History, Concepts & Stigma - Chapter 1

Introduction

For psychologists psychopathology is a field in which deviations from normal or everyday psychological functioning are being studied. Clinical psychology is a sector of psychology that deals with understanding and treating psychopathology.

Explaining Psychopathology

The view of what causes mental health problems has changed over time. We will examine the historical perspective of demonic possessions on explaining psychopathology and the contemporary models of explanation such as the medical model and psychological model.

Medical models: work with underlying biological or medical causes to explain psychopathology.

Psychological models: seek to explain psychopathology in terms of psychological rather than biological processes.

Demonic Possessions: since many forms of psychopathology seem to appear together with what looks like a personality change in the individual and which is noticed as one of the first symptoms, the historical explanation described this person as being ‘possessed’. The change in their behaviour was attributed to someone/something having taken over their personality. This has led the sufferers to be persecuted and physically abused instead of being cared for. Demonology is a term which describes the belief that someone with symptoms of psychopathology is under the possession of bad spirits.

The Medical or Disease Model

In the 19^th century it became evident that many mental or psychological illnesses could be explained in terms of biological or medical accounts. The somatogenic hypothesis describes explanations of psychological problems in terms of physical or biological impairments. The discovery was made that syphilis had a biological cause and that later stages of the disease, such as dementia, gradual blindness, and paralysis, caused dramatic changes in one’s personality. This finding contributed to the mental disorder known as general paresis. Psychiatry is a scientific approach based on medicine to primarily identify the biological causes of psychopathology and treating them with medication or surgery.

The medical model provides important implications for how we view mental health but:

1. Often times it is a person’s dysfunctional experiences and not biological dysfunctions that account for psychopathology.

2. The medical model tries to reduce the complex psychological and emotional aspects of psychopathology to simple biology.

3. The view that something is broken and needs to be fixed in the individuals is problematic, as psychopathology may just be a normal behaviour but in an extreme form. Labelling psychopathology as a normal process gone wrong or broken can lead to stigmatizing these individuals and viewing them as second-class citizens.

It is a widespread belief that people with mental health problems are dangerous, hard to talk to and that (some of) the mental health problems are self-inflicted. Psychopathology should be viewed as dimensional, and not as a discrete phenomenon that is set apart from normal experience. Medical models of mental health can often make a sufferer feel like a victim and powerless in regard to the condition and their future life. They feel socially excluded and often experience low self-esteem and depression after a psychiatric diagnosis.

From Asylums to Community Care

Not too long ago, prior to the 18^th century, mental illnesses were seen as ‘madness’, and were not treated in hospitals like non-mental diseases are. With the decrease of non-mental diseases, many hospices were transformed to asylums for the confinement of sufferers of mental health problems. Treatments were unnecessarily cruel and painful, and these asylums over time not only accepted those with mental issues, but also other people who fell below the societal desirable standards, like poor people and young pregnant women. These approaches towards the mentally ill are probably part of the roots of the nowadays still running negative stigma towards sufferers of mental illnesses. The 19^th century thankfully came with people advocating more humane treatments, like Philippe Pinel who began removing the chains and restraints of patients, and treated the patients as sick people, instead of animals. The Quaker movement (UK) developed the moral treatment approach, which abandons medical approaches and instead implements understanding, hope, occupational therapy, and moral responsibility.

Because most of the care started to rely on the (undereducated) nurses and caretakers, many patients were simply restrained. This often lead to patients developing social breakdown syndrome, making the patients aggressive, exerting challenging behaviour for the caretakers, and a lack of interest in personal welfare and hygiene. Therapeutic refinements of the hospital environment were: 1) the token economy, which consists of a reward system where patients can earn ‘tokens’ for various desired items or privileges, and 2) milieu therapies, which were implemented to develop productivity, feelings of self-respect, independence, and responsibility. This was achieved by mutual respect between staff and patients, and the opportunity for the patients to express themselves with vocational and recreational activities. It was shown that patients exposed to this kind of therapy were more likely to be discharged earlier and less likely to relapse.

Because of modern therapy and medical treatments, many people are not confided to a life in a mental health facility. Many return back to a state where they are capable of living quite a normal life. For people who still need some sort of after-care, there are assertive outreach programmes which help people who are recovering from psychosis to live a normal life as independent as possible.

Defining Psychopathology

Abnormal Psychology is an alternative term used to define psychopathology. This definition has a negative connotation though, suggesting that an individual is malfunctioning and thereby attaching a stigma to the individual. Service user groups communicate these labels that are often times attached to individuals with mental health problems. Two examples are Rethink and “Time To Change”, programmes with the aim to educate people about mental health, and fight against discrimination and negative stigma.

Deviations from the Statistical Norm

In clinical psychology the statistical norm, an average example of behaviour, is used to decide whether a certain disorder meets diagnostic criteria. Mental retardation is often diagnosed by an IQ score significantly below the norm of 100. Problematic is the view that individuals with exceptionally high IQ scores, which are also statistically rare, would not be considered as exhibiting psychopathology.

Deviations from Social Norms

It is quite difficult to use deviations from social norms as evidence for psychopathology, as different cultures have very different views on what is socially normal. Also, cultural factors are a great influence on how psychopathology manifests itself in the individual. This includes 1) the degree of vulnerability of an individual to causal factors and 2) the ‘culture-bound’ symptoms of psychopathology. Two examples of ‘culture-bound’ effects are Ataque de Nervios, a form of panic disorder found in Latinos from the Caribbean and Seiziman, a state of psychological paralysis found in the Haitian community.

Maladaptive Behaviour

We cannot define psychopathology solely in terms of maladaptive behaviour. Not all maladaptive behaviours are a result of psychopathology. One can say that many forms of psychopathology serve as protective or adaptive functions and do not represent maladaptive behaviour. Harmful dysfunction refers to the assumption that psychopathology is somehow defined by the abnormal functioning of an otherwise normal process.

Distress and Impairment

A useful way of describing psychopathology is the degree of distress and impairment the sufferers expresses. The individual can judge his or her own ‘normality’, which enables self judgment of their needs. Yet, this approach does not define a standard by which behaviour should be judged. Often times a person exhibiting psychopathology does not report experiences of personal distress, for example because they do not want to admit that they are behaving unusual, when they don’t experience any personal distress (e.g. antisocial personality disorder sufferers) or they don’t experience any distress yet (e.g. people abusing substances)

Explanatory Approaches to Psychopathology

In order to understand many mental health problems, different paradigms are used to gather information about the brain and mind. Symptoms can be explained at different levels, some of which are genetics, behaviour, biology or cognition. These different paradigms are categorized under biological and psychological models:

Biological Models

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. Some methods are 1) concordance studies, which look at different family members and the relation between a psychological disorder and the amount of shared genetic material, 2) twin studies, where monozygotic twins (identical genes) and dizygotic twins (50% shared genes) are compared to see if there is a genetic explanation in psychopathology. Many psychopathologies don’t occur spontaneously due to a person’s genes, but are rather 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 a problem develops 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.

The field of molecular genetics is also involved in identifying which individual genes are involved in the transmission of symptoms seen in psychopathology. A method of achieving this is with genetic linkage analysis, which identifies the role of genes by linking some gene responsible for a specific characteristic (e.g. eye colour) with psychopathology symptoms. So if some eye colour is strongly co-occurring with a psychopathology symptom in a family, it is quite likely that the genes important for this symptom is found on the same chromosome as the one for eye colour. A downside to this method is that some symptom is often not relatable to a single gene, but instead to a greater amount of genes interacting. Another subfield of genetics is the field of epigenetics, which does not focus on the altering of the genetic code, but on the expression of current existing genes. There can be many reasons why some genes are or aren’t expressed at a certain point in an organisms life, the field of epigenetics is concerned with finding out what can alter the expression of a gene and what implications these differences in expression might have on the individual.

Neuroscience seeks to understand psychopathology by looking at an individual’s biology to help explain symptoms, where the bigger focus is on the brain structure, its function, and also the neuroendocrine system, since hormones contribute a lot to behaviour. The two brain hemispheres are connected by the corpus callosum, which is a bundle of nerve fibres. The cerebral cortex, the outer layer of tissue, consists of four lobes. The occipital lobe, located at the back of the brain, is associated with visual perception. The temporal lobe, can be found behind the temples to the side of the head, and it’s involved with functions such as hearing, memory, emotion, language, illusions, and processing tastes and smells, and the parietal lobe is associated with visuomotor coordination. Located at the front of the head is the frontal lobe, which is known to be important for higher cognitions like problem solving, controlling voluntary movements, willpower, and planning. Especially the frontal lobes are often implicated in many psychopathologies, seeing as they have such a major executive function over behaviour. Below these lobes many other structures can be found, and some of them are collectively known as the limbic system, which is thought to be involved in emotion and learning. The limbic system consists of the mammillary body, thalamus, fornix, hypothalamus, amygdala, and the hippocampus. The hippocampus is known for being involved in spatial learning, and the amygdala is crucial for processing emotions and learning from them.

The main method of communication between brain structures and thus neurons, is with neurotransmitters. These are chemicals that are the main component of regulating brain functioning. For example, dopamine is often associated with schizophrenia and psychotic symptoms. Serotonin is linked to depression and mood disorders, and norepinephrine and Gamma-aminobutyric acid (GABA) are thought to play a role in anxiety symptoms.

Psychological Models

Psychological models attempt to provide psychological explanations of psychopathology. The model sees mental health problems as normal reactions to adaptions to stressful life conditions.

Sigmund Freud (1856-1939), neurologist and psychiatrist, attempted together with Joseph Breuer to explain symptoms such as hysteria and paralysis that could not be explained by medical causes. Using hypnosis, the symptoms of Freud’s clients eased just talking about repressed experiences and emotions. On these cases, Freud built his theory of psychoanalysis. This theory tries to explain normal and abnormal psychological functioning in regard to defence mechanisms being used against anxiety and depression. He coined the concept of three psychological forces:

• Id: describes innate instinctual, especially sexual, needs

• Ego: rational; tries to control the id’s impulses with ego defence mechanisms that also reduce the anxiety that the id impulses may generate.

• Superego: develops out of the other two psychological forces, and is responsible for integrating ‘values’, such as those learned from society or our parents.

Freud said that psychological health can only be attained if all three forces are in balance and that we develop defence mechanisms in order to avoid conflicts between the three forces or conflicts arising from external factors.

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 fixated 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)

The concepts of the psychoanalytic approach are difficult to observe, measure, and objectively define, which is why this theory is not applied by many psychologists today.

The behavioural model explains psychopathology in terms of learned reactions to life experiences. The learning theory, based on principles of classical conditioning (e.g. dog salivating) and operant conditioning (e.g. Skinner box), explain how dysfunctional behaviour can be acquired just like adaptive behaviour. For example, many emotional disorders are explained by classical conditioning such as specific phobias or even post-traumatic stress disorder (PTSD).

Behaviour therapy is set on the principles of classical conditioning and operant conditioning, the goal of which is to ‘unlearn’ behaviours or emotions that are maladaptive. Behaviour modification is a therapy that focuses on the principles of operant conditioning.

The cognitive model describes how psychopathology develops through the acquisition of irrational beliefs, the development of dysfunctional ways of thinking and information processing biases. According to Albert Ellis (1962), people judge their own behaviour according to the irrational beliefs they developed, which cause emotional distress (e.g. anxiety). Aaron Beck developed a successful cognitive therapy against depression, which rests on the idea that people develop unrealistic expectations that guide their view of themselves, the world and their future.

When the dysfunctional beliefs which maintain the symptoms of psychopathology are identified, they can be changed and replaced by functional cognitions. Cognitive behaviour therapy aims at changing behaviours and cognitions. Even though this approach has been widely adopted and successful, there is not much known about the origin of the dysfunctional thoughts. The dysfunctional thoughts could merely be a symptom of psychopathology rather than a cause of it.

The humanistic-existential approach works with the view that individuals can acquire insight into their lives from a wide spectrum of perspectives, and only by gaining this insight can they achieve insights into their emotional and behavioural problems. Then, psychopathology and conflicts can be resolved.

Client-centred therapy is an approach in which the therapist makes use of empathy and unconditional positive regard to help the client achieve a sense of positive self-worth.

This approach places little emphasis on the acquisition of psychopathology, but tries to place the client from a phenomenological perspective, such as one consisting of fears and conflicts, into one that is functional (e.g. where the client feels self-worthy). This form of therapy is used only by some clinical psychologists, as the humanistic and existentialist approach is hard to evaluate.

Mental Health and Stigma

Many still hold negative views of those with mental illnesses. This might be explained due to a lack of knowledge, which is why it is important that people are educated about mental health, so that sufferers will feel less stigmatized and be treated the same as anyone else.

What is mental health stigma and where is it seen?

There are two types of mental health stigma: social stigma which is directed at others who are suffering from some sort of mental health problem, and perceived stigma (or self-stigma) which are the internalised feelings of discrimination a sufferer experiences due to their condition. The latter can be quite discouraging and result in a negative impact on possible treatment outcomes. Some of the biggest stigmas are that 1) patients are often dangerous, 2) that some disorders are self-inflicted, and 3) that sufferers are often hard to talk to.

What causes these stigmas?

Misguided views that the mentally ill are dangerous or shouldn’t be part of the society might be the basis why some still think that these people should be excluded and treated differently. Current views on mental health can still be stigmatizing, such as the medical model which implies that sufferers are different from others, or the fact that a label is put on those suffering from a mental issue does not help to alleviate any negative stigma. Another source of misguided views on mental health are the media.

Why does stigma matter?

Stigma can be discriminating, which results in social exclusion, low self-esteem, poor social support, and poor subjective quality of life. All of these factors have a huge impact on the treatment of mental disorders, like slowing down the recovery or even worse demotivating the sufferer from undergoing any treatment.

How can we eliminate stigma?

Much is done to eliminate stigma, like the Time to Change campaign (UK), which attempts to educate people about mental health with the use of blogs, videos, TV ads and events. Campaigns like these that are made to make contact between individuals with and without mental illnesses, have been shown to improve the attitudes towards people with mental health problems, promote people’s behaviour for anti-stigma engagement, and lastly increase the willingness of people to be open about any mental health problem they might experience in the future.

Classification & Assessment - Chapter 2

Introduction

The type of technique employed by clinicians for clinical classification and assessment often depends on their theoretical orientation to psychopathology. These techniques help in diagnosing, finding the best intervention, and evaluating whether the treatment effectively targeted the symptoms of the client.

Classifying Psychopathology

• We need to use categorization and classification in order to gain knowledge about the aetiology and causes of mental health problems.

• Different approaches are required for the various mental health problems, so classifying them helps in providing good and specialized support and service for sufferers.

• We can only define success of interventions if there is an objective way of defining what makes out the symptoms of psychopathology.

Emil Kraepelin (1883-1923) defined a distinct set of symptoms as a syndrome. The World Health Organisation followed Kraepelin’s scheme and extended the International List of Causes of Death (ICD) with psychological disorders in 1939. The American Psychiatric Association (APA) improved classification by developing the first Diagnostic and Statistical Manual (DSM) in 1952. The most recent version is the DSM-5, which is the most widely adopted psychopathology classification system.

Four basic objectives of the DSM-5:

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 favouring 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.

Diagnosis should be made almost fully on the basis of observable behavioural symptoms, it therefore ignores the nature of the disorder (unless it is certain), and solely focuses on symptoms.

Certain problems do arise with the DSM-5:

• It classifies psychopathology according to symptoms and not causes. Due to classification by symptoms, it gives the impression of explaining symptoms, when it is just a different description of the symptoms.

• Labelling people according to criteria using the DSM-5 can attach stigma or be harmful.

• It can lead to the view of disorders being discrete entities, when it is 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, there have been explanations such as a disorder spectrum. They 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. Like anxiety and depression will be overarched by the group emotional disorders.

• There is extensive within-category heterogeneity within diagnostic criteria.

The DSM-5 is no longer categorized in a multi-axis system, but now consists of 20 chapters describing disorder families. Users of the DSM-5 are now encouraged to rate the disorders’ severity of symptoms on a continuum. Some other changes are:

• Some disorders are now represented by their own chapter, like Obsessive Compulsive Disorder (OCD) and Stress-related disorders.

• Many previously separate autism labels are now incorporated under Autism Spectrum Disorder.

• The new disorder Mood Dysregulation Disorder diagnoses children suffering from persistent irritability.

• Binge-eating disorder, skin-picking disorder, and hoarding disorder are now independent disorder categories.

• Personality disorders’ categorical model stays, but has an added dimensional scale.

• Bereavement is no longer excluded as a symptom in major depression.

• PTSD is now included in a new chapter on stress.

• Substance use disorder now combines both substance abuse and substance dependence.

Some criticisms of the DSM-5 are:

• The many changes now require less criteria to be met for a diagnosis. This can turn out good or bad, but it will likely ‘medicalise’ many normal human emotions and thoughts.

• The new disorder categories (e.g. attenuated psychosis syndrome, seen as a potential precursor to psychotic episodes) that are made to identify people showing early signs of disorders might also again medicalise perfectly fine and healthy people, just because they are showing normal adaptions to life that might seem abnormal at first.

• The new diagnostic criteria can result in lowered rates of diagnosis for some particularly vulnerable populations (e.g. children diagnosed with autism), and there are concerns that the changes to specific learning disabilities (relating to conditions such as dyslexia or other communication disabilities) could disadvantage people with learning disabilities.

• The usage of neuroscience in the diagnostic criteria is criticized because neuroscience has not been able to help defining mental health problems a lot lately.

• Since disorders are now generally seen as dimensional, any criteria defining a cut-off score is quite arbitrary.

Assessment Methods

Clinical Interview

During the clinical interview, a first form of contact is made and the clinical psychologist will try to get a general overview of the client as a person and their problems. This can be difficult, as a lot of clients do not give out all information to the therapist, possibly because it is something they are embarrassed about, involving a painful memory or illegal incident. Additionally, they do not have enough insight about themselves to answer questions correctly.

To get hold of standardized information, the therapist can engage in the structured interview to make a diagnosis or form a case formulation. One of those structured interviews which allow clinicians to make decisions about functioning and diagnosis is called Structured Clinical Interview for DSM-IV-TR (SCID). This interview uses a branching method whereby one response the client makes decides which question will be asked next. It is highly reliable for most AXIS I disorder diagnoses. Structured interviews also serve the assessment of overall intellectual and psychological functioning levels. One such example is the Mini Mental State Examination (MMSE), which is reliable and only takes 10 minutes.

Limitations are:

• Low reliability for unstructured interview.

• Race and sex might influence responses of client.

• Poor self-awareness of client.

• Interviewer might also be biased.

• Client wants to mislead interviewer.

Psychological Tests

Psychological tests are more structured than clinical interviews. Advantages are:

• Assessment of one trait or specific characteristics.

• A pre-conceived scoring system can be used because the test’s response requirements are very rigid (e.g. STAI, State-Trait Anxiety Inventory).

• Statistical norms, by process of standardization, can be used to determine how client’s score compare to normal distribution.

• Psychological tests are both reliable and valid.

Most of the psychological tests go by the psychometric approach, which holds that people have stable underlying traits that are active at different levels in everyone. Psychological tests can be used for example to assess psychopathology symptoms, cognitive or neurological deficits, and intelligence.

The Minnesota Multiphasic Personality Inventory (MMPI) is one of the most well-known inventories used by clinical psychologists and psychiatrists. The most recent update, MMPI-2, includes 567 self-statements which the client answers by choosing the best of the three points: ‘true’, ‘false’ or ‘cannot say’. The inventory only includes questions which were previously responded to differently by a large sample of non-psychiatric patients and psychiatric patients. The test consists of 4 validity scales and 10 clinical scales.

Results from the MMPI are displayed in a graph, presenting a profile that indicates general personality features of the client, potential psychopathology, and emotional needs. The provided validity scales are important because clients might provide false information. The MMPI has good internal reliability and scores on it seem to have very good clinical validity, due to accurate correspondence of clinical diagnoses and symptoms rated by own family members and the clinician. One limitation of the MMPI is that it takes very long. The MMPI-2 is a shorter version with good validity and reliability.

The Specific Trait Inventories measures one specific psychopathology, or a functioning that is relevant to psychopathology. The Obsessive Belief Questionnaire (OBQ) is an example to measure cognitive functioning relevant to obsessive compulsive disorder (OCD). These specific tests not only measure characteristics found in observable behaviour, but can also measure hypothetical constructs. Nevertheless, most of the specific trait inventories are not subject of validation and reliability tests, and are also not standardized.

Clients taking a projective test are confronted with a fixed set of stimuli that leave room for interpretation because the stimuli are ambiguous. The Rorschach Inkblot Test, the Thematic Apperception Test (TAT) and the Sentence Completion Test are the projective tests that are used most widely. Yet, all of them are less reliable and valid in a considerable amount than more structured tests.

