Book summary of Abnormal Psychology - Kring et al. - 13th edition

What is psychopathology? - Chapter 1 (13)

Psychopathology is the study of the nature, development, and treatment of psychological disorders.

There is a lot of stigma surrounding with psychological disorders. Stigma is the destructive beliefs and attitudes that are attributed to groups that are seen as different. It has four elements:

1. A group of people is labeled and this label distinguishes them from others.

2. Society links the label to abnormal and undesirable characteristics.

3. The label makes people with the label seem different from those without the label.

4. The label makes the people with the label being unfairly discriminated against.

In this century psychological disorders are still the most stigmatized conditions.

1.1. How is psychological disorder defined?

The best definition of psychological disorder has these aspects:

• The individual has the disorder within himself.

• There are difficulties in thinking, feeling and/or behaving that are of clinical significance.

• It often involves a kind of personal distress.

• There is impairment in processes that support mental functioning, such as: psychological, developmental, and/or neurobiological.

• The problems are not a culturally specific reaction to an event.

• The problems are not only a result of conflict with society.

Each aspect covers a part of psychological disorders. Four aspects will be further discussed.

If a person’s behavior causes him enormous distress, the behavior may be classified as disordered. A lot of psychological disorders causes distress, but not all of them.

Disability is an impairment in some important aspect of life. Psychological disorder can also be characterized by disability. Just like distress, a lot of psychological disorders can involve disability, but not all of them. There is no rule to determine which disability belongs to the study of psychopathology and which do not.

If a behavior violates social norms, it can be classified as disordered. This definition of psychological disorders is both too broad and too narrow. It is important to note here that social norms are different among cultures and ethnicity.

Harmful dysfunction, a definition for psychological disorders thought of by Wakefield, has two parts. ‘Harmful’ is a value judgment and ‘dysfunction’ is an objective component. The DSM considers developmental, psychological and biological dysfunctions as interrelated.

1.2. What is the history of psychopathology?

Demonology is the doctrine that a person can have an evil being dwell within himself, and this being can control his mind and body. This doctrine was mostly seen in times before the age of scientific inquiry. In these times events beyond human control were seen as supernatural.

The first to separate medicine from religion and superstition was Hippocrates. He believed that mental illnesses had natural causes and should be treated as such. He also believed that mental illnesses were caused by a disbalance between four fluids of the body: blood, black bile, yellow bile and phlegm.

When the church gained in influence after the Greek and Roman civilization ceased to exist, the believe in supernatural causes of psychological disorders returned. A lot of psychological disorders was ascribed to witchcraft. Witchcraft was seen as a denial of God.

In Europe there were a lot of hospitals for patients with leprosy until the fifteenth century. The old leprosy hospitals were turned into asylums, when the attention shifted from leprosy to psychological disorders due to disappearance of leprosy in Europe. Asylums were buildings used to give housing and care to people with psychological disorders.

1.3. What is the evolution of contemporary thought?

1.3.1. What are the biological approaches?

Biological approaches gained credibility when a link was made between infection, damage to the brain and a form of psychopathology. This happened for the first time in 1905, when the microorganisms causing syphilis were discovered.

Francis Galton was one of the first to ascribe many behavioral characteristics to heredity as a result of his studies with twins in the late 19th century. He talked about differences in nature (genetics) and nurture (environment). Some researchers became interested in the idea of heritability in psychological disorders and started studying it.

1.3.2. What are the psychological approaches?

Breuer was a Viennese physician who thought of the cathartic method. Catharsis is reliving an earlier emotional trauma and by expressing previously forgotten thought about the event, emotional tension was released.

Freud was a younger colleague of Breur. Freud theorized that psychopathology is caused by unconscious conflicts in the individual. This is often referred to as psychoanalytic theory.

He divided the psyche into three main parts: id, ego and superego. The id wants immediate gratification of it basic urges. Also known as the pleasure principle. Tension is produced when the urges of the id are not satisfied.

After six months of life, the ego starts te develop. The contents of the ego are mainly conscious. It needs to deal with reality and thus is driven by the reality principle. The ego mediates between the demands of the id and the demands of reality.

The superego can be seen as a person’s conscience. The superego develops throughout childhood. It incorporates the values of the parents to receive the pleasure of the parents’ approval and avoid the pain of disapproval.

