a complex pattern of learning disabilities associated with difficulty with word recognition in reading, weak spelling, and difficulty with written expression. Reading involves word distortions, substitutions, and omissions, and reading is often slow with difficulty understanding what has been read. Dyslexia is more common in boys, this may be because boys tend to be more disruptive than girls in learning environments, because girls compensate by liking reading more than boys, and because girls have more effective coping strategies to deal with the reading difficulties.

What is Dyscalculia?

Dyscalculia is a specific learning disability characterized by substantially below standard arithmetic ability based on chronological age, intelligence, and level of education. Skills that may be limited in dyscalculia include:

• Understanding or naming arithmetic terms
• Decoding problems in arithmetic terms
• Recognizing and reading numerical symbols or arithmetic characters
• Copying numbers or symbols correctly
• remembering to perform certain arithmetic operations
• Following sequences of arithmetic steps in the correct order.

What are Communication Disorders?

Communication Disorders include impairments in language, speech, and communication. The DSM-5 diagnostic categories of language disorder, speech sound disorder, and childhood-onset fluency disorder (also known as stuttering) are discussed.

What is Intellectual Disability?

An intellectual disability is a modern term to replace mental retardation to describe severe and generalized learning disabilities. The DSM-5 criteria for intellectual disability are:

• Impairments in intellectual functions, confirmed by clinical assessment and standard intelligence tests
• Impairments in adjusted functioning resulting in an inability to meet developmental and sociocultural standards of personal independence and social responsibility
• The symptoms start in the developmental period

The DSM-5 also provides the option to classify intellectual disability into mild, moderate, severe, and profound.

What support and interventions are available for individuals with Autism Spectrum Disorder?           

First, individuals with autism spectrum disorders do not like change, but this is what interventions aim to do. Second, individuals respond poorly to communication and therefore the treatment program should begin at a basic level of communication, such as learning to make eye contact. Third, children often show interest in only a narrow range of events and objects, making it difficult to find effective reinforcers. Fourth, there is strong selective attention, which makes it difficult to generalize what has been learned to other situations than in which it was learned. Finally, individuals may be treated with suspicion and restraint due to weak communication and social skills.