Hermann Rorschach created Rorschach Inkblot Test test by dropping ink onto paper and then folding it in half, creating a symmetrical image, called an inkblot. The test consists of 10 official inkblots. There is a highly structured scoring system which clinicians can use to compare the client’s score with a set of standardized personality norms that might indicate psychopathology. Nevertheless, the test is often subject to the clinician’s interpretation of the client’s responses. It can be a valid and reliable test though to detect thought disorders possibly indicating schizophrenia or the risk of developing it.

The Thematic Apperception Test (TAT) requires clients to create a dramatic story around a picture which displays people in vague and ambiguous situations. The whole test consists 30 of these pictures, which are all in black and white. The ‘hero’ is the character of the picture with whom the client identifies, and in that way the client describes what he feels, as if he was part of the scene. The TAT may in that way express expectations the client holds about relationships with various people in his life (e.g. parents, romantic partner). This test can be used well after a client was matched with an appropriate form of therapy or to evaluate individuals accused of violent crimes.

The Sentence Completion Test gives clients sentences that are uncompleted and which they need to fill in with own words. This can indicate how a client might be biased in thinking or processing information from his or her psychopathology. The test was applied for example to combat veterans with post-traumatic stress disorder. The clinician will find from the sentence completion which ways of thinking should be targeted.

Projective tests are becoming less and less popular over the years. Reasons are:

• They often reveal information just relevant to the psychodynamic approach, an approach which is experiencing decline in popularity itself.

• They have low reliability.

• They infer psychopathology when there is otherwise little evidence for it (such as the Rorschach Test), with exception of indications for schizophrenia.

• They contain intrinsic cultural biases.

• They are labour-intensive and in return give little objective information.

Intelligence tests aim to measure intellectual ability. The first intelligence test was created in 1905 by the French psychologist Alfred Binet. Most are standardized, having a score of 100 as the mean and 15 or 16 as score for standard deviation. Advantages of intelligence tests include high internal consistency, high test-retest reliability, and good validity.

Intelligence tests are used in variety of situations by clinicians:

• They are used together with other measures of ability for the diagnosis of learning and intellectual disabilities.

• They are used for the assessment of individuals with disabilities, so they can be provided with support for specific needs. Best used for this is the Wechsler Adult Intelligence Scale (WAIS), which covers a range of different ability scales.

• They are used in neurological evaluations as part of an assessment battery.

There are also limitations of using intelligence tests:

• Intelligence is a hypothetical and inferred construct.

• There is a cultural bias, many IQ tests being based on middle class majority ethnic background views, making the intelligence dependent on the reliability and validity of the individual IQ test.

• They are ‘static’ tests that capture intellectual ability at one point in time. They do not measure the potential of acquisition of new cognitive abilities.

• Many other skills are not contained in measures and conceptions of intelligence (e.g. music ability), making our current conceptions too narrow.

Neurological impairment tests deal with identifying if cognitive deficits in an individual can be attributed to brain damage, and if so, which brain areas have been affected. This is done by using EEG, PET scans and fMRI scans, blood tests, and chemical analysis of cerebrospinal fluid. Neurological tests are also very important in an assessment, and help measure perceptual, cognitive, and motor performance. By finding a specific cognitive deficit it can become easier to identify the area of brain damage. The Adult Memory and Information Processing Battery (AMIPB), the Halstead-Reitan Neuropsychological Test Battery and the Mini Mental State Examination (MMSE) are the tests commonly used by clinical neuropsychologists.

Biologically Based Assessments

To gather information about emotionally based psychological problems, psychophysiological tests can be very helpful. The electrodermal responding, also known as the galvanic skin response (GSR) or skin conductance response (SCR), measures changes in sweat gland activity by electrodes attached to the fingers. A polygraph records the changes in skin conductance caused by emotional responses (e.g. fear, anxiety). Other useful psychophysiological measures are:

The electromyogram (EMG), measuring the electrical activity in muscles, and the electrocardiogram (ECG), measuring heart rate. The lie detector is not used as often anymore, especially less in cases of finding evidence of criminal guilt, as arousal not attributed to lying can be detected and interpreted falsely as lying. The electroencephalogram (EEG) is an assessment measure that records underlying electrical activity, by attaching electrodes to the scalp. Unusual brain patterns in different brain areas can be localized.

One technique to provide images of the brain is the computerized axial tomography (CAT). For that the patient needs to lie in a large tube and 3D versions are formed of the brain. With these images abnormal growths or enlargements of the ventricles can be detected. The positron emission tomography or PET scans use radiation to develop images. Participants emit gamma radiation, which comes from small given amount of a radioactive drug. Areas coloured brightly in the image indicate high metabolism of glucose in the brain. Furthermore the magnetic resonance imaging (MRI) is a scanning technique which creates visual pictures of the brain by placing a participant inside a circular magnet that makes the hydrogen atoms in the body move. Functional magnetic resonance imaging (fMRI) allows recording of tiny changes because the clinician can take brain images very quickly with this technique.

Clinical Observation

Direct observation allows the assessing of frequency of a specific behaviour, what precedes the behaviour, and what follows it. An ABC chart can be used for this assessment, including A) what occurs before the target behaviour takes place B) what the individual had done C) what consequences follow the behaviour.

Advantages of clinical observation are:

• An important objective measure of the behaviour frequency is provided, as well as for what precedes and follows behaviour.

• Greater external or ecological validity than for other testing ways (e.g. self-reports) is provided.

• The context in which behaviour takes place might provide hints to workable answers.

Drawbacks of clinical observation:

• Time consuming assessment.

• Behaviour in one context of observation might not be typical to behaviour in another context.

• The observed individual might act differently because the observer is present. Analogue observation takes place in a controlled environment where the client can be observed secretly.

• Poor inter-observer reliability.

• Expectations of observer can influence data.

In self-observation or self-monitoring, the client keeps track of his own behavior, and notes down when and in what contexts certain behaviors take place. Ecological momentary assessment (EMA) is a method in which the client makes use of electronic diaries to capture self-observation. It helps lower the frequency of undesirable behaviors.

Assessment Methods: Reliability and Validity

When different clinicians on different occasions use a method and it gives the same results, the method is high in reliability. A method has validity when it measures what it says to be measuring.

There is test-retest reliability, which means a test yields similar results when a person repeats the test after a time interval, such as months apart. Inter-rater reliability means when two independent clinicians agree on interpretation and scoring of a test. Internal consistency holds when items in a test relate to each other in a consistent way. This can be assessed with the statistical test Cronbach’s alpha.

Test validity is made up of more specific validities such as concurrent validity, which measures correlation of scores of one test and another test that measure the same attribute. If questions intuitively seem to be relevant to the measured trait, the assessment method has face validity, which does not mean it has validity. High predictive validity helps with organizing appropriate treatment and support, because it predicts future behaviour and symptoms well. If a measure of a construct overlaps with other similar measures, it has construct validity. Lastly, a hypothetical or inferred construct for example is inflated responsibility in individuals suffering from obsessive-compulsive-disorder (OCD).

Assessment and Cultural Bias

Many tests can be culturally biased and in return 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.

There are a number of causes of cultural anomalies in assessment and diagnosis. First, there are different manifestations of mental health symptoms in different cultures. Secondly, there might be a language barrier between client and clinician. Thirdly, perception of psychopathology is influenced by religion and spiritual beliefs. Fourthly, culture differences affect client-clinician relationships. Lastly, there are different perceptions on what is considered ‘normal’ and ‘abnormal’. The judgment of clinicians is often also influenced by the confirmatory bias, which means that clinicians only pay attention to information that supports their initial hypotheses and ignore information that does not support it.

Case formulation

In case formulation, an approach is used which tries to formulate a psychological explanation from clinical information and from there on develop a plan for therapy. This approach works from an established theoretical account to explain problems the client is experiencing. This collaborative way of therapy consists of six components:

1. Creation of a list of the client’s problems.

2. Identification and description of the underlying psychological mechanism of the problem.

3. How these mechanisms generate the problem.

4. Events that led up to the problem.

5. How these events may have caused the problem regarding the psychological mechanism.

6. Development of a treatment scheme and prediction of possible obstacles.

The theoretical approach of the therapist determines the construction of the case formulation. The ABC approach aims at explaining the client’s problems by the cognitive-behavioural model by explaining (A) antecedents (B) beliefs and (C) consequences of an event. In the psychodynamic approach the problems of a client can be viewed as interactions between various ‘actors’ (family members). Clinicians like to use diagrams to represent their formulations.

Advantages of the case formulation approach include:

• Flexibility in understanding the client’s problems, regardless of any previous diagnoses they have received.

• A collaborative form of treatment.

• A basis of theoretical understanding of psychopathology.

• The past history of the client is considered.

• Appropriate treatment can be administered to target specific needs, even in complex cases that do not easily fit s­tandard diagnostic categories.

Research Methods in Clinical Psychology - Chapter 3

Introduction

With knowledge of the scientific method clinicians can evaluate objectively whether their treatment was effective. The clinical psychologist can be seen as both a researcher and practitioner, known as a scientist-practitioner, or applied scientist.

Science and Research

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.

Pros and Cons of the Scientific Method

The National Institute for Health and Clinical Excellence (NICE) is a UK organization that uses scientific evidence to see which treatments can be labelled as evidence-based, treatments that have proven to be efficient. These treatments are then recommended. In contrast to the scientific method, the alternative approach of social constructionism proposes that there are no basic ‘truths’ because reality is only a social construct. Because many disorders involve individuals developing their own realities, this approach is relevant in clinical psychology, seeing only language itself as means of understanding psychopathology.

What Do We Want To Find Out In Clinical Psychology Research?

Understanding Psychopathology

Goals of research entail: description, prediction, control, and explanation (understanding). Description defines and categorizes events that are of relevance in psychopathology. Prediction attempts to explain future behaviour under specific conditions. Risk factors indicate which factors might contribute to a greater risk of developing psychopathology at some point in life. We control events and behaviour in a way to learn more about the causal relationships that are involved and to find better treatment methods. Finally we try to arrive at the stage of understanding. By using models of a phenomenon we describe the interaction of all factors, in terms of a mechanism.

Questions Answered In Research

Aetiology is a term used for the description of the origins and causes of symptoms of psychopathology. When research is done on a healthy population to gain knowledge about the aetiology of psychopathology, this is known as analogue research. Evaluative research or clinical audit aims at investigating whether a treatment has been effective. This supports the effective use of current knowledge.

Research Designs

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, one can say the result of the study are of statistical significance.

Longitudinal Studies and Prospective Designs

The longitudinal studies, also known as prospective designs, do not obtain measures only at one point in time, but at several points to find out more about the time-relationship between variables. In the cross-sectional design only one sample from one point of time is taken.

Epidemiological Studies

Epidemiological studies try to yield details about the prevalence of psychological disorders within a specific population over a set period of time. The frequency and distribution is studied, giving an epidemiological study the form of a large-scale and descriptive survey. Prevalence rates can be described by lifetime prevalence, one-moth prevalence, and point-prevalence. Prevalence is represented by incidence x duration. It is important that the epidemiological study uses a sample that is a true representative of the population. This is hard to achieve as many people do not want to participate in studies.

Experimental Method: The Basic Features

In an experiment, which can determine a causal relationship, a researcher starts with an experimental hypothesis or experimental prediction, which predicts how the experimental manipulation might affect the outcome response. The manipulated variable is called the independent variable and the variable of the outcome is called the dependent variable. Control conditions control for confounding effects, which are effects not produced by the independent variable but by something else. The independent variable is experienced in the experimental group, but not in the control group. Still, there has to be an objective way to measure the dependent variable, so statistical analysis can be applied. Random assignment is used to assign participants to the different experimental conditions. A participant might exhibit demand characteristics, which means that the participant thinks about certain behaviours that might be expected of him or her in the experiment and behaves according to that. The experimenter might also be prone to giving certain cues to a participant because of knowing to which experimental condition he or she was assigned. To prevent this, a double-blind experimental procedure can be used.

How the Experiment Is Used In Research

Analogue populations are populations of healthy participants, and using these can help prevent the ethical difficulties which may arise in experimentation with clinical participants. They can consist of humans or non-human animals. Analogue studies are valid for a number of reasons: Psychopathology is seen as dimensional, so by studying a non-clinical population we can infer something about the clinical population. Also, psychopathology can be created in the laboratory with experimental manipulations.

Animals are also often used as subjects of experiments, such as in the animal models which are used to investigate genetics, changes in brain biochemistry and the effects of drugs in psychopathologies. Nevertheless, animal research has become more of a controversial topic, because of the question of ethics involved in using non-human animals for experiments.

Clinical trials investigate whether a treatment for mental health problems is effective, by using experimental research. The participant’s expectations of the treatment can contribute to a placebo effect, such as getting better without receiving actual drug treatment. To control for this effect a placebo control condition can be established, which measures what expectations the participants in the clinical trial hold. Clinical trials can also compare which of two treatments, A or B, is more effective or whether a new treatment is more effective than a treatment that already exists.

Mixed Designs

A mixed design is a type of research that works with participants that are not randomly assigned to groups, but rather assigned consciously to groups. This design can be especially helpful in psychopathology research because researchers can see how a group of participants with one specific psychopathology reacts to a variable in comparison to a group of participants with another psychopathology. Even though this technique is very useful, it does not provide information about the causal relationship.

Natural Experiments

Observing the effects of natural occurring events on behaviour is another form of research, coined by the term natural experiments. These events can be a natural disasters, accidents, terrorist-attacks or poverty and social deprivation.

Single Case Studies

An individual’s psychopathology can be studied by means of a case study, and case formulation can be a form of that used in therapy. Besides using case formulations, clinical practitioners can make use of the single-case experiment, which assesses an individual’s behaviour at two points, before the experimental manipulation and afterwards.

Case Studies

Case studies were one of the first research designs used, such as by Sigmund Freud with his psychoanalysis approach. Case studies are also a good source to disprove existing theories. Drawbacks of using case studies include little objectivity and control, low external validity, and the difficulty of providing evidence which supports the theory.

Single-Case Experiments

In a single-case experiment the participant acts as both the experimental and control participant. For psychopathologies that are rare this is a good option, as often there are not enough participants for the experimental and control groups. Baseline measures of the behaviour are taken before the experimental manipulation, which are then compared with the behaviour after the manipulation. The ABA design is often used, which measures changes in behaviour directly after the experimental manipulation, and hence controls for confounding factors that could occur within time after the manipulation. The ABAB design adds a second manipulation after the second stage of no intervention. Problematic is the alternation between periods of treatment with non-treatment if treatment provides important benefits for the participant. To solve this problem, the multiple-baseline design can be introduced. Two or more behaviours are measured in this design, while one behaviour is manipulated and the other behaviours serve as the control condition. Another option is to use multiple participants, where in stage A the baseline measures are taken and then in stage B the manipulation is installed successively for all participants. A limitation of single-case studies is that results are not easily generalizable to other individuals but this problem can be overcome by having more than one participant in the study.

Meta-analyses

A meta-analysis attempts to provide an objective review of existing studies by using statistical methods. A particular finding across a number of studies is assessed in its strength, detecting possible trends by comparing effect size of the different studies. Effect size measures the magnitude of the effect in an objective and standardized way, whereby the problem of different numbers of participants, forms of measurement, and procedures of the studies is overcome. Meta-analyses therefore allow a comparison between different studies that deal with similar research topics. But meta-analysis has its limitations too, such as that published studies usually provide significant results, thereby overestimating mean effect-size. Also, meta-analysis does not control for the quality of the studies they include, with effect size being influenced by the quality that the research was conducted with. A second method of assessing multiple studies is with the use of a systematic review. A systematic review is a literature review where a clearly formulated question is attempted to be answered, which is done with systematic and explicit methods for identifying, selecting and appraising relevant research.

Qualitative Methods

Next to the quantitative methods that draw conclusions from studies using statistical inference, qualitative methods represent a growing body of methods used in clinical psychology research. They place emphasis on the raw material for research, with analysis being verbal and not statistical. Because the raw data are descriptions the participants make of their feelings, experiences and thoughts, the researcher can gain insight into the daily life of individuals with a certain psychopathology. The qualitative methods are usually open-ended and can also be a good precursor to studies using quantitative methods. Also, qualitative methods allow in-depth study of individuals and interesting things can be discovered which were not initially looked for.

Qualitative Studies: Conducting and Analysing

In qualitative studies participants are usually deliberately assigned to groups, such as those with the same psychopathology. In the first phase participants are undertaken a semi-structured and open-ended interview. Participants can respond to specific but also general questions. The researcher then makes sense of the data, noting down and relating a participant’s re-occurring issues in the responses back to the original research question. The grounded theory presents an approach to organize the gathered information into units. Abstract theoretical insights are formed from identified consistent themes within the data, which then help in forming a refined research question.

Qualitative Methods: Summary

Qualitative and quantitative methods can be combined very well. Often, research in a new area will start with qualitative data and then go over to or develop quantitative methods from there.

Clinical Psychology and Ethical Issues

Ethical committees control for basic ethical standards in research to protect the participant. The three main ethical issues fall under these categories: 1) informed consent 2) causing distress or withholding benefits and 3) privacy and confidentiality.

Informed Consent

The informed consent is requested from participants prior to the study by means of an informed consent form which includes information about the purpose, procedure, duration, confidentiality, whether the participant is paid or participates voluntarily, and that they can leave the study any time without prejudice. The participant should also be given the opportunity to ask questions. Deception is sometimes used in the informed consent to prevent the results from being influenced due to revelation of all details of the study to the participant. This means for example that not all information is revealed of what the study will be about. At the end of the study they will then receive a debriefing, an explanation of any deception or withheld information. At the end it comes down to ensuring that the participation in the study is truly voluntary. A problem with informed consent is that some participants might not be able to make rational decisions about their consent, like children or individuals suffering from mental problems. The consent of children is often obtained by a parent or guardian.

Causing Distress or Withholding Benefits

The researcher needs to be attentive to any indications of stress that might come from the participant, and if this is the case, the study should be terminated or otherwise continued at a point when the participant feels well. A participant should never feel worse after having done a study. If the participant feels distressed after participation, the experimenter should provide a way for the participant to deal with these feelings (e.g. relaxation tape). Also, the ethical question stands whether one should withhold effective treatment in the no treatment control condition from a participant who would be in need for it (such as a new psychotherapy). A good way how to avoid this ethical conflict is to use participants who are on a waiting list for this treatment anyway, who would serve as the no treatment condition called waiting-controls.

Confidentiality and Privacy

Privacy and confidentiality are rights every participant in psychological research has. Confidentiality ensures participants that their data will be treated confidentially, and privacy enables participants to withhold some information that they do not want to provide, such as age or sexual orientation. The informed consent should always indicate who will access the data of the study if it collects personal information from the participant. Confidentiality is not absolute, like in case of illegal or immoral activities being revealed in data collection. For individuals who are in danger of harming themselves, the individual can be provided with reference to appropriate support after the study.

Research Methods Reviewed

Research methods in clinical psychology for psychopathology allow the description of symptoms, the understanding of causes and the assessment of efficacy of interventions and treatment services. Many research methods are based on the scientific approach, which is often criticized for not fitting the investigation of important aspects of psychopathology, such as the phenomenology.

Treating Psychopathology - Chapter 4

Introduction

The GP is usually the first person contacted by individuals experiencing symptoms of psychopathology. The doctor can prescribe medication but also refer the individual to a suitable specialist who can help the individual to deal with his distress.

Treatments for Psychopathology: The Nature and Function

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.

Theoretical Approaches

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 acknowledgement. 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 behaviour, 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 behaviours 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.

Psychoanalysis treatment takes long (3-7 years) to yield benefits and is based on the acquisition of self-knowledge.

Behaviour Therapy

Behaviour 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 behaviour analysis or behaviour modification approach evolved, which uses the principles of operant conditioning, and the behaviour therapy approach, which is based on principles of classical conditioning.

Wolpe (1958) postulated that through the classical conditioning principle of extinction emotional disorders could be cured. Associations between the situation and the threat are in that way ‘unlearned’. Popular techniques used for extinction are flooding, counterconditioning and systematic desensitization, which are all termed exposure therapies. Another principle of Wolpe is reciprocal inhibition, in which an anxiety-incompatible response is attached to the cue that induces the emotion. These techniques are utilized for a wide range of disorders. Aversion therapy tries to condition an individual to feel aversion towards a stimulus that they are wrongly attracted to (e.g. addictive behaviour, distressing sexual activities). Yet, aversion therapy is said to only have a short-lived effect and addictive responses show great resistance to this type of therapy.

Influencing the frequency of a behaviour is the target of operant conditioning. Rewards or reinforcing consequences following a behaviour increase the frequency and punishment or negative consequences following a behaviour decrease the frequency. Three principles are used in therapy: 1) functional analysis 2) establishment of appropriate behaviours by using reinforcers or rewards 3) eliminating problematic behaviour by using punishment and negative consequences. Functional analysis looks at consistencies between problematic behaviours and their consequences, such as a reward that follows a problematic behaviour thereby maintaining it. Another intervention is the token approach, in which tokens are distributed for the desired behaviour and can later be exchanged for a fancied item or activity (e.g. cinema visit). With the response shaping procedure, the frequency of new and desired behaviours is increased, thereby developing new behaviours. A behaviour that occurs already frequently serves as an approximation to the frequency in which the new behaviour should ultimately occur, and reinforcement is given to approximations that come closer to this model. With behavioural self-control, an individual can make personal use of the operant conditioning principles to bring about change in his or her own behaviour. A good example of this is the program developed by Stuart (1967) to prevent overeating.