Freud and his daughter Anna see defense mechanisms as a strategy of the ego to protect itself from anxiety. There are several forms of defense mechanisms.

Psychoanalysis is the psychotherapy based on Freud’s theory. The therapist’s goal is to understand the early-childhood experiences of the patient, the nature of important relationships, and the patterns in current relationships. The therapist pays attention to emotional and relational themes that surface again and again.

A key aspect of psychoanalytic therapy is the analysis of transference. The responses of a patient to his analyst sometimes seem to reflect ways of behaving toward important people in the patient’s past. This is what transference is.

Jung was a Swiss psychiatrist who proposed that a part of the unconscious is common to all people. That part is called collective unconscious.

Alfred Adler is known as the founder of individual psychology. An important part of his work was on helping people change their disfunctional ideas and expectations.

Freud’s influence is most visible in the next three well-known assumptions:

• Adult personality is partly shaped by childhood experiences. The focus lies often on the parent-child relationships.

• Behavior is also influences by unconscious processes.

• It is not always obvious what causes human behavior or what the purpose is of one’s behavior.

Observable behavior is the center of behaviorism rather than that consciousness of mental functioning.The behaviorist approach was influenced by three types of learning:

• Classical conditioning. A neutral stimulus is linked to another stimulus (unconditioned stimulus, UCS) that automatically elicits a certain response (unconditioned response, UCR). The neutral stimulus becomes a conditioned stimulus (CS) after repeated trials. The conditioned stimulus elicits the same response (conditioned response, CR).

• Operant conditioning. Thorndike’s law of effect states that if behavior is followed by consequences that are satisfying the individual, that behavior will be repeated. In contrast, behavior with unpleasant consequences will be discouraged. Skinner formulated the following reinforcements. Positive reinforcement is increasing the change a certain behavior will re-occur by presenting a pleasant event. Negative reinforcement strengthens a reaction by the removal of an unpleasant event.

• Modeling. Modeling is learning via watching and imitating others.

Behavior theory is based on the principles of classical and operant conditioning. In this kind of therapy, the clinicians try to change behavior, feelings and thoughts by the use of methods and discoveries made by experimental psychologists.

A big disadvantage of the behavioral approach is that there was no room for emotion and cognition.

Cognitive therapy emphasizes the idea that a major determinant in psychological disorders is how people see themselves and the world. According to the cognitive approach, people feel, think and behave.

What are the current paradigms in psychopathology? - Chapter 2 (13)

Thomas Kuhn is a philosopher of science who views the notion of a paradigm as central to scientific activity. A paradigm is a conceptual framework or approach within which a scientist works – that is, a set of basic assumptions, a general perspective, that defines how to conceptualize and study a subject, how to gather and interpret relevant data, even how to think about a particular subject.

In this chapter three paradigms, that guide the study and treatment of psychopathology, will be presented: genetic, neuroscience and cognitive behavioral. The important role of emotion and sociocultural factors in psychopathology will also be considered in this chapter.

Finally, another paradigm will be described: diathesis-stress paradigm, which is the basis for an integrative approach.

2.1. What is the genetic paradigm?

Nowadays it is known that almost all behavior is heritable to some degree and despite this, genes do not operate in isolation from the environment. Throughout the life span, the environment shapes how our genes are expressed, and our genes also shape our environments.

In other words, researchers are learning how environmental influences shape which of our genes are turned on or off and how our genes influence our body and brain.

What makes us unique is the sequencing of the genes as well as what the genes actually do. What genes do is make proteins that in turn make the body and brain work. Some of these proteins switch on or off other genes, a process called gene expression. Learning about the flexibility of genes and how they switch on or off has closed the door on beliefs about the inevitability of the effects of genes, good or bad. And with respect to most psychological disorders, there is not one gene that contributes vulnerability. Instead, psychopathology is polygenic, meaning several genes interacting with a person’s environment is the essence of genetic vulnerability.

An important term that will be used throughout this summary is heritability. This refers to the extent to which variability in a particular behavior in a population can be accounted for by genetic factors. There are two important points about heritability to keep in mind:

• Heritability estimates range from 0.0 to 1.0: the higher the number, the greater the heritability.

• Heritability is relevant only for a large population of people, not a particular individual.

Other factors that are just as important as genes in genetic research are environmental factors. Shared environment factors include those things that members of a family have in common. Nonshared environment factors are those things believed to be distinct among members of a family.

2.1.1. What is behavior genetics?

Behavior genetics is the study of the degree to which genes and environmental factors influence behavior. The total genetic makeup of an individual, consisting of inherited genes, is referred to as the genotype; the genotype cannot be observed from the outside. In contrast, the totality of observable behavioral characteristics is referred to as the phenotype. The phenotype changes over time and is the product of an interaction between the genotype and the environment.

2.1.2. What is molecular genetics?

Molecular genetics studies seek to identify particular genes and their functions.

Gene expression involves particular types of DNA called promoters. These promoters are recognized by particular proteins called transcription factors. Promoters and transcription factors are the focus of much research in molecular genetics and psychopathology.

Molecular genetics research has focused on identifying differences between people in the sequence of their genes and in the structure of their genes. One area of interest in the study of gene sequence involves identifying what are called single nucleotide polymorphisms or SNPs. A SNP refers to differences between people in a single nucleotide in the DNA sequence of a particular gene.

Another area of interest is the study of differences between people in gene structure, including the identification of so-called copy number variations (CNVs). A CNV can be present a single gene or multiple genes. These abnormal copies van be additions, where extra copies are abnormally present, or deletions, where copies are missing.

2.1.3. What are gene-environment interactions?

The influence of genes to a given person’s sensitivity to an environmental event is called a gene-environment interaction. Furthermore, it is important to know that epigenetics is the study of how environment can change the expression of a gene or its function.

2.1.4. What is the evaluation of the genetic paradigm?

Scientists working within the genetic paradigm in psychology face two major challenges:

• It is difficult to exactly specify how genes and environment influence each other.

• The task is very complex. Multiple genes contribute to a certain disorder.

2.2. What is the neuroscience paradigm?

According to the neuroscience paradigm psychological disorders are linked to abnormal processes in the brain.

2.2.1. What are neurons and neurotransmitters?

Neurons are the cells in the nervous system. The nervous system consists of billions or neurons. A neuron has four parts: a cell body, multiple dendrites, one or more axons of different lengths and terminal buttons on the many ends branches of the axon. The synapse is a small gap between the cell membrane of the receiving neuron and the terminal endings of the sending axon. What is sent and received is a nerve impulse or signal. Neurotransmitters are chemicals that make the sending possible.

Reuptake is the process of taking back neurotransmitters that have not found their way to postsynaptic receptors into the presynaptic cell. Other neurotransmitters that have not found their way will be broken down by enzymes.

Examples of important neurotransmitters in psychopathology are: dopamine, serontin, norepinephrine and gamma-aminobutyric acid (GABA).

Some of the first theories that linked neurotransmitters to psychopathology proposed that either too much or too little of a certain transmitter caused a given disorder.

Other researchers considered the possibility that the neurotransmitter receptors are at fault in some disorders. This can be studied with the use of agonists and antagonists. An Agonist is a type of drug that stimulates a given neurotransmitter’s receptors. An antagonist is a type of drug that dampen the activity of a neurotransmitter by working on a neurotransmitter’s receptors.

2.2.2. What is the structure and function of the human brain?

The brain roughly consists of two hemispheres with a major connection in between, which is called the corpus callosum. The corpus callosum makes communication between the two hemispheres possible. These cerebral hemispheres have four distinct areas: the frontal lobe, the parietal lobe, the temporal lobe and the occipital lobe.

In the very front of the cortex is the prefrontal cortex. This is an important area of the cortex, because it helps regulate the amygdala and plays an important role in many disorders.

A few brain structures will be discussed briefly:

• Thalamus: a relay station for all sensory pathways except the olfactory.

• The brain stem: consists of the pons and the medulla oblongata and functions mainly as a neural relay station.

• Cerebellum: receives sensory nerves from the vestibular apparatus of the ear and frommuscles, tendons and joints.

• Limbic system: contains different subcortical structures, such as: anterior cingulate, septal area, hippocampus, hypothalamus and the amygdala.

2.2.3. What is the evaluation of the neuroscience paradigm?

The writers want to caution against reductionism, which refers to the view that whatever is being studies can and should be reduced to its most basic parts. Most things, disorders, humans are more than the sum of their parts. The danger is that certain phenomena will be missed by researchers who focus only on the molecular level, because the phenomena only emerges at certain other levels of analysis.