Cognitive Therapies

Dysfunctional ways of thinking or processing and interpreting incoming information can cause psychopathology. Cognitive therapy tries to identify and change these faulty ways of thinking about the world. Beck’s cognitive therapy and rational emotive therapy (RET) represent two early approaches to cognitive therapy. Rational emotive therapy, by Albert Ellis (1962) focuses on how people construe themselves, their life and the world, and how this creates their feelings. This approach tries to free individuals from irrational and unrealistic beliefs, by which they judge themselves and others, and set more attainable life goals. The aim is to replace these implicit assumptions that the individual carries around with more rational beliefs. Beck’s cognitive therapy for depression requires the individual to provide evidence for the biased views held of the world, helping him or her to come to the conclusion that the existing schemas are irrational. From these approaches, the approach of cognitive behaviour therapy (CBT) was born, which aims to change both thought and behaviour.

The following points are usually part of this therapy:

• The client writes a diary, writing down important events and associated feelings.

• The therapist helps the client identify and challenge dysfunctional beliefs.

• Clients do homework, which allows them to see that their assumptions are irrational.

• For situations eliciting their psychopathology, clients practice new ways of thinking, behaving and reacting.

New forms of cognitive behaviour therapy are developed over time, and these different forms of CBT are described as waves. The first wave of CBT was represented mostly by behaviour therapy based on conditioning and learning. The second wave focuses more on our cognitions, so the way we think. This was also the wave out of which Beck’s therapy developed. The third (and current) wave being developed focuses more on the mindfulness and acceptance of our cognitions. Mindfulness-based cognitive therapy (MBCT) attempts to improve one’s emotional well-being by increasing the awareness of how our automatic responses to thoughts, sensations and emotions can be distressing. This is done by achieving a mental state with a focus on the present-moment while maintaining a non-judgmental attitude. MBCT has been shown to have a positive effect on reducing many symptoms, among which are anxiety and depression symptoms. Another third wave variant of cognitive behavioural therapy is acceptance and commitment therapy (ACT). ACT teaches one to ‘simply’ accept any thought or feelings a person might experience, compared to traditional CBT which focuses on changing these thoughts. When someone applies ACT and accepts their thoughts and feelings, they are not distressed by the negative valence they give to these thoughts, and therefore they might be more successful in clarifying their values and taking action on them.

Humanistic Therapies

Humanistic therapies place emphasis on the client as a ‘whole’ person, such as in holistic therapies, and focus primarily on the individual and his feelings. The therapy should be built on a good client-therapist relationship that allows cooperation, and should enable the client to feel in control of solving his own problems. The most successful therapy of this approach is the client-centred therapy, in which the therapist demonstrates empathy and unconditional positive regard to help the client develop into a well-adjusted, happy individual. The therapist takes the role of the listener and thereby helps the client to grow and move from one phenomenological state to another.

Family and Systemic Therapies

The family therapy is helpful if psychopathology is caused by communication and specific conflicts between family members. The systems theory attempts to re-mold the relationships within a family, especially the relationship between the two parents, so it can function well again. In therapy it is explored how the problem affects functioning of the family and usually the emphasis does not lie on the cause of the problem but rather why it is maintained. The goal is to identify patterns of interaction in the family that are unknown to the members. The therapist will then offer them other ways of responding to each other that are more effective.

Drug Treatments

As a common first line treatment, drug treatments come in various forms. Antidepressant drugs are prescribed against depression and mood disorders, anxiolytic drugs treat symptoms of anxiety and stress, and antipsychotic drugs deal with symptoms of psychosis and schizophrenia. The first drug against depression, which increased the amount of norepinephrine and serotonin available for synaptic transmission, was called tricyclic antidepressants. This was around the year 1960, and other antidepressants that came on the market during that time were the monoamine oxidase (MAO) inhibitors. If a patient with major depression has not responded to any medication, MAOIs can be effective for some. Bipolar depression and panic disorder can also be treated effectively with MAOIs. Newer types of drugs that have developed (e.g. against depression), such as fluoxetine, sertraline, paroxetine and citalopram, are collectively referred to as selective serotonin reuptake inhibitors or SSRIs. They affect the uptake of only serotonin and produce fewer side effects than for example tricyclic antidepressants that yield the same effects in reducing symptoms of depression. Recent studies have suggested that antidepressants are only more effective than placebos for those suffering from major depression, and that they are not more effective than placebos for people suffering from milder versions of depression. Prevalent disorders of anxiety, such as specific phobias, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder (GAD), and post-traumatic stress disorder, can be treated with benzodiazepines. They increase levels of the neurotransmitter GABA at synapses in the brain and should be taken for short periods only to avoid dependency.

Due to the development of antipsychotic drugs the prognosis and view of sufferers of schizophrenia has changed a lot with the time spent in psychiatric institutions having come down to 2 months, when before the introduction of the drug in 1980 the patients spent most of their lives in a psychiatric institution. Antipsychotic drugs, reducing high levels of dopamine in the brain, can target the major positive symptoms but also the major negative symptoms, but also have side effects (e.g. blurred vision, muscles spasms) that lead the patient to stop taking the drug often times. Even though drug treatment is mostly effective, they give an individual the constant feeling of having a disease and being dependent on the drug to alleviate symptoms. There is also evidence that holds that drug treatment worsens a disorder seen over long-term and increases likelihood of relapse. Drug treatment paired with psychological treatment yields most effective results.

Treatment Delivery

With the rising demand of psychotherapy, more cost-effective and efficient ways of administering therapy have been developed.

Group Therapy

Group therapy is a form of therapy that is useful if an individual benefits from comfort provided by the other members and from the presence of other people that share the same problem and that can help to treat certain psychopathologies in which being surrounded by people plays a role. Different forms of group therapy are: experimental groups and encounter groups in which self-growth is fostered through disclosure and interaction and self-help groups in which a common problem is the basis and members support each other through the sharing of information.

Counselling

Counselling provides the opportunity for personal-growth and productivity of an individual. This approach has become popular in the last 20-30 years, also because of the greater demand of support and treatment. Counselling can also help in resolving problems of underlying psychopathology. Counsellors differ in approaches they use and also specialize in specific areas. This gives the names to counselors such as mental health counsellor, marriage counsellor or student counsellor, and often there is direct service provided for people with specific medical conditions and their care-takers.

Computerized CBT (CCBT)

As the name already says, Computerized CBT works with software packages that can be used independently by clients. Two CCBT packages are recommended by the UK Department of Health, Beating the Blues for moderate to mild depression, and Fear Fighter for managing panic and phobia. Beating the Blues was found to be more effective than a GP treatment for depression and anxiety.

E-therapy

With the rise of the internet, e-therapy has evolved into an effective add-on to conventional therapy. Treatment can be continued over distance, the client’s behaviour can be monitored daily and family members of the client can communicate that way with the therapist as well. Furthermore the client can initiate contact with the therapist easier, which is especially good if the client is shy in personal interviews or lives in a remote area. Drawbacks of online communication are miscommunication, effective intervention when a client is experiencing a crisis and difficulty to ensure confidentiality.

Therapy by Telephone

Telephone therapy, an accepted and effective approach, has proven to be more effective than drug treatment with antidepressants up to 12-18 months after treatment. This form of therapy can be cost-effective by saving on travel costs and thereby also less time consuming.

Mental health problems not only affect the people suffering from it, but also the economy. Much money is spend on mental health care and lost because of individuals suffering from mental problems. Because of this, many countries are now working hard to supply better access to therapies such as CBT, which has proven its efficacy. Improving Access to Psychological Therapies is a programme by NHS which provides services across the UK for people suffering from anxiety or depression disorders. In order to do this, they:

• train many practitioners therapies such as CBT, and these people get known as psychological well-being practitioners (PWPs)

• improve the access to treatment and reducing its waiting times

• increase the client choice and satisfaction

The money that is spend on programmes like these are thought to be well returned by the money saved because of people gaining more access to therapy, which results in more people returning back to work.

Treatment Evaluation

Evaluating treatment is not as easy as it sounds, as one has to take in 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 out 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.

Evaluation of Treatment: Affecting Factors

A client’s rating that therapy was effective does not mean that there has been a therapeutic gain, and if there has been a therapeutic gain it does not mean that this was an outcome of the specific type of therapy used. A treatment high in internal validity means the treatment is effective due to the principles it contains.

Spontaneous Remission

Spontaneous remission can be a confounding factor when assessing the effectiveness of a treatment, because it means that over time the people with disorders will get better anyways, without structured treatment. The rate of remission is currently 30%.

Placebo Effects

When individuals expect to get better by taking a medication for example, they simply get better just by the expectation of improvement. When this happens the placebo effect occurs, but it only holds for a short time and actual psychotherapies show more improvement.

Unstructured Attention

Befriending is a way how to compare effects of structured therapy with the effects of simple social support (attention, understanding and caring) to see if it is the principles contained in the structured therapy that produce improvement. Befriending acts as a control condition in which the therapist applies social support, but does not directly target symptoms. Topics of the interview are usually neutral (e.g. hobbies).

Assessing Effective Treatment: Methods

Some forms of therapy do not start with the assumption that the success can be quantitatively or objectively measured, because they focus on the reconstruction of the client’s world. Nevertheless, being able to assess treatment is important to provide some sort of a benchmark measure.

Randomized Controlled

Randomized controlled trials (RCTs) use a variety of control conditions and possibly also other forms of treatment to see how they compare to the treatment being assessed. Random assignment is used to place participants into a control group, either 1) a no treatment or a waiting-list control group 2) an expectancy and relationship control group and 3) a comparative treatment group. A therapy is said to possess internal validity and be effective if it is more effective than groups 1 and 2 and at least as effective as group 3 named above.

Limitations:

• Drop-outs are common, especially in no treatment conditions.

• RCTs take a lot of time and are expensive.

• Some participants may like some types of therapy better than others, and in random assignment this is not controlled for.

Objectivity is hard to obtain in RCTs, and explicit or implicit bias is often seen. First, an allegiance between a researcher and the psychotherapy tested is common, and this can increase the experimenter bias resulting in biased statements about the psychotherapy. A second form of bias is that many papers containing valuable data are not published, and therefore often not considered when making statements about something. There can be three studies supporting a hypothesis and 100 failing to accept the hypothesis. But the three studies supporting it are often more interesting, and are therefore more likely to be published, and the other 100 might be forgotten about, therefore one can make statements about studies supporting a hypothesis. Third, it has been shown that studies about the effectiveness of a treatment are more often claimed significant when it is funded by some industry. Lastly, most research only tells us something about the comparison between a treatment group and a control group, and they don’t mention anything about individuals recovering from a condition (known as recovery rates) or the percentage of participating individuals exhibiting clinical significant change resulting in them no longer meeting the criteria for a clinical diagnosis (clinical significance).

Meta-analysis

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.

Effective Treatments

Most contemporary, accepted therapies seem to be more effective than no therapy, but when compared to each other, no therapy is significantly better than the other. This is also known as the Dodo Bird Verdict, an expression from Alice’s Adventures in Wonderland.

Characteristics that can be commonly found in successful therapists include giving good feedback, helping clients gain self-efficacy and autonomy and supporting clients so they can understand their own thoughts and further their relationships. In a large-scale study where clients were asked to rate their satisfaction of the psychotherapy, they mentioned:

• Significant benefit from the therapy.

• It did not differ to psychotherapy plus medication in comparison.

• The types of therapists were equally effective and.

• The longer the treatment was the more they gained from it.

Anxiety-Based Problems - Chapter 5

Introduction

An anxiety disorder is “an excessive or aroused state characterized by feelings of apprehension, uncertainty and fear (Psychopathology, Graham Davey). 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. An individual experiences comorbidity if they experience several anxiety 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.

Specific Phobias

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 life time prevalence of 16%, which is higher than the men’s 7% life time 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.

Specific Phobias and Aetiology

A common debate is whether phobias are learned or acquired through evolution. A view held today is that different ways of acquisition go with different phobias. Phobias under the psychoanalytic view are defences against anxiety coming from id impulses that were repressed. This is a way of avoiding confrontation with the real conflict. Symbolic interpretation of case histories in psychoanalysis can serve as a source of insight.

The popular study of “Little Albert” (1920) still stands today as an example of classical conditioning as an explanation for phobia. Yet, criticism of the classical conditioning explanation are:

• While the classical conditioning approach says traumatic experiences are necessary for conditioning, some phobics cannot remember such an event at the point when they acquired their fear.

• Even if an individual experiences a traumatic event, it does not necessarily mean that a phobia will be acquired.

• Phobias are usually limited to a specific group of stimuli, even though in the simple conditioning model all stimuli should be equally likely conditioned. Also, stimuli that pose a danger that did not exist in the old age, such as an electricity outlet, are less likely to be associated with aversion or danger, even though they pose a potential source of danger as well.

• The clinical phenomenon of incubation cannot be applied to the simple conditioning model. Instead of growing fear with more and more encounters of the stimuli, the conditioning model postulates that extinction should rather occur.

At least some phobias can be explained by the occurrence of traumatic conditioning experiences, but not all.

People acquire phobias of life-threatening stimuli that have always existed, but rarely of stimuli that pose a danger that have only recently evolved. The first theory by Seligman called biological preparedness proposes that if we avoid stimuli that have been dangerous to our ancestors we will have a greater chance of surviving. An experiment showed that people are more easily conditioned with a picture of a fearful stimulus together with an electric shock than if it is a picture of a non-fearful stimulus, and are more resistant to extinction. The second theory by Poulton and Menzies argues that adult phobias can be explained by a failure of normal habituation, which usually occurs in childhood when children are first frightened of a stimulus but after several exposures the fear disappears. The evolutionary account is not easy to verify, because of possible post-hoc construction of evolutionary explanations. According to the adaptive fallacy any stimulus can be explained by coming up with a threatening consequence for it.

With functional neuroimaging techniques, we can look at specific brain regions playing a role in specific phobias. The key structure mediating fear responses to phobic stimuli is the amygdala. It is involved in forming and storing memories associated with emotionally-relevant events. It coordinates this with info from subcortical nuclei and higher cortical areas and then relays feedback to the thalamus, which coordinates motor responses. It has also been seen that BII phobia and dental phobia are different in the way that they affect the brain, since it can result in a decrease of parasympathetic response resulting in fainting.

Phobias are acquired in different ways depending on the type of phobia. Not all phobias are acquired through the occurrence of a traumatic event, and might be acquired over long-term and gradual experiences that the individual is not always aware of (mostly in animal and height and water phobias). There is evidence that disgust, a food-rejection emotion, plays a role in small animal phobias and blood-injury-injection phobia. The disease-avoidance model states that an individual with high level of disgust sensitivity is more prone to acquiring an animal phobia. Also there is evidence for a link between specific phobias and panic and panic disorder. Comorbidity rates lie between 40 and 65%, meaning that people with specific phobias also often suffer from panic, especially those with situational phobias. Claustrophobia and height phobia have close links to panic disorder, because sufferers also hold anxiety expectations and focus on bodily sensations. In height phobia ambiguous bodily sensations are experienced as threatening, which is common in panic disorder.

Treatment

Exposure therapy offers an individual suffering from a specific phobia to overcome their dysfunctional beliefs by experiencing that they do not take place when exposed to the feared stimuli. This form of therapy together with cognitive therapy techniques can yield results in just a 3-hour session.

Social Anxiety Disorder

Individuals experiencing social anxiety disorder fear social situations and try to avoid these because they are afraid of negative evaluation or that they will embarrass themselves. Sufferers may also experience problems with depression and substance abuse. The lifetime prevalence rate lies between 4 and 13% (for western societies), with females being affected more than males. Onset is in the early to mid-teens, usually before turning 18. From all main anxiety disorders it has the lowest remission rate. There are cultural differences in prevalence rates, with Southeast Asian countries showing lower rates than Western countries.

Aetiology

Social anxiety disorder is not put in the same category as simple phobias in DSM-5 because social anxiety is central to the aetiology of social anxiety disorder and information processing and interpretation biases are involved. Social anxiety disorder can be compared to generalized anxiety disorder (GAD) in its prevalence as being the most common anxiety disorder.

Genetic Factors

There is more and more evidence that genetics might reflect a component of social anxiety disorder. Twins studies reveal moderate genetic influence and parents with social anxiety disorder often times have children with social anxiety disorder. Submissiveness, anxiousness, social avoidance, and behavioural inhibition (where children seem quiet and isolated) seem to have a genetic component in social anxiety disorder. A different account proposes that social anxiety disorder shares genetic components with other anxiety disorders. Yet, the possibility is proposed that there is an inherited and unique element specific to social anxiety disorder that makes up 13% of the variance in social fears. There is evidence that children that have an inhibited temperament style are more likely to acquire social anxiety disorder. Because social anxiety disorder occurs at such an early age in comparison to most main anxiety disorders, there is the argument that developmental factors contribute to the acquisition of social anxiety disorder. Individuals suffering from social anxiety disorder have parents that control them more, discipline them using shame as a tool, are in general colder and do not socialize as much. If those are actual causal factors cannot be said at the moment. Sufferers of social anxiety disorder believe more than any other group of sufferers of anxiety disorders that a negative social event will occur, which makes them avoid social situations. Also, they are more critical when judging their own performance and do not process positive social feedback as easily. This supports the maintenance of dysfunctional beliefs that a social phobic holds. When self-focused attention occurs during a social performance, a social phobic directs attention onto himself and his anxiety, and this leads to their belief that people can see how anxious they feel inside. They take on an observer’s perspective rather than a personal perspective. This is known as self-focused attention, which in a way acts as a distractor from the actual task, and prevents the individual from best performance. After a social event, a social phobic engages in post-event rumination in which critical self-evaluation is practiced.

Treatment

An effective way of treating social anxiety disorder can occur by administering cognitive behaviour therapy and pharmacological treatment. CBT treatments that are effective include:

1. Exposure therapy, in vivo or with the therapist playing a stranger.

2. Social skill training with modelling, behavioural rehearsal, corrective feedback and positive reinforcement.

3. Cognitive restructuring, challenging dysfunctional beliefs and reducing self-focused attention.

The best approach is combining pharmacological treatment (MAOIs, SSRIs, benzodiazepines and beta-adrenergic blockers have all been found to be effective) with cognitive-behavioural therapy, with the former providing immediate gains and the latter ensuring long-term effectiveness.

Panic Disorder

In panic disorder a person repeatedly experiences panic or anxiety attacks. They are accompanied by physical symptoms that occur in great variety (e.g. dizziness, nausea, heart palpitations). Many will experience a feeling of terror or depersonalization, a feeling of being disconnected from one’s body or surrounding. The diagnosis of panic disorder is made when the attacks occur repeatedly and unexpected, and when the individual suffers from at least one month of concerns of experiencing another attack. Panic attacks may either occur through association with a specific situation or they occur unpredictably. In an attack a peak is reached within 10 minutes consisting of intense fear and the development of a number of symptoms. Panic disorder often occurs together with agoraphobia, because the person tries to avoid unsafe, public places where an attack could occur, and therefore they often stay home. Agoraphobia is a separate diagnosis represented in the DSM-5, and is characterized by feelings of fear and/or anxiety of a place where the individual feels either trapped or unsafe, with a strong urge to return to a safe place like home. Sufferers often do not leave the house, or only rarely with trusted friends and family. Due to this fear of leaving their safe place, they become severely disabled in daily life and often have to rely on others to assist them with basic tasks like grocery-shopping.

Onset occurs in early adulthood or in adolescence, often after a stressful life period. Prevalence rates lie between 1.5 to 3% for panic disorder and 0.4 to 3% for agoraphobia, with women suffering more often from either of them. There is a cultural difference in manifestation and variance in prevalence of the disorder. In Western cultures individuals deal with panic disorder by employing avoidance and withdrawal strategies, while Latinos show their distress in an external form (e.g. screaming).

Aetiology of Agoraphobia and Panic Disorder

Biological factors were often a focus in finding causes for panic disorder, but now it has become acknowledged that psychological and cognitive factors also contribute to the aetiology and maintenance. Because agoraphobia only recently become a distinct disorder in the new DSM-5, not much research has been spent on its aetiology. Therefore the following theories are focused on panic disorder.

Hyperventilation plays a central role in panic attacks. Through the rapid breathing, the blood pH level is raised and body cells receive less oxygen, which in turn produces cardiovascular changes that ultimately create symptoms of panic attacks. These symptoms are recognized by the individual as anxiety. Evidence for this comes from biological challenge tests that artificially create panic attacks. Suffocation alarm theories propose that increased CO2 intake may activate an alarm system that is overly sensitive to suffocation and therefore produces the typical anxiety of a panic attack. More than patients of other anxiety disorders, patients of panic disorder often report problems with a feeling of suffocation and shortness of breath during phases of anxiousness. Yet, when told to hold their breath, they do not experience more anxiety than control subjects, meaning a more sensitive suffocation alarm system is not present. Interpretation of the physiological changes seems to be a critical point of the causal factor in panic disorder, as induced symptoms only create a full panic attack for individuals that have suffered from repeated panic attacks before.