2.3. What is the cognitive behavioral paradigm?

2.3.1. What are the influences from behavior therapy?

The idea that problem behavior is likely to continue if it is reinforced is one of the important influences from behaviorism. Generally, four possible consequences is seen as reinforcements of problem behavior: getting attention, escaping from tasks, generating sensory feedback and gaining access to desirable things or situations. Treatment can be tailored to change the consequence of the problem behavior, when the source of reinforcement is known.

The biggest criticism behaviorism received is that it minimized the importance of two factors, namely: thinking and feeling.

2.3.2. What is cognitive science?

The term used to describe the different kinds of mental processes is cognition.

The focus with cognitive science lies on how people structure their experiences, how they make sense of their experiences and how people relate their past experiences to current ones.

A schema is an organized network of already accumulated knowledge. Cognitive scientists see people as active interpreters of a situation and trying to fit new information into their existing schemas.

Attention is a much studied mental process within cognitive science. These studies are important to psychopathology, because people with certain disorders often have problems with attention.

2.3.3. What is cognitive behavior therapy?

Within cognitive behavior therapy the focus is on private events, such as thoughts, perceptions, judgments, etc. Changing a pattern of thought is called cognitive restructuring.

An well-known cognitive therapy is developed by psychiatrist Aaron Beck. Beck based his therapy on the idea that depression is caused by distortions in the perception of experiences. The goal of his therapy is to give people hope by trying to give people experiences that will change their negative schemas. These experiences can be both inside and outside the therapy room.

2.4. Which factors cut across the paradigms?

2.4.1. What is the link between emotions and psychopathology?

Emotions help us organize our thoughts and actions and emotions direct our behavior. In contrast to moods, emotions are thought of as states lasting for only a few seconds, minutes or at most hours. Moods lasts longer, but are also emotional experiences.

According to contemporary emotion theorists and researchers, emotions have a number of elements, including: expressive, experiential and physiological elements. It is important to consider which of these elements is affected when thinking of emotional disturbances in disorders. All can be affected, but it can also just be one element.

Emotions can be studies from multiple perspectives and thus cuts across the paradigms.

2.4.2. What is the link between sociocultural factors and psychopathology?

Various researchers have considered the role of gender in different disorders and concluded that some disorders affect the genders differently.

Other researchers conducted studies that show that poverty is a major influence on psychological disorders.

Sociocultural factors are getting more and more attention in genetics and neuroscience.

2.4.3. What is interpersonal therapy?

The importance of different relationships in a person’s life and how problems in these relationships can cause psychological symptoms is emphasized in interpersonal therapy.

In this therapy, four interpersonal problems are assessed to determine whether one or more might be causing symptoms: unresolved grief, role transitions, role disputes and interpersonal deficits.

2.5. What is the diathesis-stress paradigm?

Not one of the stated paradigm is adequate enough on its own to explain or treat the psychological disorders, because the disorders are much too diverse. Because of this, the diathesis-stress paradigm was introduced. This paradigm links genetic, neurobiological, psychological and environmental factors together and therefore is an integrative paradigm.

There is no guarantee that a person will develop a disorder, even if he has the diathesis. Possessing the diathesis is possessing a predisposition towards a disorder. Stress together with diathesis is needed to trigger a disorder. This is a key idea of the diathesis-stress model. Another key idea of this model is that a disorder is most likely caused by multiple factors.

What is diagnosis and assessment? - Chapter 3 (13)

The extremely important first steps in psychopathology are diagnosis and assessment, because:

• a good diagnosis is necessary for good clinical care.

• having a diagnosis can evoke feelings of relief in the patient, mostly because it helps with understanding their own symptoms.

• diagnosis helps therapists and researchers to talk accurately with each other.

• for research on causes and treatments, it is necessary to have diagnosis.

• assessment is necessary to make a good diagnosis.

• assessment can give additional information about a patient beyond the diagnosis.

3.1. What are the cornerstones of diagnosis and assessment?

The cornerstones of diagnosis and assessment are reliability and validity.

The consistency of measurement is called reliability. Good reliability means the measurement measures the same thing everytime.The degree to which two independent observers agree on what has been observed is called interrater reliability. The extent to which people being observed several times receive similar scores is measured by test-retest reliability. Both interrater reliability and test-retest reliability are important to assessment and diagnosis.

If clinicians use two different forms of a test, it is important that both forms are consistent. This is alternate-form reliability. The items on a test should be related to each other. The extent to which this is the case is called internal consistency reliability.

Validity is complex. If a test has good validity it means that the tests measures what it is suppose to measure. An important forms of validity in diagnosis are:

• Content validity: the degree to which a test adequately samples a particular domain.

• Criterion validity: the degree to which a test is linked in an expected way to another test.

• Concurrent validity: the degree to which, among patients with the same diagnosis, previously undiscovered characteristics are found.

• Predictive validity: to what degree can predictions be made about the future behavior of patients with the same disorder?

• Construct validity: the degree to which scores on an assessment test are linked to other variables or behaviors suggested by some theory or hypothesis.

3.1.1. What is the DSM-5?

DSM stands for Diagnostic and Statistical Manual of Mental Disorders. It is the diagnostic system used by many mental health professionals. The DSM-5 is the latest issue of the manual. In the DSM specific diagnostic criteria are spelled out precisely. For each diagnosis the characteristics are described extensively.

3.1.2. What are the changes in DSM-5?

Before DSM-5, mental health professionals used the previous issue: DSM-IV-TR. There are some changes in DSM-5 from the previous edition:

• The multiaxial system is removed.

• Diagnoses are organized by causes.

• Sensitivity to the developmental nature of psychopathology is strengthened.

• Some new diagnoses were included.

• Some diagnoses were combined.

• Ethnic and cultural factors are considered in diagnosis.

3.1.3. What are specific criticisms of the DSM?

Some people criticized the number of possible diagnoses in the DSM. The latest edition contains more than 300 diagnoses. Some critics argue that:

• some relatively common reactions to trauma should not be called a psychological disorder.

• there are too many small differences between diagnoses, which increases the likelihood of comorbidity.

• A lot of risk factors seem to trigger multiple disorders. The diagnoses therefore do not seem to differ in their etiology or treatment.

Categorical classification is used in the DSM-5 for clinical diagnoses. This system forces mental health professionals to define one threshold as “diagnosable”, but these thresholds often have little support from research.

In a dimensional system, one can describe the extent to which an entity is present. This can be more helpful. Such a system is included in the appendix of the DSM-5 for personality disorders.

It is important for diagnostic systems to have high interrater reliability. The DSM-5 has improved on this point in comparison to the DSM-III, but there is still room for disagreement between clinicians. It can be difficult to agree on the definition of words like ‘abnormal’ for example.

3.2. What is psychological assessment?

Different psychological assessment techniques can help clinicians to make a diagnosis. It is very common to use multiple techniques to reach a diagnosis. The measures complement each other.

3.2.1. What are clinical interviews?

In psychopathological assessment, clinicians use both structured and less structured interviews. A difference to a casual conversation is the way the clinician pays attention to the individual’s response.

It is necessary for mental health professionals to establish rapport with the person seeking their help. Trust is important for the person to open up.

Structured interviews are used when mental health professionals need to collect standardized information, like making diagnostic judgments based on the DSM-5. In such an interview, the questions are set out in a prescribed order for the interviewer. In practice though, the clinicians keep using unstructured interviews for their diagnosis. This makes the reliability much lower. This can be much higher with adequate training.

3.2.2. What are assessments of stress?

Stress is defined as the subjective experience of distress in response to perceived problems in the environment. Stress is a major aspect of many different disorders, that makes it a very important thing to measure. The assessment widely used to study life stressors is the Bedford college life events and difficulties schedule (LEDS). This interview is semistructured. Both the interviewer and the interviewee work to produce an overview of the major events withing a time period. The stressors will be rated on the severity and various other dimensions. This way, the importance of every single life event can be personalized. Some other life events that might be a consequence of symptoms can be excluded.

LEDS takes a lot of time to administer. Self-report checklists are used to assess stress quicker. These kind of checklists often list a series of different life events. People need to answer whether these life events happened to them. A problem with this kind of assessment is that people can view the same life events in different ways.

3.2.3. What are personality tests?

Personality tests are a commonly used psychological test. Self-report personality inventory is an example of such a test. In such an inventory, the individual is asked to fill out a self-report questionnaire indicating whether statements apply to him. The statements are about habitual tendencies.