Norepinephrine plays a role in the aetiology of panic disorder. The proposition of overactivity in the noradrenergic neurotransmitter system holds that there is a deficiency of gamma-aminobutyric (GABA) neurons in patients with panic disorder and GABA neurons have the task of inhibiting noradrenergic activity.

Goldstein and Chambless (1978) have worked with the classical conditioning approach, according to which a predictor of a panic attack is the internal conditioned stimulus (CS), established by the experienced internal cue (e.g. dizziness). Bouton, Mineka, and Barlow argues that anxiety precedes an attack, which is the learned reaction (CR) to detected cues (CS), and that panic is a way of handling the existing trauma.

Anxiety sensitivity explains that sufferers of panic disorder acquire a set of beliefs that symptoms will bring about consequences that will cause them harm, which in turn leads them to fear anxiety symptoms. Non-clinical controls or individuals with different anxiety disorders score significantly lower on the Anxiety Sensitivity Index than individuals with panic disorder.

Often times bodily sensations are ambiguous and panic disorder sufferers interpret these sensations directly as threating, making it a catastrophic misinterpretation of bodily sensations. This causes the anxiety which leads to a panic attack. Individuals with panic disorder pay more attention to bodily sensations. The expectancy of the attack is critical, as when participants were given compressed air, which they were told was CO2, they had a panic attack nevertheless. Hence, there is a cognitive bias in the interpretation of and reaction to bodily symptoms.

Even though some sufferers experience many panic attacks, they often do not seem to realise that the feared outcome never happens. This happens because of developed safety behaviours, which are certain behaviours that are automatically done by sufferers when they believe they are having a panic attack. This automatic behaviour is then thought of to be the reason why some catastrophic outcome didn’t occur, therefore they continue doing it every time, resulting in the maintenance of anxiety. Because of this big role they play in the maintenance of anxiety in panic attacks, it is one of the key behaviours that should be modified or eliminated in therapies.

Treatment

Effective treatments include psychoactive medication (usually as first line treatment), tricyclic antidepressants and benzodiazepines, structured exposure therapy, and cognitive behaviour therapy (CBT). In exposure therapy, the bodily experiences that precipitate a panic attack are induced and physical and cognitive techniques can be used to deal with the symptoms of panic in a safe condition. Cognitive therapy aims to achieve success by having the individual learn through information and experiences that their beliefs are dysfunctional and that their responding is faulty. A program would include educating the individual about the nature and physiology of panic attacks, breathing training for controlling hyperventilation, cognitive restructuring therapy, interoceptive exposure, and the prevention of safety behaviours.

Generalized Anxiety Disorder (GAD)

People with generalized anxiety disorder consistently worry about future events due to the anxiety they experience in regard to them. Worrying is no longer experienced as a normal reaction to some events, but becomes chronic and is directed to issues that other people would not even consider a threat. The individual feels their worrying is not under control, neither being able to control beginning nor end of a bout of worry. They also engage in catastrophizing (magnification) of worries and the problem does not seem to get better, but rather worse through the continuous worrying. Physical symptoms such as fatigue, muscle tension, nausea, headache and trembling may also be present. A diagnosis of GAD based on the DSM-5 can be made if the person exhibits:

• Unreasonable much fear or anxiety relating to multiple areas such as health, finance, family, work, school etc.

• Fear relating to at least two of the above mentioned areas and accompanying severe anxiety lasting for at least three months.

• Restlessness, agitation or muscle tension is seen besides anxiety.

• Behaviours such as frequent reassurance seeking, avoiding areas of activity relating to anxiety, an excess of procrastination or excess effort preparing activities are also seen as a result of the anxiety

There is a high comorbidity rate with other anxiety disorders and depression and there are double as much women suffering from GAD as men. The lifetime prevalence rate of GAD is more than 5%. GAD is also associated with a significant impairment in the sufferer’s psychosocial functioning, role functioning, health-related quality of life and work productivity.

Aetiology

There is the suggestion that there is an inherited component in GAD. Yet, because of only modest evidence of a specific genetic component, most focus is on the psychological and cognitive accounts. However, some recent neuroimaging studies have shown that the prefrontal brain areas are implicated in extreme worry, and that some areas important in emotional regulation seem to be less active, suggesting that a diminished capacity for emotional regulation could be associated with GAD.

There is experimental evidence that sufferers of GAD pay more attention to threatening stimuli and information, with information processing biases supporting the maintenance of bouts of worries and perceived threats. Anxious individuals also show a threat-interpretation bias, meaning that they interpret ambiguous stimuli more often as threatening or negative. Attention is pre-attentively directed to threatening stimuli, to verbal stimuli and pictures of threatening emotional faces. Opposing to that, people that are not anxious deliberately avoid attending to threatening stimuli. Information processing biases may be the cause for experienced anxiety. Evidence from studies inducing information processing biases show that this leads to changes in state anxiety and to threatening interpretation of new stimuli. It was thought that anxiety causes threat-interpretation biases, but it seems to be the other way around, learned threat-interpretation biases result in elevated levels of anxiety. Therefore attention bias modification (ABM) was created, which is a treatment where biases are reversed.

Individuals with GAD hold the dysfunctional belief that by worrying they can prevent future catastrophes, which motivates them to continue worrying. Another account holds that this chronic worrying takes the function of a distractor from other negative emotions or phobic images that are even more stressful. This can be supported by the evidence that little physiological or emotional arousal is produced by worrying. Another theory focuses on metacognitions, which are overarching processes responsible for our thinking. Metacognitions are responsible for adaptive thoughts of worry in order to anticipate and avoid problems and if they occur, find solutions. However, sufferers from GAD have developed beliefs about worrying which makes it distressing on one hand, but they also find worrying positive as it helps them avoid and solve problems. This contradiction causes problems.

Worriers do not tolerate uncertainty, they are perfectionists and feel responsible for negative outcomes. The individual tries to resolve the problems, but this gets hindered through feelings of doubt to successfully solve the problem.

Treatment

A crucial point is deciding which treatment works best for successful therapy outcomes of GAD. Psychological therapies, such as CBT or self-help programs are usually the best option for a long-term treatment success, but if the patient experiences suicidal intentions or other extreme stress, medication can be used for first management of the problem. Also, it should be considered what approach is effective at what point in treatment, regarding symptom severity and what the client prefers.

Anxiolytics such as benzodiazepines are often thought of as the best prescribed drug for anxiety GAD. However, more than 50% are prescribed antidepressants (SSRI’s or SSNI’s) as they have been proven effective, and ‘only’ 35% are prescribed benzodiazepines. The use of antidepressants makes sense because they are better tolerated by patients, and anxiety is often comorbid with depression.

Psychological treatments are developed out of behavioural and cognitive methodologies, and an example is stimulus control treatment, which works by helping the client minimize the contexts in which they can worry, such as only at a certain time of day or in a specific location.

These elements are included in CBT to provide relief from cognitive biases and dysfunctional beliefs:

• Self-monitoring: clients become aware that they cognitively construct future events and that these are not real and hence will most likely not occur.

• Relaxation training: these types of techniques, such as progressive muscular relaxation, yield same effects as some forms of cognitive therapy.

• Cognitive structuring: dysfunctional thoughts and biases are challenged and replaced with more accurate thoughts. Achieving this can be aided by the use of an outcome diary. Another form is metacognitive therapy, where metacognitive beliefs are challenged.

• Behavioural rehearsal: coping strategies are applied when a worry is triggered. This can be done through imagined or actual rehearsal.

Obsessive-Compulsive Disorder

An individual suffering from obsessive-compulsive disorder (OCD) experiences obsessions and compulsions, the former being characterized by intrusive and recurring thoughts and the latter by repetitive or ritualized behaviour patterns. The thoughts are seen as uncontrollable by the individual and he or she engages in rituals to prevent a negative outcome. The ritualized behaviour is also seen as a way to reduce stress and anxiety. This can take place in the form of repetitive behaviours (e.g. hand washing, checking) or mental acts (e.g. counting, repeating words mentally). The sufferer knows that these excessive compulsions are irrational and experiences the obsessions and compulsions as unpleasant. Common obsessions are fear of contamination, unwanted sex, thoughts about harm, and fear of accidents.

Life time prevalence of OCD is about 2.5%, with more women being affected. OCD is characterized by onset in early adulthood or early adolescence. This is true regardless of cultural background, with the exception of more religious and aggressive obsessions being present in Brazilians and Middle Easterners. OCD is now a separate chapter in the DSM-5, and the criteria for it are:

• Presence of obsessions like unwanted and repeated thoughts, urges or images which the individual wants to ignore and/or.

• Experiencing compulsions compelling the sufferer to carry out and repeat certain behaviours or mental activities.

• The sufferer believes that these actions must be carried out in order to prevent some sort of catastrophic outcome, which is illogical and has no connection to the behaviour.

• Compulsions and obsessions cause difficulty in a person’s life and consume one hour or more of a person’s day.

Some OCD-related diagnostic categories are:

Body dysmorphic disorder: an obsession with ones perceived flaws or defects in their physical appearance

Hoarding disorder: a sufferer’s difficulty discarding possessions resulting in a living area severely congested by clutter.

Hair-pulling disorder (trichotillomania): the compulsively act of pulling out one’s own hair.

Skin-picking disorder: recurrent picking of the skin resulting in skin lesions.

Aetiology

OCD can begin after a traumatic brain injury, creating a neurophysiological deficit that produces the ‘doubting’ characteristic of OCD. The frontal lobes and basal ganglia seem to play a role in this. Another account of ‘doubting’ holds that basic information processing and executive functioning are impaired in sufferers of OCD, alongside with spatial working memory, spatial recognition, visual attention, visual memory, and motor response inhibition deficits. There is also the argumentation that compulsions are produced from genetically stored and learned behaviours that cannot be inhibited by the brain, mostly involving the inhibitory pathways projecting via basal ganglia.

With ‘doubting’ being a main component in OCD, it is suggested that OCD might involve a general memory deficit, and also less confidence from the client’s side that the memory reviewed is correct and whether a memory was real or imagined. However, recent evidence shows that doubting in OCD may not be due to a deficit in memory, but due to a general deficit in executive functioning instead. It is also consistent with much evidence showing that the lack of confidence in ones recall is a consequence of the compulsive checking, so the more one checks, the less confident they end up being about what they checked.

Clinical constructs are constructs that describe a combination of thoughts, beliefs, cognitive processes, and symptoms that are seen in psychopathology. These constructs are then observed to see how symptoms are affected by cognitive factors. Three constructs now looked at are inflated responsibility, thought-action fusion, and mental contamination.

A main feature of OCD is that sufferers feel that they hold responsibility for the content of their thought. They also believe that there are potentially harmful consequences to their obsessional thoughts. Another dysfunctional belief is that of inflated responsibility, which means an individual believes he can prevent harm and that it is his or her responsibility to make sure that this negative outcome does not occur. In an experiment, inflated responsibility was induced, which subsequently caused an elevated amount of compulsive checking.

Believing that one’s thoughts are like actually performing them or that one’s thoughts will come true, is known as thought-action fusion. It is commonly seen in OCD, and is best described as thinking that one’s thoughts can (in some way) directly affect whatever happens in the world. If the believed action is negative, trying to suppress the thought and action can be quite effortful, causing significant distress in the person.

Feelings of ‘dirtiness’ caused without any physical touch can be provoked by thoughts of specific images or memories, or they can be provoked by emotional experiences like humiliation, betrayal or degradation. These thoughts cause mental contamination, and can be a reason why one has to compulsively wash themselves.

Individuals with OCD engage in thought suppression if they encounter an intrusive thought. The ‘rebound effect’ says that suppressing thoughts will make them come back in greater frequency once suppression is stopped. Suppression of intruding thoughts creates a negative emotional state which becomes associated with the intruding thought. Experiencing this negative emotion at some other point in time will then elicit the intrusive thought.

In OCD a critical feature is that of perseveration, meaning an individual with OCD engages in longer perseveration of an activity than non-OCD sufferers. They themselves recognize it as excessive and unpleasant. The mood-as-input hypothesis explains that the current mood is a way of measuring whether a task was completed with success or not. Regarding the nature of OCD, the sufferer feels a strong negative and anxious mood during the task, which leads him or her to feel that they never successfully completed it. The ‘stop-rule’ says one must continue until the task is completed successfully, which is perpetuated by the inflated responsibility. Inflated responsibility has to occur with negative mood together though so an individual will persevere at a compulsive activity.

Treatment of OCD

The most effective treatment is exposure and ritual prevention (ERP), which consists of two components. The first component aims at graded exposure to what elicits the distress. In the second component, the goal is to prevent the client from following their rituals, by which anxiety is extinguished and dysfunctional beliefs are disconfirmed. When rituals are abolished, anxiety is not negatively reinforced anymore. Long-term effectiveness of the treatment lies at 75% and it is flexible in its application.

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.

Pharmacological and Neurosurgical Treatment

Even though pharmacological treatments, usually serotonin and SSRIs, are effective, they have a high relapse rate when medication is not continued. Tricyclic antidepressants are effective if OCD occurs together with depression. Psychological treatment such as ERP has equally good short-term effects as drug treatment, does not produce side effects and yields better results in the long-term. Neurosurgery such as cingulatomy is a last resort treatment when all other approaches have failed.

Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)

In post-traumatic stress disorder (PTSD) a causal factor for the symptoms is the identification of exposure to a specific fear-evoking event. PTSD is characterized by symptoms that follow a fear-evoking traumatic event (e.g. war, rape, abuse). The symptoms are grouped in three categories: increased arousal and reactivity, avoidance responding, negative changes in mood & cognition and intrusive symptoms. In the DSM-5, severe (but not life-threatening) stress has been added under the possible causal factors in PTSD, which sparked controversy due to facilitating the faking of symptoms. The diagnostic criteria are:

1. Death or threatening death is experienced to oneself or is being witnessed.

2. Flashbacks or intrusive images or thoughts of the traumatic event are re-experienced.

3. Stimuli that are associated with the trauma are avoided.

4. Two or more changes to mood and/or thought processes (e.g. feeling disconnected, reduced interests, inability to remember moments of the traumatic event)

5. Constant experiencing of symptoms for over a month such as increased arousal, with sleep difficulty, anger outbursts, concentration difficulties, hypervigilance and startle response. This causes the individual to be impaired in occupational or social functioning.

6. Symptoms worsened or started after the traumatic event and lasts for at least a month

At least between 1 and 3% of people experience PTSD at one point in their lifetime, with women being more vulnerable to developing PTSD and culture differences existing between Caucasian disaster victims and Latinos or African Americans.

Acute stress disorder (ASD) is very similar to PTSD, but characterized by a shorter duration (3 days to a month). The symptoms exhibited are basically the same of PTSD. There is debate whether or not ASD is a disorder or just a normal way of reacting to some disturbing events. ASD is also seen as a potential precursor for PTSD by some, whether this is true is not yet determined.

Aetiology of PTSD

There are five main theories which aim to explain PTSD, all concentrating on different features of the disorder: avoidance and dissociation, conditioning theory, emotional processing theory, ‘mental defeat’, and dual representation theory.

Studies have led to finding a genetic element to PTSD, and the heritability component has been estimated to be 30%. Therefore it has been suggested that PTSD develops from an interaction between a biological vulnerability and an extreme traumatic experience. Some biological causes for a vulnerability to PTSD are speculated to be:

• An underdeveloped hippocampus (of which it is known to be critical in relating memories to emotions)

• Failure of areas like the ventromedial frontal cortex in controlling fear centres such as the amygdala

• Heightened startle responses due to genetics, and fear-related hormonal secretion

Since not all people develop PTSD following a life-threatening event, some individuals must be vulnerable to developing it. Factors that contribute to this include feelings of responsibility for the traumatic event, having experienced instability in the family life, history of PTSD in the family, higher levels of anxiety or suffering from another psychological disorder. People with high intelligence are a lot more resistant to PTSD than people of low intelligence, which can be led back to the ability to develop coping strategies. Also, the experiences which are reported by the victims indicate how information about the trauma was processed and stored.

Individuals exhibiting avoidance or dissociation coping strategies are more likely to develop PTSD. Avoidance coping strategies are seen in individuals who actively try not to think about their trauma. Feeling detached from one’s mind and body is known as dissociation, and if an individual experiences this coping strategy right before or during a traumatic experience, they are known to be of higher risk for developing PTSD.

The conditioning theory works with the explanation of classical conditioning, saying that when individuals encounter cues that were associated with place and time of the trauma, they trigger the same experience as that of the trauma.

A PTSD sufferer will avoid contexts that will trigger associations to the trauma. It becomes difficult for cues associated with the trauma to be associated with positive associations again. Because the event holds such a strong significance, the formed associations are unlike those from everyday experiences. This is called the emotional processing theory.

If an individual adopts the mental defeat view, then they take on the role of feeling like a victim, and see the world as negative and also recall the trauma according to those feelings and views. Maladaptive behaviours and cognitive strategies may be adopted that support the maintenance of PTSD. An account by Ehlers and Clark holds that the sufferers do not see the event as part of their life, because they feel they are not in control over it. They feel as if they cannot change the course of their life anymore and that the traumatic event has changed it in a permanent way.

In the dual representation theory there are two separate memory systems, the verbally accessible memory (VAM) system and situationally accessible memory (SAM) system, the former recording conscious memories from the time of the trauma and the latter registering information that was not recognized consciously because it occurred too brief. The SAM system hence stores sensory and response information. Evidence supports this theory, both systems being linked to the amygdala and findings showing that PTSD sufferers explain the flashback periods in an elaborate and detailed way, frequently mentioning death, horror, fear, and helplessness.

Treatment

Treating PTSD has two aims. Preventing the development of PTSD and if this is (partly) unsuccessful because symptoms do appear, treatment of the symptoms. If the latter is the case, most treatments rely on some form of exposure like flooding, EMDR and cognitive restructuring.

In order to prevent an individual from developing PTSD after a traumatic life event, there has been an established intervention called psychological debriefing, or immediate and rapid debriefing, that is administered within 24-72 hours of the occurrence of the event. Techniques such as critical incident stress management are used where the individual can express his feelings and experiences, is reminded that he is a normal person that had to experience such an event and can learn coping strategies. Yet, psychological debriefing does not separate people that would not develop PTSD in the first place from those that would and that need long-term support. Also, there is lacking evidence of the effectiveness of rapid debriefing.

The extinction of associations between trauma cues and fear responses and the disconfirmation of dysfunctional beliefs is aim of the effective exposure therapy. Exposure is achieved by the client depicting the situation in a written narrative or with computer-generated imagery. Imaginal flooding is a further technique in which the client is supposed to visualize the traumatic event for a long period of time. This is often paired with graded in vivo exposure. Exposure therapies are more effective than medication and social support, as studies show. In another critically-judged form of PTSD treatment, called eye-movement desensitization and reprocessing (EMDR), the client follows the therapist’s finger, moving backwards and forwards, while concentrating on a traumatic image or memory. The fearful images are thereby reconstructed and deconditioned.

In cognitive restructuring the aim is to change the individual’s dysfunctional beliefs about the world and themselves, acquired from the trauma, and exchanging negative or intrusive thoughts. Foa and Rothbaum suggest that the two dysfunctional beliefs an individual with PTSD holds are: “The world is a dangerous place” and “I am totally incompetent”. Chronic PTSD is the result of avoiding situations which could disprove the dysfunctional beliefs. While exposure therapy disconfirms these beliefs, cognitive therapy aims to change PTSD-related cognitions, but findings show that a therapy combining these two approaches does not achieve changes in dysfunctional cognitions.

Depression and Bipolar Disorder - Chapter 6

Introduction

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, behavioural, physical, and cognitive domains. Mania is the emotion opposite of depression, and it is characterized 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. Behavioural 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.

Major Depression

Diagnosis and prevalence of Major Depression

One of the two main types of depression is major depression. It is characterized by relatively long periods of clinical depression causing significant suffering in the patient, and also impairing their social and/or occupational functioning. Another used term for major depression is unipolar depression. Due to changes in the DSM-5, major depression is now diagnosed only when a single major depressive episode has occurred, and the symptoms must have caused clinically significant impairment or distress in social, occupational, or other types of functioning. A major depressive episode consists of the presence of five (or more) depressive symptoms during a period of two weeks. Some of these symptoms include a depressed mood most of the time, significant weight change unrelated to dieting, lack of energy, feelings of worthlessness or guilt, recurrent thoughts of death or suicide and lack of concentration.

Mood disturbances can also occur less intense but still impairing someone’s life significantly, like when one is diagnosed with dysthymic disorder, where the person experiences a depressed mood on more days than not, for at least two years. These individuals often experience many symptoms of major depression, but these tend to be less severe.