Projective tests are based on the projective hypothesis. The projective hypothesis states that the individual’s response to inkblots will be primarily determined by unconscious processes, because the inkblots are unstructured and ambiguous. The responses will then show the person’s true attitudes, motivations and modes of behavior. The Thematic Apperception Test (TAT) and the Rorschach Inkblot Test are examples of projective tests.

3.2.4. What are intelligence tests?

A way to assess an individual’s current mental ability is by the use of an intelligence test. This kind of testing is often use to predict school performance, but is also used in the following ways:

• Together with achievement tests, it can be used to diagnose learning disabilities and to identify areas of strengths and weaknesses.

• To help assess whether an individual has intellectual disability.

• To find out if a child is intellectual gifted.

• As part of neuropsychological testing.

Reliability of intelligence tests are high and they have good criterion validity. Other factors besides IQ play an important role in how well a person will do in school:

• Family and circumstances.

• Motivation.

• Expectations.

• Performance anxiety.

• Difficulty of the curriculum.

3.2.5. What is behavioral and cognitive assessment?

Assessments can also focus on behavioral and cognitive characteristics, like:

• Characteristics of the individual.

• The frequency and type of problematic behaviors.

• The consequences of the problem behaviors.

• Elements of the environment that might contribute to symptoms.

This assessment is mostly done through observation. A direct observation of behavior can be done, for example, or self-observation (often referred to as self-monitoring). Reactivity is the term used for the phenomenon wherein behavior changes because it is being observed.

3.3. What is neurobiological assessment?

3.3.1. What is brain imaging?

It is interesting to identify brain dysfunction, because this can cause many different behavioral problems.

The CT or CAT scan (computerized axial tomography) helps to see if there are structural brain abnormalities.

The MRI (magnetic resonance imaging) can als be used to see the living brain. It produces images of much better quality than the CT scan.

The fMRI (functional MRI) is a technique that can measure both brain structures and brain function, by taking MRI pictures extremely fast. Metabolic changes can be seen because of this fastness.

3.3.2. What is neuropsychological assessment?

It is important to know the difference between a neurologist and a neuropsychologist. A specialist (physician) in diseases that affect the nervous system is called a neurologist. A neuropsychologist is someone who studies how impairments or disfunctions of the brain affect the way people feel, think and behave.

The idea that different psychological functions rely on different areas of the brain forms the basis for neuropsychological tests. These tests are often used besides the brain-imaging techniques.

In psychopathology assessment various neuropsychological tests are used. Two batteries of such tests will be named: Halstead-Reitan neuropsychological test battery and the Luria-Nebraska battery. Examples of the Halstead-Reitan tests are:

• Tactile Performance Test – Time.

• Tactile Performance Test – Memory.

• Speech Sounds Perception Test.

The Halstead-Reitan battery is valid for detecting behavior changes related to brain impairments.

3.3.3. What is psychophysiological assessment?

People working in psychophysiology are interested in bodily changes that are linked to psychological events. Sensitivity of psychophysiological assessments is not strong enough to be used for diagnosis. It does give important information about an individual and it is useful when a someone wants to compare individuals. Several measures can be used to measure the activities of the autonomic nervous system:

• Electrocardiogram (EKG).

• Electrodermal responding.

• Electroencephalogram (EEG).

3.4. What is known about cultural and ethnic diversity in relation to assessment?

It is important to remember, while reading the next paragraphs, that there are typically more differences within cultural, and ethnic groups than between them.

3.4.1. What is cultural bias in assessment?

A measure that is created for one culture or ethnic group may not be as reliable and valid with a different cultural or ethnic group. This notion is referred to as cultural bias. Multiple factors can affect assessment, e.g.:

• Differences in language.

• Differences in religious and spiritual beliefs.

• Presumed timidity of members of ethnic groups.

To avoid cultural bias when conducting assessments, three important issues should be taught to graduate psychology students:

• They should learn about basic issues in assessment.

• Students should learn about the ways in which culture and ethnicity can impact assessment.

• Students must become aware that culture or ethnicity may not impact assessment in every case.

What are the research methods in psychopathology? - Chapter 4 (13)

4.1. What is science?

Science is trying to gain knowledge via observation. A theory is formed and then tested by systematically gathering data.

A collection of propositions thought of to explain a class of observations is called a theory.

A theory gives room for generation of more and specific hypotheses. Hypotheses are expectations about what should occur if a theory is true.

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

4.2. What are the approaches to research on psychopathology?

4.2.1. What is a case study?

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

• It can be used to give a detailed description of a clinical phenomenon. This is possible, because a case study focuses on one person instead of a group of people.

• A case study can disprove a hypothesis.

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

4.2.2. What is the correlational method?

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

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

Both statistical and clinical significance should be considered. Statistical significance means that the observed correlation is unlikely to have occurred by chance. Clinical significance means that the relationship between the variables is large enough to matter.

There is a major disadvantage to the use of the correlation method, namely: no conclusions can be drawn about the causation of the relationship. It is not known if one variable causes the other. It is also possible that a third variable has caused the relationship between the two variables. This is known as the third-variable problem.

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

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

Family method: the average number of genes shared within a family is known and therefor a study of genetic predisposition can be done with a family. The starting point in the family method is the person with the diagnosis, those people are called index cases or probands.

Twin method: with this method twins are compared. Both kind of twins, monozygotic twins and dizygotic twins, are used. Monozygotic twins are interesting because they are genetically the same. Dizygotic twins are about 50% the same genetically. If a disorder can be inherited, the disorder should be seen more in monozygotic twins.

Adoptees method: adopted children are raised by parents other than their biological parents. If a disorder is seen in adoptees, while their foster parent do not have the disorder, but their biological parents do, then their is convincing support for the heritability of the disorder. Environmental influences can be determined as well, when the foster parent has a disorder and the biological parent does not.

4.3. What is an experiment?

To determine a casual relationship between two variables the experiment is the best tool to use. Participants of an experiment will be randomly assigned to different conditions. An independent variable will be manipulated and a dependent variable will be measured.

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

Random assignment is also important to reach internal validity, because it helps ensure that groups are similar.

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

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

• The sample being studied must be clearly defined.

• The treatment being offered must be clearly described.

• The study must include a control group.

• Random assignment.

• Reliable and valid outcome measures.

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

In randomized controlled trials (RCT) clients are randomly assigned to treatment group or control group. The independent variable is the received treatment and the clients’ outcome is the dependent variable.

Sometimes physical or psychological improvement might be observed, because of the patients’ expectations instead of the active ingredient in a treatment. This is called the placebo effect.

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

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

If the researcher studies how one person reacts to manipulations of the independent variable, he is conducting a single-case experimental design. This kind of study can have high internal validity. In reversal design, or ABAB design, one form of a single-case design, the participant’s behavior must be measured in a specific order:

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

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

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

4. A reintroduction of the treatment (B).

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

The lack of external validity is also with this method the biggest disadvantage.

What are mood disorders? - Chapter 5 (13)

In mood disorders disabling disturbances in emotion are seen. On the one hand there is extreme sadness in depression and on the other hand there is the extreme elation of mania.

5.1. What are the clinical descriptions and epidemiology of mood disorders?

The DSM-5 distinguishes between to kinds or mood disorders: the ones that only include depressive symptoms and those that involve manic symptoms.

5.1.1 What are depressive disorders?

The inability to experience pleasure and/or experiencing extreme sadness are the key features of depression. Symptoms in depression vary. People with depression often show physical symptoms too. Some people might have psychomotor retardation, while others might have psychomotor agitation. With the first, thoughts and movements may be slow, and with the second, people might not be able to sit still.

5.1.1.1. What is major depressive disorder?

Major Depressive Disorder (MDD) is a episodic disorder. This means that symptoms tend to be present for a certain period of time and then clear. Although it clear, the episodes are likely to recur. The chance of getting a new episode goes up after every episode.

DSM-5 Criteria for Major Depressive Disorder

Sad mood or loss of pleasure in usual activities. At least five symptoms (counting sad mood and loss of pleasure):

• Sleeping too much or too little.

• Psychomotor retardation or agitation.

• Weight loss or change in appetite.

• Loss of energy.

• Feelings of worthlessness or excessive guilt.

• Difficulty concentrating, thinking, or making decisions.

• Recurrent thoughts of death or suicide.

• Symptoms are present nearly every day, most of the day, for at least two weeks. Symptoms are distinct and more severe than a normative response to significant loss.

5.1.1.2. What is persistent depressive disorder?

The key aspect of the persistent depressive disorder is the chronicity of the symptoms.