Some disorders occur comorbid with depression: premenstrual dysphoric disorder, which is a condition suffered from by some women where severe depression is experienced some days prior to the start of their menstrual cycle, seasonal affective disorder (SAD), characterized by regularly feelings of depression in winter where a remission is seen the next spring or summer, and chronic fatigue syndrome (CFS), which is a disorder distinguished by depression and fluctuations of mood together with some physical symptoms such as muscle pain, chest pain, headaches, noise and light sensitivity, and extreme fatigue. Lastly, because anxiety is very comorbid with depression, many sufferers from depression are diagnosed as suffering from mixed anxiety/depressive disorder. This has also brought up the notion of depression and anxiety not being as independent of each other as we might think, and that they rather represent subcategories of a bigger class of emotional disorders.

Depression occurs very often, and is known to have a steady rise of incidence over the last 90 years. The prevalence rates differ however over different cultures, which may be due to many reasons:

• Different measurement methods used by different researchers.

• The social stigma attached to depression especially in non-western countries.

• The challenge in the measurement of the abstract concept of depression.

• The tendency of the west to express psychological symptoms in physical symptoms (somatisation).

Major Depression: Aetiology

Genetics are thought to play an important role in the development of major depression. First-degree relatives of people suffering from major depression are seen to experience depression symptoms two to three times more often. Twin studies also suggest that depression is more likely to be due to shared genes instead of shared environment, with a heritability estimated to be between 30% to 40%. However, specific genes responsible for depression have yet to be found. Abnormalities in the levels of neurotransmitters have been shown to be associated with mood disorders. For instance, low levels of serotonin, norepinephrine, and dopamine are often linked to major depression. Medications prescribed in the 1950’s for high blood pressure sometimes lead to depression, this was found to be due to the lowering of serotonin levels in the brain by these medications. This lead to the development of tricyclic drugs (TCA) and monoamine oxidase inhibitors (MAOI), both of which block the reuptake of both serotonin and norepinephrine. Tricyclic drugs work by blocking the reuptake (in the presynaptic neuron) of serotonin and norepinephrine, therefore leading to higher quantities of these neurotransmitters active in the synaptic cleft. A newer alternative are the selective serotonin reuptake inhibitors (SSRIs), which targets only the serotonin levels in the brain. The thought that specific neurotransmitter levels are responsible for depression is quite simplistic, and many theories suggest quite complex mechanisms. A recent theory is that depression is due to an imbalance between multiple neurotransmitters, instead of deficits in specific neurotransmitters.

The prefrontal cortex is known to be important for the representations of goals and the means to achieve them. Lower activity in this area is seen in depressed people, and this may lead to a lack of the ability to anticipate incentives, which is commonly seen in those suffering from depression. Activity in the anterior cingulate cortex (ACC) is seen when behaviour requires effortful emotional regulation in order to achieve an outcome. Lower activity in this region may represent the lack of will to change, also seen in those who are depressed. One of the functions of the hippocampus is to learn the context of affective reactions, and a lack in this function might lead to dissociating negative affect from their contexts, making people feel sad independently from the context. The hippocampus also plays an important role in the adrenocorticotropic hormone secretion, which will be mentioned in more detail later. Finally, the amygdala is crucial for direction attention to emotionally salient stimuli, for instance when your attention is needed for a potential threat. Increased activity in the amygdala, which is seen in depression, may lead to the person prioritising threatening information and associating it with negative thoughts.

Cortisol is an adrenocortical hormone, and is known to be secreted in times of stress. The before mentioned hippocampus is important in the adrenocorticotropic hormone secretion, and a dysfunction in the hippocampus might therefore lead to high levels of cortisol. Another big influence in the regulation of cortisol is the hypothalamic-pituitary-adrenocortical (HPA) network, which is our biological system managing and reacting to stress, and triggering the secretion of cortisol when stress is experienced. A lack of inhibitory control over this network is linked to depression, and about 80% of hospitalized sufferers from depression show a poor regulation of this HPA network. An increase of cortisol might enlarge the adrenal glands, which results in a lowered level of serotonin neurotransmitters. Because stress is often reported to be experienced before someone got depressed, it is possible that the stress elevated the body cortisol levels, which resulted in a lowered level of serotonin, which is known to be playing a role in depression, resulting in the cognitive, behavioural and motivational symptoms seen in major depression.

It is clear that depression has an inherited component, and that levels of brain neurotransmitters play a crucial role in the maintenance of depression. Specific brain areas are also known to be important in the aetiology of depression, and neuroendocrine factors are seen to be associated with it. However, not everything can be explained with biological factors. Biological factors may be the direct cause of symptoms, but psychological processes could be the trigger to those biological factors.

The most used psychodynamic view of depression is the one of Freud and Abraham, which states that depression is a person’s response to loss, and especially the loss of a loved one. The first stage is introjection, which states that a person in the introjection stage regresses to the oral stage of their development, which allows them to integrate the identity of the person they have lost. Regression to the oral stage also allows the person to direct the feelings they hold of the loved one towards themselves, which can be feelings such as anger of guilt. The individual can start to experience self-hatred, which develops quickly into low self-esteem, resulting in feelings of hopelessness and depression. A problem with this view is that not all depressed people have lost a loved one, to which Freud coined the concept symbolic loss, in which other types of losses are viewed by the person as equally important as losing a loved one. This can lead to regression to the oral stage and trigger potential memories of bad parental support during their youth. Now we view poor parenting as a more likely cause of depression, and parental loss is not a prerequisite anymore. There is a link between depression and having experienced affectionless control, which is a type of parenting where there is a lack of warmth combined with high levels of overprotection.

Depression is highly characterized by a decrease of motivational and initiative-taking behaviour, together with a lack of positive feelings about their future. Based on these characteristics of depression, some theorists suggest that depression results from a lack of reinforcement of positive and adaptive behaviours, leading to a decrease of the existing behaviours, which is illustrated by the inactive and withdrawn behaviour seen in depression.

Depressed individuals tend to be less skilled at communicating with others and tend to transfer their negative mood to others, resulting in the reinforcement of depression. This social reinforcement is because people will respond more negatively towards depressed individuals, because of the poor social skills depressed people often show. This also lead to interpersonal theories, which argue that the maintenance of depression is because of the reassurance that depressed individuals keep on seeking that is subsequently not given by family and friends, because they are approached in such a negative way by the sufferer. This reassurance is often given, but because depression makes one doubt the reassurance, they keep on trying to confirm the reassurance, which is why family and friends might end up rejecting the reassurance at some point.

Beck’s cognitive theory about depression is very influential, and it states that depression might be caused by biases in the way we think and process information. Beck claims that depressed people have developed many negative schema, which are beliefs that tends to make someone view the world and themselves more negatively. These negative views have a big influence on the selection, encoding, categorisation and evaluation of information that we encounter, and this is often long lasting. Beck also states that this negative approach of interpreting everything around us develops because of negative childhood experiences, and can start again in adulthood due to some stressful experience. The negative triad is a theory stating that depressed people hold negative views of themselves, their future and the world. These negative beliefs result in self-fulfilling prophecies, making the people interpret events negatively because they believe they are negative. There is evidence that these cognitive biases indeed exist as:

• attentional biases to negative stimuli, especially if they are depression related

• memory biases, where depressed individuals recall more negative words than positive, again this applies mostly to depression-relevant material

• interpretational biases, making them interpret ambiguous events more negatively

Research suggests two types of negative schema. The first one is focused on dependency and the second one on criticism. Depression triggered by losses is characteristic of dependency self-schemas, and depression triggered by failure is seen with criticism self-schemas. Pessimistic thinking (the thinking that nothing can improve in situations) is often thought of to be characteristic of depressed individuals, but research has shown that people suffering from depression are actually much more accurate at evaluating control over situations and evaluating the impression they made on others.

Seligman proposes that negative life experiences give rise to a ‘cognitive set’ which makes the person learn to become helpless, depressed and lethargic, this is known as the learned helplessness theory. The level of uncontrollability of these negative life events is important, and the more uncontrollable a situation, the more pessimistic beliefs the person will adopt. Battered woman syndrome is an example where learned helplessness of an abused woman’s situation results in their belief that they are powerless, making them express symptoms of depression. The original learned helplessness theory does not explain why experience with negative events may actually help performance, and that passivity in battered woman syndrome may actually be a learned response to avoid abuse. Because of these difficulties, the original theory got revised to include the concept of attribution.

Attribution theories state that people are more likely to become depressed because of certain attributional styles that consist of negative thinking, like attributing a negative event to factors that aren’t easily changed, therefore thinking that they are powerless. There are multiple ways in which life events can be attributed:

• one can interpret an event as internal (personal cause) or external (environmental cause)

• an event can be seen as stable (lasting over time) or unstable (short lasting) factors

• and something can be global (relatable to many domains of life) or specific (only to a specific part of life)

Depressed people tend to think of negative life events as internal, stable and global, and think of positive events as external, unstable and specific. The repeated use of negative attributional styles will lead to more and more perceived helplessness over time.

Attributing negative events for global and stable reasons combined with negative life events is suggested to increase the level of vulnerability to symptoms such as retarded initiation of voluntary responses, lack of energy, apathy and psychomotor retardation, which are all symptoms of hopelessness. Hopelessness theory states that individuals show the expectation that positive outcomes won’t occur, that negative outcomes will occur and that no change can be made about this. Hopelessness theory is quite similar to the previously mentioned attributional and helplessness theories, but hopelessness theory suggests that factors like low self-esteem also play a role. Hopelessness can therefore be predicted by a negative attributional style, negative life events and low self-esteem. Hopelessness can be used to predict suicidal tendencies and especially completed suicide. Some limitations to the hopelessness theory are:

• many studies supporting it are carried out on healthy or mildly depressed individuals

• a majority of the studies done on the model cannot generate evidence for a causal role of hopelessness thoughts on the development of depression, because the studies are correlational in nature

• the model only explains symptoms related to hopelessness, and other DSM-5 required symptoms of depression are not explained

• some evidence shows that the prevalence of negative attributional styles can decrease after one recovers from depression

Rumination is an individual’s tendency to repeatedly mull over the experience of depression and to find out its possible causes. Indulging too much in these ruminating activities can cause and predict depressive episodes and relapses. Rumination seems to be caused by meta-cognitive beliefs that it is necessary in order to resolve one’s depression.

Bipolar Disorder

A person suffering from bipolar disorder has mood swings from one extreme to the next. On one side of the spectrum you have 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 in the manic person. A state of mania can last for days or weeks, and the onset can be quite quick.

Diagnosing and Prevalence of Bipolar Disorder

The DSM-5 differentiates between bipolar disorder I and bipolar disorder II. The first, bipolar disorder I, is characterized by full alternating episodes of major depression and mania. Bipolar disorder II is slightly different, since it does contain major depression episodes, but then followed by hypomania episodes. A hypomania episode is a milder version of a mania episode, and an episode of hypomania does not have to be impairing the ‘sufferer’. Prolonged episodes of hypomania can however lead to full blown mania. A milder form of bipolar disorder is cyclothymic disorder, where the individual suffers from mood swings for at least two years, and the mood swings consist of mild depression to hypomania symptoms like euphoria, happiness and excitement.

Bipolar Disorder: Aetiology

Bipolar disorder has an inherited component, since it has been estimated that about 7% of first-degree relatives of those suffering from bipolar disorder, also have bipolar disorder themselves. Concordance studies have shown that on average, sharing all genes (as seen in monozygotic twins) more than doubles a person’s risk of developing bipolar disorder compared to dizygotic twins.

The neurotransmitters norepinephrine and dopamine also play an important role in bipolar disorder, just like in depression. The role of serotonin however seems to be not that important in bipolar disorder. A commonly used medical treatment for bipolar disorder is the combination of the antipsychotic olanzapine and the antidepressant SSRI fluoxetine or Prozac.

The depression episodes in bipolar disorder seem to be triggered by many of the same triggers that are also seen in major depression, like the loss of a loved one or failures in life. The triggers for a manic episode vary, and often seem to be due to an increased reaction to rewarding situations, like a positive life event. Other triggers seem to be antidepressants, unusual circadian rhythms or disrupted sleep patterns, stressful life events, the exposure to intense expressions of emotions by family or caregivers, and seasonality, since manic episodes tend to increase in spring or summer.

Treating Depression and Mood Disorders

Treating depression and mood disorders can be done with biological-based treatments, like electroconvulsive therapy (ECT), an old treatment where an electric current volts through the patients, or with the use of psychological therapies. Emphasizing the method of treatment according to the severity of the symptoms an individual is experiencing is often preferred. These stepped-care models are implemented to make sure that a treatment is effective and not too invasive when it’s not necessary. An example of a stepped-care model could be:

• not simply responding with medication right away, and assessing the individual properly

• reserve medication only when there is more evidence that it will be effective, in the case of depression this would count for moderate to severe depression

• mild depression is best treated with short behavioural and cognitive interventions

Biologically-based treatments

There are currently three main types of medications for the treatment of depression:

• tricyclic antidepressants (TCAs)

• monoamine oxidase inhibitors (MAOIs)

• selective serotonin reuptake inhibitors (SSRIs)

Tricyclic drugs and MAOIs elevates levels of both serotonin and norepinephrine, while SSRIs only work specifically on serotonin levels. Tricyclic drugs have been seen to work for 60-65% of individuals taking it, and this is 50% of those taking MAOIs. Tricyclic drugs and MAOIs are known to be quite effective, but the downside is that they come with many possible side effects. The newer SSRIs are known to be effective in 55-60% of the cases, but come with much little side effects and are harder to overdose on. A downside to SSRIs is that they seem to take longer to have an effect, and they might increase the risk of suicide. Relapse is common when individuals quit drug therapy, and it is therefore advised to combine drug therapy with psychological therapies for the maximum result and the smallest risk of relapse.

Bipolar disorder is treated differently, with the traditional treatment being lithium carbonate. There are many theories as to the mechanisms of lithium on the symptoms of bipolar disorders, but a clear reason is unknown. The disadvantages of lithium treatment are that ending a treatment often increases the chance of a relapse, and since lithium is a toxic substance, the often prescribed dosage tends to be close to the toxic level. An overdose can constitute of delirium, convulsions, and occasionally death.

ECT consists of the passing of an electric current through the head of a patient for about half a second, which often results in a temporary relief from symptoms of severe depression. A serious side effect of electroconvulsive therapy is the possibility of both anterograde and retrograde amnesia which can last up to 7 months. Besides the possible serious amnesia, many people also tend to not be jolly about the fact that a strong electric current is being passed through their brains. The relief of depression often doesn’t last long, since a relapse of depression has been seen after the small duration of only four weeks of relief. Some even state that any kind of direct trauma to the brain would give relief of depression for a considerable amount. Despite the criticisms, electroconvulsive therapy is still an effective treatment in some cases, and this is especially beneficial when there is a high risk of suicide due to depression if the depression isn’t alleviated quickly.

Psychologically-based Treatments

The psychodynamic view of depression; that depression develops out of anger projected inwards instead of toward a loss, is the basis of the psychoanalysis, where the goal is to achieve insight into an individual’s anger and release the anger towards themselves. Finding the long-term source of one’s depression is done with various techniques to explore conflicts and investigate problematic relationships with attachment figures (e.g. parents). An example is dream interpretation, which helps the person recall early experiences of (symbolic) loss, which may be a source of conflict. The efficacy of psychodynamic therapy is not clear, as it is hard to study because therapists often have a different view of psychodynamic principles. One study however showed that psychoanalysis may be as effective as CBT, but another study found no long-term efficacy.

Social skills therapy focuses on supporting the depressed individual with acquiring appropriate social skills and attempting to reduce the amount of maladaptive social skills, and assuming that it will help alleviate symptoms of depression. Social skills training has shown to improve social skills and decrease the amount of depression symptoms.

The loss or lack of pleasant rewards as the reason for depression is the main point in behavioural activation therapy. It focuses on increasing the access to pleasant rewards and events in a depressed individual’s life, therefore taking the focus away from negative events. Behavioural activation therapy consists of monitoring daily events that are pleasant or unpleasant and behavioural interventions. Social skills training and time management are also taught in behavioural activation therapy. It has been shown that cognitive change is just as likely to occur from behavioural activation therapy as from cognitive interventions.

According to Beck’s cognitive theory of depression, depression is maintained by dysfunctional negative beliefs, which turns into a negative schema which the individual uses to view itself, the world and the future. The most widely used therapies for treating depression are developed from this theory of Beck, and are often named cognitive therapy or cognitive retraining. Cognitive retraining works in three steps, which are:

• assist the individual in identifying negative beliefs and thoughts

• challenge these beliefs and thoughts as dysfunctional, illogical or irrational

• help the person replace these negative thoughts with more adaptive and rational ones

Overgeneralization is often seen in depressed individuals, and these irrational patterns of thinking that one specific failure relates to one’s ability in other domains are identified by the cognitive therapists and are challenged to be irrational. Asking the client to monitor negative automatic thoughts helps with the identifying them and possibly replacing them with more rational thoughts. Another method used to correct the individuals negative thinking is reattribution training, which is a technique which attempts to get individuals to relabel their difficulties in a more optimistic and constructive way, rather than in a negative way.

Cognitive therapy has been shown to be very effective in treating the symptoms of depression, and at least as effective as drug therapy. However, the chance of a relapse is smaller with cognitive therapy, compared to drug therapy. The combination of both drug therapy and cognitive therapy still appears to be the superior treatment of depression.

Deliberate or Intentional Self-Harm

Direct and deliberate bodily harm without any suicidal intent is considered to be 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 behavioural therapy and problem-solving therapy, which teaches people to cope with negative thoughts and arriving at an effective solution.

Suicide

The best predictor of suicide seems to be if someone matches the concept of hopelessness, which was described earlier. Women appear to be three times more likely than man to attempt suicide, but men ‘complete’ suicide four times more often than women. This is because men more often take a more lethal method (e.g. jumping or weapons) than women, which more often choose methods like attempting suicide with pills or cutting themselves. The prevalence rate of suicide in youth has risen a lot, for reasons unknown, although the following factors may be relevant:

• nowadays teenagers are exposed to more life stressors earlier, and often lack the coping mechanisms that adults do have

• suicide is also a sociological phenomenon, and media attention to suicide are known to increase suicide rates for teenagers

• the strong relationship between suicide, depression and substance abuse (and the fact that teenagers are more exposed to drugs and alcohol now) may influence the increasing suicide and self-harm rates

Risk Factors in 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:

1. a diagnosis of depression, borderline, panic disorder, schizophrenia, alcoholism, and substance abuse

2. the construct of hopelessness and low self-esteem

3. physical disability and poor physical health

4. low socio-economic status

Life stress seems to be a very common predictor seen in suicide, and negative life events often precede suicide. Different types of life events are seen across different age groups. For teenagers and adolescents, relationship issues and interpersonal conflicts are often the trigger. Financial issues is most often the reason of suicide in middle age, and disability and (lack of) physical health for those in later life.

A genetic component exists in suicidal behaviour, as the inherited component may be up to 48%, according to twin and adoption studies. Low levels of serotonin metabolites in the brain has been associated with suicidal behaviour, and since this may partially be controlled by inherited components, which could explain the heritability of suicidal tendencies.

Identification and Prevention of Suicide

Surveys suggest that 47% of those who attempted suicide, actually did not want to die, but that their attempt was a cry for help. Intercepting people who do not actually wish to die but find no other way of conveying their cry for help, is very important in the prevention of suicide. Approaches like educational programmes or hotlines help some, but often only specific groups (young women in this case). Other approaches to suicide prevention are developed, and the most common ones are to train general practitioners to identify and treat suicidal intentions, improving the access to care for those at risk of suicide, and restricting the access to suicide. The latter might be hard in many cases, but restricting locations for hanging in at-risk living facilities might be one way. Medications (e.g. antidepressants or antipsychotics) and cognitive behavioural therapy can also decrease the risk of suicidal tendencies.

Schizophrenia Spectrum Disorders - Chapter 7

Introduction

Disturbances in thought, language, behaviour, regulation of emotions, and sensory perception are all classified as psychotic symptoms, and a psychosis is the collective name given to a wide range of these symptoms. These symptoms can also result in sensory hallucinations and thinking biases relating to the world and themselves. A psychosis can leave the sufferer confused and frightened, and it may also lead to a diagnosis of any of a number of schizophrenia spectrum disorders. Many symptoms can be so crippling, that the sufferer is unable to hold social contacts and a job, therefore downgrading them to the bottom of the social ladder and even making them homeless. This is also known as a downward drift. The DSM-5 now categorizes these symptoms as multiple psychotic disorders differentiated by severity, duration, and complexity of symptoms. The main diagnosis under schizophrenia spectrum disorders are now schizophrenia, schizotypal personality disorder, delusional disorder, brief psychotic disorder, and schizoaffective disorder.

Psychotic Symptoms and its Nature

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).

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:

• 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.

• Grandiose delusions make the person belief that they are a person with fame or power or with exceptional abilities

• 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.

• Delusions of reference result in the person believing that external events, normally seen as independent, are referring to them.

• 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.

• Erotomanic 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.

Hallucinations

Sensory abnormalities across multiple modalities (e.g. auditory, olfactory, and visual) are known as hallucinations. Most reported hallucinations are known to be in the auditory modality. These auditory hallucinations usually manifest as voices, and can be experienced as two or more voices conversing, commands to the individual to act in certain ways, or a voice commenting on the individual’s thoughts. All these voices are perceived as distinct from a person’s own thoughts. Imaging techniques have shown that when an individual reports hearing these voices, there is a neural activation in the brain areas involved in the perception of sounds and speech generation. The second most common form of hallucinations are visual, which vary from simply perceiving colours and shapes that are not present to seeing specific things such as individuals who aren’t there. Hallucinations can also occur in other modalities such as tactile and somatic (e.g. burning or tingling skin) or olfactory and gustatory (e.g. unusual tasting food or smells that are not present). Some individuals believe their hallucinations, but many also don’t. This lead to the suggestion that psychotic episodes are related to a reality-monitoring deficit, meaning that it may be difficult for a sufferer to distinguish 1) whether some belief or percept is real and 2) whether they created it or if someone else did. A study where individuals had to remember words generated by themselves or by the experimenter found that individuals diagnosed with schizophrenia differed from controls in three aspects:

• they identified more items belonging to the generated list of words when they were not

• they were more likely to say that words generated by themselves were actually generated by the experimenter

• they reported that spoken items were presented as pictures

This suggests that those suffering from schizophrenia have a reality monitoring deficit, which results in a problem between distinguishing what actually occurred and what not, and that they have a self-monitoring deficit, meaning they have trouble distinguishing between thoughts and ideas generated by themselves and ones generated by others.

Disorganized Thinking in Speech

Disorganized 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 leading to 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.

Disorganized or Abnormal Behaviour

Unusual behaviour present in schizophrenics can be seen in a variety of ways, such as very childlike behaviour or behaviour inappropriate in a specific context (e.g. masturbating in public). The behaviour can be unpredictable, they may show trouble with goal-directed activities (e.g. maintaining hygiene) and the person may seem agitated (e.g. shouting). The appearance of a person can also be strange or inappropriate in specific contexts (e.g. only wearing underwear in the streets). Catatonic motor behaviours are seen in several ways:

1. Catatonic stupor: a significant decrease in a person’s reactivity to the environment.

2. Catatonic rigidity: a rigid and immobile posture.

3. Catatonic negativism: resisting any attempts to be moved.

4. Catatonic excitement or stereotypy: excessive, purposeless and unnecessary motor activity consisting of stereotyped movements.

Negative symptoms

Some negative symptoms seen in schizophrenia spectrum disorders are:

• Diminished emotional expression (or affective flattening) consists of a reduction in many characteristics of emotional expression, such as eye contact, voice intonation, facial expressions related to emotions and head and hand movements related to emotions.

• Avolition is the inability to do normal daily goal-oriented activities, which may result in little interest in social activities or work.

• Alogia is the lack of verbal fluency when an individual gives only brief and empty replies to questions.

• Anhedonia is seen when individuals are unable to recall pleasurable events and show a decreased ability to experience any pleasure from normally positive stimuli.

• Asociality refers to the lack of interest in social interactions, possibly due to the withdrawal from social interactions in general.

Diagnosing Schizophrenia Spectrum Disorders

The DSM-5 categorizes schizophrenia spectrum disorders along a continuum of less severe to disabling, while taking into account the number, duration, and severity of symptoms. The diagnostic criteria for four of these schizophrenia spectrum disorders are explained below. It is important to note that all symptoms must not be attributable to some sort of substance or medication.

Delusional Disorder

A delusional disorder is characterized by one or more delusions lasting over a month, and it contains several subtypes:

• The persecutory type is the most common subtype in which the individual believes they are being cheated on, conspired against, spied on, poisoned, followed, harassed, or obstructed in the attainment of long-term goals.

• Another subtype is the erotomanic type, where the person believes another person of higher status is in love with them or making romantic advances towards them.

• The grandiose subtype is seen in individuals who believe they have some great power, insight or wealth. Grandiose beliefs often contain a religious or spiritual content.

Apart from these delusions, sufferers often behave quite normal and display no bizarre behaviour. The delusions can however be detrimental to any social or work lives, and mood problems are also common in individuals diagnosed with delusional disorder.

Brief Psychotic Disorder

When an individual is suddenly (within a 2 week period) experiencing at least one of the main psychotic symptoms, one can speak of a brief psychotic disorder. These main psychotic symptoms are delusions, disorganized speech, hallucinations or abnormal psychomotor behaviour. The sudden change is likely to cause emotional turmoil or overwhelming confusion in the sufferer, and the disturbance lasts one day to a month before one returns back to normal behaviour.

Schizophrenia

Schizophrenia is diagnosed when the disturbance influences major life areas (such as work, social or romantic), and no single symptom is characteristic of the disorder. The disturbances last at least 5 months and are caused by at least two of the following: delusions, hallucinations, disorganized speech, highly disorganized or catatonic behaviour, or negative symptoms. Prodromal symptoms are symptoms that precede the active disturbance phase, and residual symptoms are ones that may follow the active disturbance phase, examples of which are negative symptoms or social isolation. Other symptoms seen in schizophrenics may be depressed mood, anxiety or anger, inappropriate affect (laughing at inappropriate moments), disturbed sleep patterns and low interest in eating. Individuals may also show a lack of insight in their condition and be hostile or aggressive. The latter is more common in younger male sufferers and individuals with a history of violence, substance abuse, impulsivity or non-adherence to treatment. Usually schizophrenics are not aggressive and more likely to be the receiver of violence instead of the one that exerts it.

Schizoaffective Disorder

When one also displays mood problems such as depression or mania alongside schizophrenia symptoms, a diagnosis of schizoaffective disorder is possible. The psychotic symptoms must remain for 2 weeks or more after the mood problems are (temporarily) gone. Schizoaffective disorder can seriously affect occupational functioning, and may also restrict social functioning. Difficulties in caring for themselves and an increased risk of suicide is also associated with schizoaffective disorder.

Prevalence of Schizophrenia Spectrum Disorders

The lifetime prevalence rate of schizophrenia seems to be around 0.3 to 0.7%, and it seems to arise most in the age group of 15 to 35 years. It is one of the most disabling medical disorders with a mortality rate of up to 50% higher than normal and sufferers tend to die ten years younger on average. Also about 10% of sufferers commit suicide. Despite improvements in treatment, about 80% of those diagnosed will suffer lifelong impairment, and about the same amount will have no job.

The prevalence seems to be about the same across the world, only the course of schizophrenia appears to be less severe in developing nations. Some important factors contributing to this may be beliefs about the origins of psychological disorders or the supporting role of family. Rates of diagnosis of schizophrenia are usually higher in some ethnic groups, which may be due to racial disparities in the treatment of mental health. Immigration or a family history of immigration seems to be an important risk factor, especially immigrants from developing countries. This may be due to experienced stress from language difficulties, poor housing, unemployment and low socio-economic status. Schizophrenia occurs as much in males as in females, but females tend to have a later onset and less hospital admissions, possibly resulting from higher levels of social role functioning prior to their illness. Delusional disorder is estimated to have a lifetime prevalence rate of 0.2%, and this is 9% for brief psychotic disorder.

Psychotic Symptoms and its Course

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

• the prodromal stage

• the active stage

• the residual stage

Prodromal Stage

The majority of individuals developing psychotic symptoms show signs of symptoms during their late adolescence or early adulthood. For some the onset is quick, but for most it is a long process where normal functioning deteriorates over a period of around 5 years. This slow process of deterioration is known as the prodromal stage. The prodromal stage consists of: a slow withdrawal from ones normal life and their social interactions, and shallow and inappropriate expression of emotions and a deterioration in work, personal care or academics (research shows that even grey matter loss may occur in areas mediating social cognition).

A psychosis usually develops during late adolescence, which is a basic fact. This specific time period may be best explained with the diathesis-stress model, stating that a disorder develops out of a biological vulnerability with an environmental trigger. A majority of individuals showing symptoms of psychosis experience stressful life-events in the prior three weeks. The transition from adolescence to adulthood is known to be one of the most stressful periods in a person’s life, and this may therefore be the reason why so many psychoses develop during this time period. A theory is that psychotic symptoms may emerge when a person fails to cope with normal maturation, resulting in social exclusion and other psychotic symptoms. Another (biological) reason for the onset in the adolescence is that many symptoms are associated with prefrontal cortex functioning, and since this area is usually not fully developed before adolescence, this could be contributing to fact that the onset is not prior to adolescence.

Active Stage

The active stage follows the prodromal stage, and this is when the person shows unambiguous symptoms of a psychosis, which are delusions, hallucinations, disordered communication and speech, or full-blown symptoms characteristic of the disorder.

Residual Stage

Usually recovery is a gradual process, but symptoms can continue to show over a long period of time. When one ceases to show any prominent signs of positive symptoms, the individual has reached the residual stage. Negative symptoms may still show during the residual stage, and it has been shown that relapse is common in schizophrenia spectrum disorders. Stressful life events or returning back to a stressful environment from some sort of hospitalization is a big predictor of relapse. Not taking treatments or medication is also traceable as the cause for a relapse. Reasons for not adhering to treatments may vary from lack of insight, history of substance abuse, negative attitudes towards medication or poor therapeutic relationship.

Psychotic Symptoms: Aetiology

Psychosis consists of a broad range of varying symptoms, and not a single one is sufficient enough to diagnose a condition like schizophrenia. Therefore the aetiology also varies, with explanations from different domains including the biological, psychological and sociological domain. Understanding psychosis is often attempted with the diathesis-stress perspective. This means that psychosis is thought to be explained due to partly a biological vulnerability to developing psychosis, and an environmental stressor being the decider whether or not this vulnerability will turn in a psychosis. Environmental stressors can be many things, such as dysfunctional relationships, troubled youth, educational demands and many more. Explaining psychosis is mostly done by looking at the specific features of a psychosis, which is known as the complaint-oriented approach, which also states that symptoms may underlie normal psychological mechanisms.

Biology-based Theories

Concordance studies have shown that psychotic symptoms have an inherited predisposition. Developing schizophrenia when a family member has a schizophrenia diagnosis, depends on how closely they are related to each other. Because family members not only share some genes but also share environments (which can be a stressful one), one can also develop schizophrenia due to that environment and not due to their genes. Therefore research on monozygotic and dizygotic twins has been done, which has shown that heritability is about 80% for schizophrenia, making it the most heritable psychiatric disorder.

Of course there are problems with twin studies, some of them being that MZ twins are always the same sex, that MZ twins might be treated differently than DZ twins because MZ twins look identical, and that MZ twins have shared prenatal influences due to their shared placenta, which is not the case for DZ twins. These problems are tackled by studying the offspring of monozygotic twins, which has shown that the amount of children (of MZ twins) developing psychotic symptoms are approximately the same (16.8% with parent diagnosed vs. 17.4% with parent not diagnosed), irrespective of whether their parent is diagnosed with schizophrenia or not.

Another method of looking at the genetic role played in the development of schizophrenia, is to use adoption studies. These focus on the fact that children do share genetic material with their parents, but are raised in a different environment. A study found that 16.6% of children adopted from their schizophrenic mother showed symptoms of psychosis, while the control group (consisting of children adopted from non-schizophrenic mothers) showed no symptoms. More studies showed that the adopted environment also played an important role, where adopted children of mothers diagnosed with schizophrenia were more likely to develop it themselves if their adopted environment had dysfunctional communication patterns, thus more evidence for the diathesis-stress model. Heritability studies are even starting to show that some symptoms are more heritable than others, like experiencing hallucinations or catatonia, while delusions and anhedonia seem to be less heritable.

Identifying which specific genes are responsible for conditions, characteristics or other qualities are done with molecular genetics. Genetic linkage analysis is one of the main methods, and works by looking at an individual’s characteristic of which a gene location is known (e.g. eye colour) and comparing it to the inheritance of various psychotic symptoms. So if some characteristic follows the same pattern within a family as some psychotic symptom, it can be reasonably assumed that the genes controlling both are probably on the same chromosome. Another technique is genome-wide association studies (GWAS) identifies rare mutations, which could possibly give rise to psychotic symptoms. Mutations resulting in ‘copy number variations’ (CNVs), which refers to an abnormal deletion or duplication in one’s DNA, are especially known to be associated with schizophrenia.

Although these techniques can be extremely useful, it must be remembered that some genes are responsible for really specific functioning which is indeed related to schizophrenia, but which is also often seen in many other disorders (e.g. deficits in executive functioning). Many people suffering from a schizophrenia spectrum disorder don’t share the underlying genetic factors, yet still share their symptoms, showing once again the heterogeneity of schizophrenia disorders. Also some of the studies linking genes to schizophrenia have been failed to be replicated.

It is known that communication in the brain is largely done by neurotransmitters, therefore cognition and behaviour are very depended on them working efficiently. Therefore researchers think that many problems seen in schizophrenia could be caused by a malfunction in the workings of brain neurotransmitters. A very known and prominent biochemical theory of schizophrenia is the dopamine hypothesis, which argues that symptoms of schizophrenia are associated with an excess of activity of the neurotransmitter dopamine. This is thought for the following reasons:

• Drugs that alleviate (positive) symptoms of psychosis (e.g. antipsychotics like phenothiazines) act by blocking dopamine receptor sites in the brain, thus reducing dopamine activity.

• Amphetamine psychosis, excessive use of amphetamines leading to symptoms characteristic of psychosis, was found to be caused by amphetamines raising dopamine activity in the brain, thus further proving that excess dopamine can lead to psychosis-related symptoms.

• Brain imaging indicates that excessive levels of dopamine is released from areas such as the basal ganglia in those diagnosed with schizophrenia.

• Higher levels of dopamine and more receptor sites for dopamine (especially in the limbic area) are found in deceased individuals diagnosed with schizophrenia.

Two dopamine pathways in the brain especially important in schizophrenia spectrum disorders appear to have different roles when it comes to the role they play in the generation of symptoms.

First there is the mesolimbic pathway, starting in the ventral tegmental area and projects to the hypothalamus, amygdala, hippocampus, and nuclear accumbens. This pathway is known to contain an excess amount of dopamine receptors in those diagnosed with schizophrenia. This excess of dopamine receptors is responsible for the positive symptoms, and thus often alleviated with medication blocking these receptors. The second pathway, the mesocortical pathway, also starts in the ventral tegmental area, but projects to the prefrontal cortex, and it appears that dopamine neurons may actually be underactive in the prefrontal cortex. This may be the cause for the negative symptoms, since the prefrontal cortex is known to play a role in many of the behaviour associated with negative symptoms (motivation, planned behaviour etc.).

Some things that don’t completely fit the dopamine hypothesis, and thus should not be rejected, are the fact that antipsychotic drugs usually start working after six weeks, even though they are known to block dopamine receptors just hours after intake. Also, many new effective antipsychotics only have minimal effects on the brains dopamine levels, and focus more on other neurotransmitters. It is also known that other neurotransmitters known to play a role in psychosis symptoms are serotonin, glutamate and GABA, which makes sense since these neurotransmitters all interact and influence others (e.g. dopamine release in the mesolimbic pathway is regulated by serotonin).

Individuals with psychotic symptoms appear to have a structurally different brain when compared to healthy controls. These differences are there when psychotic symptoms first start, thus it is not necessarily a result of the symptoms. The differences also continue to develop over the person’s lifetime. Some important structural differences are:

• Enlarged ventricles.

• Reduced grey matter in the prefrontal cortex.

• Functional and structural abnormalities in the temporal cortex and the structures surrounding it, such as reduced volume in the hippocampus, basal ganglia and limbic structures.

Enlarged ventricles result in an overall reduction of cortical grey matter. This enlargement of the ventricles seems continue over time with chronic schizophrenia, and it is also apparent when psychotic symptoms first start showing. The reduced grey matter in the prefrontal cortex is associated with the negative symptoms in schizophrenia, as the prefrontal cortex is important in many executive behaviour such as planning, motivation, planned behaviour, problem-solving and memory. Impairments in these fields are seen in sufferers, and sufferers exhibiting the negative symptoms show less metabolic rates in the prefrontal cortex. Recent research shows that deficits in prefrontal functioning may not only be due to less neurons, but due to disrupted connections between the synapses in pathways of other neurotransmitters. A reduction in dendritic spines (branches on the dendrites) leading to less connectivity between cells is also thought to be a cause for the decrease in prefrontal cortex functioning.

Abnormalities in the temporal cortex, limbic structures, basal ganglia and the cerebellum are all seen in sufferers from schizophrenia, and are most associated with the positive symptoms. Reduced volume in the temporal cortex and hippocampus have also been associated with the symptoms seen in sufferers, and hippocampal function and the role it plays in memory and pattern completion are both associated with those functions’ disruption in schizophrenia. These structural differences seen in those diagnosed with schizophrenia suggest that different symptoms, positive or negative, may be relatable to different deficits in brain areas.

The cause of these brain abnormalities is not quite clear, but the prenatal period of an individual’s life seems to be contributing to abnormalities in the brain. Brain damage occurring after the third trimester is usually self-repaired, yet this does not seem to be the case for schizophrenia sufferers, therefore brain damage must have occurred prior to the third trimester in schizophrenia. Birth complications and infections during pregnancy are also sometimes seen to increase the risk of developing psychotic symptoms.

Psychology-based Theories

Recently the interest in psychological models of schizophrenia has increased, and this is especially true for the cognitive models viewing symptoms as a result of cognitive biases in attention, interpretation and reasoning.

According to Freud, a psychosis is a result of a regression to a previous ego state resulting in a preoccupation with the self, known as a regression to a state of primary narcissism. It is thought to be caused by cold, distant and un-nurturing parents, and this regression gives rise to loss of contact with reality, and attempts to re-establish contact would lead to hallucinations and delusions. Because of the focus on dysfunctional families in the causes of schizophrenia, the concept schizophrenogenic mother was developed. This is a cold, rejecting, dominating and distant mother causing schizophrenia (according to Fromm-Reichmann). Empirical evidence for these psychodynamic explanations is slim, such as the little evidence that mothers of sufferers actually display these characteristics.

Learning theories focuses on explaining some of the bizarre symptoms of schizophrenia, like Krasner focused on operant condition, as he stated that because sufferers often find it difficult to focus on normal social interactions, they start focusing on the unusual and irrelevant cues in their surroundings. This is noticed by others, the behaviour gets attention and so the behaviour gets reinforced, and finally the behaviour is strengthened. Another behavioural theory arguing that unusual behaviour could be learned, is the fact that extinction can occur when an individual diagnosed with schizophrenia experiences a decrease in attention or reward when displaying the behaviour.

Attentional abnormalities are commonly seen in schizophrenia, such as under-attention (inability to focus on relevant aspects of the environment) or over-attention (attending to irrelevant aspects too much). The orienting response, a normal attentional process consisting of physiological changes when presented with a novel or prominent stimulus, shows abnormalities in 50% of cases of schizophrenia. These deficits have shown to be correlated with negative symptoms such as blunted effect and withdrawal. Over-attention in schizophrenia is when a person attends to many cues in their environment and they are unable to filter these out, which leads to sufferers being very distractible, and therefore scoring lower on cognitive tests when distractions are present. They score higher on tests where being easily distracted leads to better performance, like with the negative priming test. The over-attending to distractions correlates highly with positive symptoms.

Paranoid schizophrenia occurs over 50% of the time with cases of schizophrenia, and this sub-type of schizophrenia which is characterized by delusions of persecution is therefore of great interest. These thoughts of persecution may be explained by the fact that sufferers are 20 times more likely to have experienced some threatening or confrontational event, therefore they might be more wary of these events. Cognitive biases may also be responsible for paranoid delusions, and the four types are explained below.

Evidence show that individuals experiencing paranoia delusions exhibit attentional biases towards cues with emotional meaning or cues that are paranoia-relevant. Then again, research shows that sufferers of delusions of persecution are slower to recognize angry faces than controls, and fixate less on salient features of the face. This might be a defence mechanism the person has developed, where an avoidance strategy makes the person avoid allocating attention to threatening stimuli.

People with delusional beliefs appear to have a bias towards attributing negative life events they experience to external causes. A study found that when experiencing paranoid delusions, individuals attributed negative events to stable and global reasons, yet they did attribute positive events internally and negative events externally (the latter seems to only count when there is a perceived threat to the self).

A reasoning biases commonly seen in persons with delusional disorders is that of jumping to conclusions. Individuals make a decision about some event based on less evidence than normally, which leads to an early acceptance and belief of paranoid thoughts, resulting in delusional symptoms. The threat-anticipation model of paranoid and persecutory delusions attempts to answer how these reasoning biases are caused. The model argues that there are four factors important in contributing to the formation of persecutory thoughts:

1. Anomalous experiences (e.g. hallucinations) which lack an obvious explanation.

2. Depression, anxiety and worry causing a bias towards thinking and interpreting events.

3. Reasoning biases causing the individual to find confirming evidence instead of questioning these anomalous experiences.

4. Social factors which could add to feelings of threat, fear, anxiety and suspicion.

Hearing voices are not necessarily a psychotic symptom, but the interpretation of these auditory hallucinations depends on whether or not the voices are negative or not. Diagnosed individuals perceive voices as more dominating, distressing and uncontrollable when compared to healthy individuals hearing them, and this distress is what characterizes voices as a symptom of psychosis. A theory as to how these voices are interpreted is that they start as an overstimulation of the auditory neural networks, and the failures in detecting signals lead a person to believe the voices are real, meaningful and not generated by themselves. The deficits in working memory and executive functioning common in schizophrenia may also cause the person to be unable to suppress the voices or use logic with top-down reasoning to suppress them, causing more distress. Sufferers can become so obsessed with their voices, that they withdraw from their social world and generate hallucinations to make sense of the voices.

Inferring the beliefs, intentions and attitudes of others is known as the theory of mind. A deficit in TOM is characteristic in autism, but it appears to possibly also play a role in schizophrenia, as a study found that individuals suffering from persecutory delusions found it harder to inter the mental state of a character in a joke. An inability to infer other people’s intentions may lead to suspicious thoughts and fear that others may be hiding their intentions. TOM deficits are seen across schizophrenia spectrum disorders and can be detected at various stages of the development of a disorder, as well as in the prodromal stage.

Sociocultural-based theories

Higher rates of schizophrenia diagnosis are usually found in the lower socio-economic class, resulting in two sociocultural theories of schizophrenia. The sociogenic hypothesis states that individuals in a lower socio-economic class are more likely to experience more life stressors such as financial problems, unemployment, poor educational levels etc. These stressors can then evoke a psychosis in those people vulnerable for one. However, studies have found that people diagnosed with schizophrenia are just as likely to have parents of high socio-economic status compared to having parents of low socio-economic status, despite the fact that the diagnosed person is more likely to be of low socio-economic status themselves.

An alternative explanation therefore is that individuals’ low socio-economic status is a result of their disorder, instead of it being the cause of their disorder. This occurs due to the downward drift sufferers experience when symptoms lead them into unemployment, exclusion from social situations and poverty. Drifting to a lower socio-economic status due to one’s disorder is known as the social-selection theory, where there are more schizophrenia-diagnosed individuals in the lower socio-economic group because of their disorder. A final social factor in schizophrenia is that sufferers are often treated differently when they are labelled with a disorder, and that they may also see and treat themselves differently because of this label. This social labelling can lead to a self-fulfilling prophecy where a diagnosis makes the person and the people around them act in a manner that only maintains and strengthens the pathological symptoms.

Poor communication between parents and children is often also seen as a risk factor, and it is argued that a psychosis could develop when communication is ambiguous and double-binds the child. The double-bind hypothesis states that a parent may exhibit a loving display of affection at one moment, and then reject it because it may be seen as a weakness. This leaves the child confused and in a conflicted situation, which could end up in a withdrawal from social interaction. Communication deviance (CD) is a construct describing forms of communications that are difficult to follow and often leaving a person puzzled. It includes abandoned or ceased sentences, inconsistent references to situations, using phrases wrongly and the use of strange logic. CD has shown to be a predictor of developing psychotic symptoms in children, independent of biological predispositions. The construct expressed emotion (EE) is also strongly linked to the development and relapse of psychotic symptoms. EE consists of a family environment which is hostile and critical and where family members are intolerant of the patient’s problems. Family members who display these kinds of behaviours are also often seen to have the attributional style where they blame the sufferer for their own problems.

Treating Psychosis

With the right tools, many people suffering from psychotic symptoms can cope with their daily struggles and live close to a normal life. However, many sufferers are unable to achieve this, and continue to have problems for very long. Relapse is very likely, as it has been found that around 81% of people who recovered from their first episode will relapse within five years. Relapse is very dependent on whether or not the sufferer adheres to treatment. Discontinuing medication increases the risk for a relapse by close to five times, and dependence on illegal drugs is also a big risk factor for potential relapse.

Biology-based treatments

Electroconvulsive therapy, which consists of passing an electric current through the head for a very short duration, used to be a common form of treatment and is only used today when other treatments don’t work and if the psychotic symptoms are comorbid with depression. A prefrontal lobotomy involves separating the pathways between the lower brain areas and the frontal lobes. It was used to make disruptive and violent patients calmer and easier to treat. Because of its high fatality rate (up to 6%) and the fact that it affected the patient’s intellectual and emotional responsiveness a lot, it became questioned in the 1950s and later discontinued.

Neuroleptics or antipsychotics are one of the most effective forms of treatment, and especially for treating positive symptoms. There are two types of antipsychotics, first and second generation, referring to when they were developed.

First-generation antipsychotic drugs were originally antihistamine, but it was noticed that they also calmed people. The use of them on patients with severe psychological disorders showed that the psychotic symptoms dropped in these patients, so shortly after they were widely adopted in treating schizophrenia, alleviating positive symptoms. The first problem with these antipsychotics is that they don’t cure the problem but merely treat it, so lifelong medication is necessary. The second problem is that these antipsychotics also have unwanted side-effects. One is tardive dyskinesia, a motor movement disorder developed by 20 to 25% of people taking the medication, and it is characterised by symptoms of Parkinson’s disease like limb tremors or involuntary tics, which is explained by the lowering of dopamine activity. Side effects like these cause many patients to quit their medications, and therefore increase risk of relapse.

Second-generation antipsychotic drugs (or atypical drugs) were developed more recently, and were thought to have the following benefits over the first generation antipsychotics:

1. they target more specific dopamine and serotonin receptors, so the effect are more precise

2. less risk of relapse compared to the first generation antipsychotics

3. fewer serious side effects like motor problems

4. takers of these newer medications are more likely to continue treatment

5. the newer, atypical antipsychotics also help reducing negative symptoms

Recent research has cast a doubt on these assumptions, as second generation drugs tend to have some of their own side effects (e.g. affected immune functioning) and the side effects resembling Parkinson are sometimes also seen in atypical drugs. Studies have also found no significant differences in effectiveness when they compared the first to the second generation drugs, and the second generation produced just as many unwanted side-effects as the first generation.

Psychological-based Therapies

Psychotic symptoms can result in inappropriate behaviours towards friends and family, which can make daily life even harder for sufferers. Social skills training focuses on teaching the appropriate skills one needs in basic social interactions, therefore hopefully reducing the risk of social withdrawal. The training consists of role-playing, modelling and teaching one how to respond in specific social situations. Teaching these skills and other skills such as physical gestures, eye contact, facial expressions etc. have been shown to positively affect many things, such as overall communication skills, coping strategies, finding work, reaching out for help when they need it, finding accommodation and a general decrease in psychopathology. Supported employment is a programme which helps individuals find work fit for their abilities and goals, and has been found to lead to better rates of work and higher wages than other programmes.

Cognitive therapies were thought of as inappropriate for treating psychosis, because of the lack of insight patients have and the thought that psychosis were largely due to biological and not psychological causes. This is not true today, and it is thought that cognitive behavioural therapy is effective in challenging many psychotic symptoms, so cognitive behaviour therapy for psychosis (CBTp) was developed. The negative bias that many patients hold towards their hallucinations (e.g. they are dangerous and negative), can make the person indulge in safety behaviours such as shouting at the voices or drinking alcohol. CBTp can help challenge these negative biases, help identify a non-psychotic meaning for their symptoms and reduce negative symptoms one experiences by challenging their low expectations they hold about themselves. CBTp also helps with the adjustment when an individual returns to the ‘normal’ world after hospitalization, and help maintain the use of medications. CBTp can be extended to also include helping paranoid delusional individuals challenge their attributions concerning their delusions, which is done in reattribution therapy. Individuals’ paranoid beliefs are challenged by the therapist simply by asking them if their belief logically makes sense, which is often sufficient. If necessary, a ‘reality-test’ can also be conducted, where the therapist actually tests the belief that the patient may hold.

After being discharged from some kind of hospitalization, one can receive personal therapy. Personal therapy is focused on teaching the skills needed with daily life after discharge. These skills include: how to identify and deal with signs of relapse, acquiring relaxation techniques, identifying inappropriate behavioural and emotional responses and learning better ones, identifying inappropriate thinking biases and cognitions and how to deal with them, and learning to deal with criticism and negative feedback from others and themselves.

Because symptoms of schizophrenia affect cognitive deficits such as attention, memory and executive functioning, cognitive remediation training (CRT) or cognitive enhancement therapy (CET) are used to improve these cognitive skills, which may speed up progress in other treatments and improvement in social skills.

Interventions in Families

As mentioned before, families can play a big role in how an individual handles psychotic symptoms. Expressed emotion (EE) and communication deviance (CD) can play a big role in whether or not a patient gets their life back on track. Family psychoeducation focuses on teaching the family of a sufferer the nature of- and how to deal with- schizophrenia or other psychotic symptoms. A method used to help the family learn about everything related to psychotic symptoms (e.g. recognising relapse or helping with medication) is supportive family management, which consists of counselling sessions with families sharing their experiences and thus also building social support. Applied family management is a more intensive version of supportive family management, where families are actively taught how to help the afflicted family member. Research has shown that family interventions are very effective in reducing risks of relapse, reducing symptoms and improve the patient’s social- and vocational functioning.

Communal Care

Before the US’ Community Mental Health Act of 1963, many mental health sufferers were detained in hospitals. After the act passed, many countries followed, and now mental health sufferers usually have the right to receive many services that help with their affliction. Some of these cares are outpatient therapy, preventative care, aftercare and emergency care. Assertive community treatment is a service developed out of this change in the care of the mentally ill. Assertive community treatment assists people with medication regimes, guidance with decisions, help with vocational training and offering psychotherapy. Assertive outreach is a form of care for individuals who have not yet experienced any effect with other mental health services. Assertive outreach is focused on helping individuals with severe mental problems, and some of the main goals are to increase social life, prevent relapse, find accommodation and help with medication adherence. Staff of assertive outreach meets the individual regularly over a long period and therefore hopefully builds a solid bound with the individual. Community care helps in many domains, but it is often hard to resource and coordinate.

Studies have found that sufferers from schizophrenia are much more likely to be victim of murder for many reasons, some of which are that they are more likely to live in a more dangerous part of town or they might provoke hostility because of their symptoms. Sufferers from mental illnesses are also more often seen as dangerous and violent in media. Some studies support this, and some studies contradict it, and it is still not safe to say which is true, since many variables have to be accounted for. However, one study did indicate that 99.97% of all sufferers from schizophrenia won’t exhibit any serious form of violence in any given year. Substance abuse does seem to occur much more in those suffering from schizophrenia, so it is a challenge for community care to tackle this problem.

Substance Abuse and Dependence - Chapter 8

Introduction

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.

Defining & Diagnosing Substance Use Disorders

Before the DSM-5 there were two categories for defining substance and drug use. Substance abuse is the use of substances despite one’s knowledge about its negative effects. Substance dependence is a full-blown version of substance abuse characterized by cognitive, behavioural and physiological symptoms where the individual continues use of a drug despite its significant negative effect. These two categories are now combined in the category ‘Substance Use Disorder’ in the DSM-5. This change is because many showing substance abuse not always end up showing substance dependence, and analysis showed that substance abuse and dependence represented one instead of two categories.

Substance Use Disorder (SUD) is characterized by at least one substance disorder diagnosis, and its criteria fits within four broad groups:

• Impaired control, such as taking the substance for longer than intended, failed attempts to quit/moderate or daily activities revolve around obtaining the high.

• Social impairment, like withdrawal from family/hobbies or drug use is resulting in failure at work/school/social relations.

• Risky use, like taking the drug despite being in a hazardous situation and taking the drug despite ones awareness of the harm it does.

• Pharmacological criteria, like tolerance showing that the body is affected heavily by the drug and showing withdrawal symptoms after not taking the substance.

Some terms often seen in the discussion of substance use and abuse are addiction (use of drugs up until the point where one is more often high than not), cravings (strong subjective drives to use a drug), tolerance (requiring higher doses for the same effects), withdrawal (negative behavioural changes seen when one’s body lacks the drug) and psychological dependence (when a person changes their life significantly to ensure continued use of the drug).

Prevalence & Comorbidity of Substance Use Disorders

Lifetime prevalence rates for the US have been calculated to be 2.6 to 5.1%. Substance use disorders are very comorbid with many other psychological disorders. Especially mood disorders and anxiety are seen to be very prevalent in those suffering from a substance dependence. Some argue that substance abuse/dependency may result in a psychiatric illness, but most evidence suggest the opposite, that substance use results from a psychiatric illness. Perhaps substances are used to cope and alleviate the many symptoms (known as self-medicating).

Characteristics Seen in Specific Substance Use Disorders

The specific substance use 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.

Alcohol Use Disorder

Alcohol is extremely often used across the globe, and patterns of its use are becoming problematic. Males drinking 5+ and females drinking 3+ drinks on a typical drinking day are labelled as hazardous drinkers, and the amount of hazardous drinkers is rising. Another problem is the surge of binge drinking, which is basically a very high intake of alcoholic drinks on a single occasion. Amounts of drinks required to be considered a binge drinker depends on the country. The effects of alcoholic drinks come from the chemical ethyl alcohol. It is absorbed in the bloodstream through the lining of the intestine and stomach. When it reaches the central nervous system, it works by facilitating the use of GABA, resulting in more inhibition thus relaxation. The final effects of alcohol intoxication are motor coordination difficulties, blurred vision and slowed reaction times. This is where the term biphasic comes from when describing alcohol’s effect, since the effects of alcohol can be both stimulating and depressing. It is often thought that the wanted effects of alcohol (increased sociability, reduced inhibitions and stress-alleviating) are largely due to the users expectations, instead of it being truly caused by alcohol.

Longer use of alcohol can result in negative effects over time, such as larger quantities needed for the same effect. When the body is deprived of alcohol, one can show restlessness, inability to sleep, depression and anxiety and many more. If one has drank heavily for years, withdrawal can lead to delirium tremens (DTs), making the person delirious and experiencing unpleasant hallucinations, and exhibiting muscle tremors and shaking. Heavy alcohol use for longer periods can result in hypertension, stomach ulcers, cancer, heart failure, cirrhosis of the liver, brain damage and early dementia. Alcohol contains calories, but no nutrients, so users can feel full but lack vitamins and minerals, which can lead to Korsakoff’s syndrome, characterized by dementia and memory disorders. Heavy drinking in pregnant mothers can result in fetal alcohol syndrome, where children show severe physical deformities and psychological problems due to prenatal alcohol exposure.

Prevalence rates for dependence and abuse appear to be respectively 12.5% and 17.8%, and dependence is seen more in younger, unmarried men of lower socio-economic class. Alcohol abuse is often part of what is known as a polydrug abuse, which means that more than one drug is abused at the same time (e.g. many heavy drinkers are smokers).

Alcohol use disorders are problematic patterns of drinking where if often passes through stages of heavy and regular use, then alcohol abuse is exhibited and finally an alcohol dependence is seen. Risk factors for alcohol use disorders include: a family history of alcoholism, the experience of long-term negative affect, conduct disorder seen in childhood, experiencing stress (especially childhood stressors), and believing that alcohol has favourable outcomes.

Society is affected by alcohol use disorders because of the lost productivity, spending on healthcare, crime and many other costs. Alcohol use is closely related to motor vehicle crashes, boating accidents, drownings, crime, sexual assault, child molestation and suicide. All of these impact society in many ways, which is why it is important to deal with overuse of alcohol.

Tobacco Use Disorder

Nicotine is the compound found in tobacco responsible for multiple effects when affecting the brain. It increases blood pressure and heart rate, therefore having stimulating effects. However, smokers also report less anxiety, anger and stress, so it also has calming effects. The opposite happens when there is a lack of nicotine in the body, resulting in increased stress and anxiety, therefore nicotine is seen as a both psychologically and physically addictive substance. A growing body of evidence shows that nicotine’s positive effects (elevated mood, enhanced cognitive functioning and decreased appetite) are caused by the release of dopamine in the mesolimbic system. The calming effect that is often reported after having a cigarette appears to be because of the reversal of withdrawal symptoms. So smokers do not feel more calm and less anxious than non-smokers, they (on average) feel equally calm as non-smokers only when they have just smoked, and actually feel worse when there is a lack of nicotine.

Nicotine follows alcohol for the second place of most used drug worldwide, and half the users die from smoking. Approximately one third of the adult population smokes, and this number is one in five for teenagers aged 13-15. These numbers are dropping for developed nations, and increasing for developing nations. Many smokers (about 2/3) report wanting to quit but say they would find it too hard to go a day without smoking, which is a criterion of the DSM-5 for a substance use disorder.

Some characteristics of tobacco use disorder are the need to smoke within 30 minutes of waking up, craving the use of tobacco, unsuccessful attempts to control use, or tobacco use becomes more over time. When first taking tobacco one often experiences nausea and dizziness, these effects lessen over time as one gets more tolerant of nicotine. Abstinence of nicotine will lead to withdrawal symptoms (e.g. depressed mood, insomnia, restlessness, anxiety, anger, difficulty concentrating, impatience). Tobacco use seems to be comorbid with other disorders such as alcohol (or other substance) use disorder, depression, bipolar disorder, anxiety disorder, personality disorder and ADHD.

Smoking is most detrimental to the user’s health, and nicotine dependence is the largest preventable cause of death. Smoking kills over 6 million people each year and it is a significant factor in stroke, heart disease, chronic lung cancer and cancer of the larynx, mouth, bladder, cervix, oesophagus, pancreas and kidneys. It is estimated that about half of all smoking teenagers will die from a tobacco-related disease if they continue smoking. These serious health-issues also result in huge amounts of money spend on society’s health problems caused by smoking. Not only the smoker’s health is compromised, breathing in other persons second hand smoke (known as passive smoking) can also cause physical and psychological effects.

Cannabis Use Disorder

Cannabis is obtained from the plant cannabis sativa. Hashish is the most powerful type of cannabis, and marihuana is a weaker derivative made from dried and crusher cannabis leaves. Cannabis effects are feelings of relaxation, euphoria, sharpened perceptions (which might result in mild hallucinations), and increased sociability. Less wanted effects include difficulties in concentration and memory impairment. Higher doses can also induce stimulating effects (increased anxiety or paranoia) despite its classification as a sedative. The (main) active ingredient in cannabis is tetrahydrocannabinol (THC), and cannabis is thought of to not have many addictive qualities. It works mildly stimulating by increasing heart rate, and the psychoactive effects are caused by the cannabis working on the cannabinoid receptors CB1 and CB2 in the striatum, hippocampus and cerebellum. These receptors are known to regulate dopamine, which is thought to be the reason for the positive psychoactive effects. Cannabis is used for some medical ends, but it is mainly used for recreational purposes. Despite few harmful effects on behaviour and health, it is still an illicit drug in most countries.

Cannabis is the most often used illicit substance, and its estimated global prevalence is about 2.6 to 5%. Use has increased significantly since the 1960s, especially in North America, Western Europe & Australasia. Prevalence in western countries vary from around 5 to 15%.

Because of an increase in strength of THC contents in street-cannabis, more evidence has accumulated for a cannabis abuse and dependence syndrome in users. Withdrawal and tolerance have been seen in long-term users, some of the withdrawal symptoms being irritability, restlessness and flu-like symptoms. Cannabis use disorder can be diagnosed when an individual reports a reduction in pleasure obtained from cannabis, and continuing increased use. Cannabis use disorder is usually not accompanied by some other substance disorder, and sufferers report using cannabis to cope with mood, sleep better, and reduce pain or some other psychological or physiological problem.

Cannabis intoxication is characterized by a reported ‘high’ feeling, followed by euphoria, inappropriate laughter and grandiosity, sedation and lethargy, memory and judgement problems, perception of time seems to be slowed, distorted sensory perception and impaired motor skills. Risk factors for cannabis use disorder are age of onset, regularity of tobacco and cannabis use, impulsivity and mood-swings, a diagnosis of an emotion disorder or a conduct disorder during childhood, and prior alcohol or drug dependence. Cannabis use disorder is a risk factor for other psychiatric disorders such as anxiety and panic disorder, major depression, schizophrenia and increased tendency for suicide. It is not certain whether cannabis use is the cause of mental problems, or whether cannabis is used because of mental problems. Currently both appear to be possible, as some studies have shown that there is a causal relationship between cannabis use and the risk of developing psychotic symptoms. So whether one causes the other is not yet clear, as it is also possible that there is a third variable causing both cannabis use and psychotic symptoms (e.g. childhood problems).

Cannabis use has some effects on cognitive skills such as reduced reaction time, decreased attention span, slower problem-solving ability, deficits in verbal ability and loss of short-term memory. These effects can be very dangerous in certain settings, and evidence has shown that cannabis affects driving skills and driving safety. Cannabis users tend to underachieve, where regular users have lower IQ’s, lower educational achievement and deficits in motivation. Besides this association with an underachievement syndrome, there is only little evidence for long-term neurophysiological effects. Regular users do tend to end up with a lower educational achievement and lower income. Amotivational syndrome is seen in regular users exhibiting apathy, loss of their ambitions and more difficulty concentrating. Long-term physical risks of cannabis may be exposure to tar from cannabis smoke, a reduction in male’s testosterone, and impairment of the efficiency of the body’s immune system (although no effect has been seen yet on users physical illnesses).

Stimulant Use Disorders

Substances causing increased central nervous system activity, increased blood pressure and heart rate are known as stimulants. They provide alertness, feelings of energy and confidence and enhance thinking speed. Cocaine is one of the stimulants, and it is a natural substance extracted from the coca plant. Amphetamines are synthetic drugs found in the common forms of amphetamine, dextroamphetamine and methamphetamine. Caffeine is probably the most common stimulant, and it is usually found in coffee, tea, chocolate and some supplements.

After cocaine has been processed, it appears as a white powder which can be snorted, injected or when its more pure smoked (crack cocaine). The act of smoking cocaine is known as free-basing. When snorted, a rush of cocaine takes about 8 minutes and lasts 20 to 30 minutes. This rush is characterized by feelings of euphoria, energy, and excitement. After this initial feeling, the drug affects other areas resulting in increased arousal, alertness, and wakefulness. The main effects are due to blockage of dopamine reuptake.

Lifetime prevalence rates in developed countries is 1 to 3%, with European rates varying from 0.5 to 6% and the US rate being estimated at 14.4%.

Because of cocaine’s short duration, many doses are needed to keep the pleasurable feelings provided by the white powder. Cocaine also tends to be an expensive drug, so maintaining a cocaine rush is expensive and leads some users to resort to theft and fraud. Cocaine dependence is seen when a person finds it hard to resist using the drug when it is available, which in turn can lead to neglecting important things such as work or child care. Tolerance also occurs in cocaine use, as users often have to take larger doses to achieve similar effects. Abstinence from cocaine can result in hypersomnia, increased appetite and a negative/depressed mood. Cocaine dependence can be accompanied with social isolation and sexual dysfunction, and it can result in the person developing symptoms of other disorders such as major depression or anxiety disorders.

Regular cocaine users show evidence for deficits in decision making, working memory, and judgement. Cocaine use by pregnant mothers can cause development deficits in the unborn child, and this is seen in a retarded development of the child in its first two years of life, a higher chance of ADHD at age 6, and deficits in visual motor development. This may at least partially be caused by cocaine’s effect on blood flow, causing irregularities in the placenta flow. These same cardiovascular effects influence blood pressure and possibly aggravate existing cardiovascular problems, which can result in heart attacks, brain seizures or death.

Amphetamines are synthetic substances stimulating the central nervous system. Common amphetamines are amphetamine itself, dextroamphetamine and methamphetamine, and they are very addictive. Their psychological effects include enhanced feelings of confidence, energy and alertness, and their physical effects include increased blood pressure and heart rate. They work by both releasing more dopamine and norepinephrine and at the same time also blocking the reuptake of these neurotransmitters. Tolerance build to methamphetamine, which is smoked, can occur extremely quick. Withdrawal symptoms include paranoia, anxiety, irritability, confusion, and restlessness.

Worldwide prevalence is estimated to be around 0.3 to 1.2%, and is the second most used drug. The lifetime prevalence rate of amphetamine use disorder is thought to be 1.5%, and of all illicit drug abuse, amphetamine can be accounted for about 16%.

Amphetamines generally last longer than other stimulants (e.g. cocaine), but tolerance builds quicker. Once a high usage dose is achieved, one can also start experiencing temporary but intense psychological effects such as paranoia, anxiety or even psychotic episodes. Individuals dependent on methamphetamine (thus spending most of their time trying to achieve the drug and ignoring duties) often use the drug for several days for a long-lasting high, followed by a couple days of exhaustion and depressed feelings, which is then again followed by methamphetamine use. Amphetamine intoxication starts with a high followed by either positive (euphoria, energy, alertness) or negative (anger, aggression, impaired judgement) effects. Physical symptoms include pupil dilation, nausea, chest pains or in severe cases seizures or coma. Withdrawal symptoms include depression, fatigue, unpleasant and vivid dreams, insomnia, and increased feelings of agitation.

Studies have found that amphetamines may cause long-term damage to the central nervous system. Chronic methamphetamine is seen to affect both serotonin and dopamine systems (reflected in poor decision making in sufferers) and the production of dopamine in the orbitofrontal cortex. This area is important in compulsive behaviour and resistance to extinction of behaviours when the reward isn’t present, which might explain why addicts find it so hard to quit even when they don’t enjoy methamphetamine anymore.

Use of caffeine is extremely common, as around 85% of the world population is familiar with taking it. Caffeine also stimulates the central nervous system, resulting in increased alertness and motor activity, while also fighting fatigue. More negative effects that can also be experienced are insomnia, anxiety, headaches, dizziness, and less fine motor coordination. Caffeine reaches its peak concentration with one hour, but half the concentration is still present in the body six hours later, making it a substance that might have some detrimental long-term effects if it prevents sleep. As mentioned, daily use can have the positive effects of increasing alertness, attention, cognitive functioning, elevated mood and fewer symptoms of depression. However, overuse will often result in anxiety, and can sometimes result in psychotic and manic symptoms.

Sedative Use Disorders

Sedatives are known as central nervous system depressants due to their effect of reducing the body’s activity, responsiveness, pain, tension, and anxiety. Sedatives include alcohol, opiates and alike (e.g. heroin, morphine, codeine and methadone), and synthesized tranquilizers (e.g. barbiturates). Sedatives have serious effects on regular users like rapidly build tolerance, severe withdrawal symptoms and high doses leading to a disruption of the important body functions.

Sap from the opium poppy is known as opium, which is a form of opiate. Other derivatives are the opiates morphine, heroin, ‘methadone’ (technically an opioid) and codeine. Used at first as a medical end for treating pain, it quickly became known that opiates are highly addictive. Methadone, developed by the Germans during WWII, is a synthetic form of opiates (thus an opioid) and is known for its less severe effects, slower onset and its ability to be taken orally. Heroin, derived from morphine, is the current most widely used ‘opiate’ (also considered an opioid). Opiates usually cause drowsiness and euphoria, but heroin also gives an ecstasy rush at the beginning of the six hour lasting trip, therefore making it a more popular drug. As many good things come with a price, heroin’s regular users quickly develop tolerance and its withdrawal effects are severe and start six hours after the person has injected the drug. Opiates affect the brain by attaching to endorphin receptors and signalling these receptors to produce more endorphins. Endorphins are the body’s natural painkillers as these neurotransmitters relieve pain, reduce stress and give pleasurable sensations.

Estimated worldwide (annual) prevalence is about 0.3 to 0.5%, but these numbers are higher for developed nations, varying from about 1.2 to 4.2%.

As mentioned multiple times, opioids and opiates are extremely addictive to many users. Withdrawal effects occur right after the trip ends, so about six hours after use. Symptoms of withdrawal are anxiousness, restlessness, muscle aches, an increase to sensitivity of pain and craving more of the drug. Severe withdrawal can also include insomnia and fever. Symptoms generally peak after one to three days, and last about five to seven days. Opioid use disorder is characterized by a developed tolerance to opioids and opiates, and it is generally hard to treat due to the severity of the withdrawal symptoms. In those diagnosed with opioid use disorder, marital difficulties and unemployment are definitely not uncommon, just as other drug related crimes like distribution of drugs. However, studies have shown that many people can periodically use opioids or opiates recreationally and function just fine. The terms controlled drug user and in the case of heroin unobtrusive heroin user are therefore coined, which describes a long-term drug user who has never received specialized treatment and displays occupational status and academic achievement just as much as the general population. Due to these findings, some theorists state that the use of opiates is linked to life stressors, and if these stressors are only temporary, so will the drug use be.

Apart from the severe withdrawal symptoms regular users experience, other risks are 1) an accidental overdose due to failure of diluting pure forms of heroin, 2) being sold heroin that contains additives that are lethal, and 3) the risk of obtaining HIV or hepatitis from shared needles. A US study concluded that 28% of heroin addicts died before the age of 40, with only one third being from overdose, while over half were from suicide, homicide or accidental death.

Hallucinogen-Related Disorders

Psychoactive drugs or also known as hallucinogens affect the users perceptions. They can create sensory illusions and hallucinations or simply sharp the sensory abilities. They are less addictive than previously mentioned substances and have fewer effects on arousal level. The two hallucinogens discussed are lysergic acid diethylamide (LSD) and MDMA. MDMA is a hallucinogen and stimulant at the same time, and it is also known as ecstasy. Other common hallucinogens part of the group phencyclidines are PCP, ‘angel dust’, ketamine, cyclohexamine, and dizocilpine. Phencyclidines are known to produce feelings of separation from mind and body when low doses are taken, and stupor and coma at high doses. Its prevalence caused the DSM-5 to include Phencyclidine Use Disorder.

Consciousness-expanding or mind-expanding drugs are known as psychedelic drugs, and LSD was probably the first widely used psychedelic. LSD, also known as acid, is usually sold as tablets or capsules. Its effects start 30 to 90 minutes after ingestion, and some of its physical effects are raised body temperature, sweating, increased heart rate and blood pressure, dry mouth, sleeplessness and tremors. LSD’s ability of heightened perception make some state that it allows for enlightenment about the world. Besides heightening perception, LSD also causes hallucinations including distorted perception of time and space, perceiving objects and people not present and the belief that one contains skills they in reality don’t have (e.g. ability to fly, which is of course a dangerous belief). Feelings of anxiousness, fear or stress when taking LSD can result in the exaggeration of these feelings, which then can result in the user experiencing a bad trip. These bad trips can be characterized by extreme terror and panic which can last the remaining trip. Vivid flashbacks to a trip are also known to be experienced by regular users. LSD appears to produce its effects by affecting serotonin in the visual and emotional brain areas.

LSD used to be more popular in the 60s and 70s, but since stimulants became a more common recreational drug, prevalence rates have declined to 0.3 to 0.5%.

Although hallucinogens are not that addictive, some users report craving the drug after they stopped using them. Because many hallucinogens last very long, users often spend hours or days recovering from them. Especially MDMA is known for its hangover the next two days after use.

MDMA is the working substance in the common drug ecstasy. Ecstasy has been a very popular recreational drug for the last twenty years, especially in the club and raving scenes. Its stimulating and hallucinogenic effects are produced by affecting the release of the brain’s dopamine and serotonin levels. Increased levels of serotonin result in euphoria, sociability, well-being and enhanced perception of sounds and colours. Effects start about twenty minutes after ingestion and last up to six hours. High levels of dopamine, seen in regular users, can result in symptoms like confusion and paranoia.

Average global use appears to be 0.2 to 0.6%, about the same for cocaine use. Recent evidence show there might be a resurgence of Ecstasy in Europe and the US. Individuals regularly taking Ecstasy usually spend many hours or days recovering from it. The hangover includes insomnia, fatigue, headaches, drowsiness, depression and sore jaw muscles from teeth clenching.

Inexperienced users can experience dehydration or water intoxication due to a lack of knowledge about proper hydration. Users with prior cardiovascular problems can be heavily affected by the drugs’ increase in heart rate and blood pressure. Also, ecstasy is a neurotoxin destroying axons where serotonin usually binds. This can lead to long-term problems including memory deficits, sleep problems, lack of concentration, verbal-learning deficits, and increased depression and anxiety.

Aetiology of Substance Use Disorders

Many individuals using drugs do not end up with severe problems in their lives. What differentiates these individuals from people developing a substance use disorder is the kinds of risk factors they are exposed to, and how this affects them. Individuals becoming dependent on a substance go through a series of stages. Each stage is characterized by different risk factors influencing a possible transition to the next stage. The three stages are experimentation (a period where an individual tries out different drugs), regular use, and abuse & dependence, which all will be explained. Other factors important in the development of a substance use disorder are neurological and behavioural factors, of which examples are the neurocircuitry associated with addiction and the conditioning of cues to cravings.

Experimentation

One of the factors predicting experimentation with drugs is whether or not the drug is available to an individual. Two main causes for a substance availability are its cost and whether it is legally available.

Whether a family member uses a substance or not predicts later use of an individual, as with a person’s problematic (or not) home situation. Negative background factors predicting long-term substance use are 1) substance use in one’s childhood home, 2) severe poverty in one’s childhood home, 3) legal or marital problems in the household, 4) childhood abuse and neglect (especially sexual abuse), and 5) psychiatric problems in a person’s household.

Peer pressure is often states as a reason for one to do something, yet actual pressure to use a drug is not commonly seen, but social peer influence is a big predictor for drug use. Adolescents might start using some substance so they can self-categorize themselves to be a member of a specific group. Younger people might want to identify more with a group and conform to the group, and adopting behaviours seen in the group is thought to help this process. Not only can a social group determine what substance a person might experiment with, substance use also predicts which kind of people the person relates to. So a regular drinker will be more likely to hang out with other regular drinkers, and this group environment of drinking will then again consolidate regular use.

Advertising and media exposure to substances also greatly influences young adolescents chances of taking up a drug. Studies have shown that exposure to tobacco advertisements encouraged children to start smoking, and banning these advertisements produced a significant fall in the use of the substance in adolescents.

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.

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: 1) the intrinsic rewarding effects of the drug leads to physical dependence, 2) the users life is so negative that the positive effects of the drug outweigh the negative effects, and 3) 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.

Abuse and Dependence

Normal use of drugs does not often lead to a dependence. Other factors like genetics play a role in whether a person will end up abusing drugs. The heritability component of substance use disorders have been found to be around 0.46, and as high as 0.78 for alcohol and nicotine dependence. MZ and DZ twin studies and adoption studies both support the genetic role in substance dependence. One reason for this genetic component is that environmental situations trigger substance use in those who have a genetic predisposition. These environmental triggers are not necessarily stressors, but also factors like peers using the substance or modelling ones parents. Another possibility is that genetic differences result in different tolerance levels to drugs and different ways in how the brain responses to drugs. This is seen in some people being easily intoxicated and others requiring many drinks. A third reason for the genetic component in substance abuse is that some genes affect the persons tolerance, as for example the gene ALDH2 responsible for the speed of the breakdown of the toxic substance acetaldehyde (which results from alcohol) into non-toxic acids. If metabolism is more slowly, one has a smaller tolerance towards alcohol. This is supported by the fact that Asians often have a mutant allele for ALDH2, resulting in a slower metabolism, and therefore alcohol use disorder is twice as rare in Asians as in non-Asians.

Whether or not specific drugs have long-term cognitive effects is still not clear for most of them. However, most substance abuse disorder sufferers are shown to have an underachievement syndrome, which a lower IQ, lower educational achievement and motivational deficits. It may be true that these qualities were already present prior to drug use, and actually caused the person to use drugs. It is also possible and sometimes shown in research that regular substance use causes intellectual and motivational deficits, but this of course depends on the drug.

Substance users who suffer from comorbid psychiatric disorders often have more trouble with avoiding substance abuse and dependence. This is thought to be for the following reasons: 1) individuals with comorbid psychiatric disorders often face more problems and life stressors, and are less likely to have good coping resources. Therefore these individuals resort to self-medication quicker and 2) persons suffering from comorbid psychiatric disorders tend to not consider drugs as problematic as fast as their peers, and relapse after treatment faster.

An individual’s chance of experiencing an illicit drug increases as one lives in or near a poor neighbourhood. Lower socio-economic status is often characterized by higher unemployment rates, less forms of recreation available, little hope of educational achievement and exposure to drugs-cultures. These circumstances all contribute to the use and abuse of drugs and maintaining possible drug dependence. Crime is also more often seen in poor areas, and these crimes are often associated with drug use.

Treating Substance Use Disorders

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, 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.

Programmes Based on Communities

There are many community-based services for treating substance use disorders. Alcoholics Anonymous (AA) is a well known support group for individuals dependent on alcohol. Its focus is to replace the individuals drinking group with a group that they can relate to and that are also trying to quit drinking. Some studies have shown that AA is an effective treatment for long-term results, but other studies did show that it is not significantly better than other kinds of structured treatment. Services known as drug-prevention schemes aim to prevent individuals using drugs or to prevent experimental use turning into regular use. This is done by lecturing communities and school, having websites available or 24/7 phone helplines. Specific strategies of drug-prevention schemes are 1) peer-pressure resistance training, helping students resist drugs in situations when confronted with drugs, 2) countering media influence with campaigns and advertisements, 3) peer leadership, which attempts to have students transfer anti-drugs messages to peers, and 4) changing false views that students hold of drugs (e.g. alcohol is harmless). Residential rehabilitation centres are centres allowing individuals to work, socialize and in general just live with others who are also undergoing treatments. They also receive psychological interventions, advice and support from professionals. Multiple studies have concluded that longer stay results in significantly better outcomes.

Behaviour Therapies

Aversion therapy is focused on changing the use of substances from a positive experience to a negative experience. It is most used with alcohol dependence, and classical conditioning principles are used when the individual (in this case) receive alcohol, which is quickly followed by an aversive drug causing nausea and sickness. Just thinking about negative events and pairing this thought with the thought of substance use is also possible, and this is known as covert sensitisation. Aversion therapy has only limited evidence for its effectiveness, and especially in long-term substance dependence aversion therapy seems to be limited in its effectiveness. However, aversion therapy can still be combined with other treatments.

Helping the individual identify environmental cues and triggers leading to substance use is known as contingency management therapy. It helps the individual identify and avoid certain triggers, rewards them for abstinence, helps them become aware of situations of substance use and its frequency, and setting non-abstinence goals for the person to work on. There are multiple new variations developed as we speak, and one variant of behavioural self-control therapy (BSCT) is controlled drinking. Instead of helping with complete abstinence of alcohol, it puts emphasis on controlled drinking. Its assumptions are that because alcohol use is so normal in most western societies, it is very hard to avoid alcohol altogether. Another assumption is that teaching one to control their drinking gives more self-esteem, a sense of responsibility and feelings of control in other domains of their lives. Some of these outcomes are often the reason why they started to drink first of all, so it also treats the root cause of the substance abuse. Teaching clients to have true control over their drinking and that relapses are normal and can be overcome has shown to be an effective treatment and at least as effective as total abstinence treatments.

Cognitive Behaviour Therapies (CBTs)

Substance use disorders are known for their difficulty to treat over the long-term. Cognitive behavioural 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 1) the person’s beliefs about relapsing, and 2) 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 behavioural 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.

Couple & Family Therapy

Including family and spouses in the treatment of substance use disorders can be very helpful for several reasons. 1) many individuals abusing drugs are adolescents and thus living at home, so family can give direct support to them, 2) often parents of the client abuse drugs themselves, and so be part of the problem that needs to be solved, and 3) individuals with a substance use disorder may physically, emotionally or sexually abuse family members, so this also needs to be addressed. Family therapies are often effective in altering dysfunctional family situations, and this form of treatment is focused on including family members in a non-judgmental manner. Couple and family therapies have shown to be at least as effective as individual forms of CBT, and it is especially effective in adolescent substance use problems.

Biological Treatments

The process of supervised systematic withdrawal from some substance is known as detoxification. It is often accompanied with other drug use which helps the detoxification process, which has the following functions: 1) reducing withdrawal symptoms like drugs which reduce cravings, 2) preventing relapse with the use of aversive drugs making relapse also aversive (see ‘aversion therapy’), 3) blocking the neural activity that would make a drug pleasurable, and 4) switching to a weaker substance, which is done in methadone maintenance programmes where users take the less harmful methadone instead of more dangerous opiates like heroin.

Antabuse (disulfiram) is one of the aversive drugs that makes alcohol intake a negative experience by slowing bodily processes making the user nauseous or vomit. If administered in a supervised manner, antabuse can be very effective in short-term abstinence. Some drugs affecting endorphin receptor sites are naltrexone, naxolone and buprenorphine. These drugs prevent opiates and opioids from having their euphoric effect which has its origin at endorphin receptor sites. However, these drugs must be carefully dosed and regulated, and their effectiveness is based on however long the person is taking them. Some of these drugs appear to not only be effective for opiates, but also for alcohol and cocaine dependency. This may be due to the fact that endorphin receptors are intimately associated with our brain’s reward centres.

Drug replacement treatment is mostly done with opiate dependent individuals, and focuses on substituting a less severe drug for the more severe one. It is important to realise that in the case of opiate drug replacement treatment, methadone is still a very addictive substance and will often take long to withdraw from. Outcome studies suggested that methadone maintenance treatment is the most effective when accompanied with other forms of intervention like psychotherapy, drug education, contingency management and skills training. Other positive outcomes of drug replacement treatments is that they lower the crime that otherwise would result from the users’ need to support their dependence and reduce health risks (e.g. HIV from infected needles). Drug maintenance therapies are mostly seen in opiate dependency, although lately there are other drug developed to substitute for other substances, like Sativex which substitutes cannabis use.