DSM-5 Criteria for Persistent Depressive Disorder (dysthymia)

Depressed mood for most of the day more than half of the time for two years (or one year for children and adolescents). At least two of the following during that time:

• Poor appetite or overeating.

• Sleeping too much or too little.

• Low energy.

• Poor self-esteem.

• Trouble concentrating or making decisions.

• Feelings of hopelessness.

The symptoms do not clear for more than two months at a time. Bipolar disorders are not present.

5.1.1.3. What are other DSM-5 depressive disorders?

In the DSM-5 two other depressive disorders can be found: disruptive mood dysregulation and premenstrual dysphoric disorder.

5.1.1.4. What is the epidemiology and what are the consequences of depressive disorders?

Major depressive disorder is the most seen psychological disorder. The disorders are more common among women than among men. The disorder is also more prevalent in poorer people than wealthier people. Across cultures there is a difference in prevalence of depression. The reasons for this might be very complex. The same is true about the symptom profile.

5.1.2. What are bipolar disorders?

The DSM-5 distinguishes three types of bipolar disorder. The key features of these disorders are manic symptoms. A state of intense elation, irritability or activation is called a mania.

In hypomania the symptoms are less severe, and does not include significant impairment.

DSM-5 Criteria for Manic and Hypomanic Episodes

Distinctly elevated or irritable mood. Abnormally increased activity or energy. At least three of the following are noticeably changed from baseline (four if mood is irritable):

• Increase in goal-directed activity or psychomotor agitation.

• Unusual talkativeness; rapid speech.

• Flight of ideas or subjective impression that thoughts are racing.

• Decreased need for sleep.

• Increased self-esteem; belief that one has special talents, powers, or abilities.

• Distractibility; attention easily diverted.

• Excessive involvement in activities that are likely to have painful consequences, such as reckless spending, sexual indiscretions, or unwise business investments.

• Symptoms are present most of the day, nearly every day.

For a manic episode:

• Symptoms last 1 week, require hospitalization, or include psychosis.

• Symptoms cause significant distress or functional impairment.

For a hypomanic episode:

• Symptoms last at least four days.

• Clear changes in functioning are observable to others, but impairment is not marked.

• No psychotic symptoms are present.

5.1.2.1. What is bipolar I disorder?

The diagnosis of bipolar I disorder can be given if one experiences a single episode of mania during his lifetime. Manic episodes reoccur even more often than MDD episodes.

5.1.2.2. What is bipolar II disorder?

This is a milder form than bipolar I. For diagnosis, an individual must have had at least one major depressive episode and at least one episode of hypomania.

5.1.2.3. What is cyclothymic cisorder?

The cyclothymic disorder, just like persistent depressive disorder, is a chronic mood disorder. The symptoms are mild and frequent

DSM-5 Criteria for Cyclothymic Disorder

For at least two years (or one year in children or adolescents):

• Numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode.

• Numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

• The symptoms do not clear for more than two months at a time. Criteria for a major depressive, manic, or hypomanic episode have never been met. Symptoms cause significant distress or functional impairment.

5.1.2.4. What is the epidemiology and what are the consequences of bipolar disorders?

The prevalence of bipolar I is much lower than MDD. It is hard to estimate the prevalence of the other types of bipolar disorders, because of the bad reliability of the diagnostic interviews. Men and women are equally often diagnosed for these type of disorders. Bipolar I is one of the most severe forms of psychological disorder.

5.1.3. What are subtypes of depressive disorders and bipolar disorders?

The symptoms of the people diagnosed with the same disorder can vary a lot. The DSM-5 includes specifiers or subtypes for both MDD and bipolar disorder.

5.2. What is the etiology of mood disorders?

In this section, the focus will be on major depressive disorder and bipolar I disorder, because most research on etiology and treatment is focused on these two disorders.

5.2.1. What are the genetic factors?

The heritability estimates for major depressive disorder are 37 percent. When studies focus on more severe samples, the estimates are higher. The heritability estimates for bipolar disorder is 93 percent. This makes bipolar disorder among the most heritable of disorders.

It is unlikely that there is one single gene that explains mood disorders, because the symptoms patients can experience differ tremendously. Researchers therefore think a set of genes is responsible.

Genes should be considered in combination with other risk factors, like those in the environment.

A few neurotransmitters have been studied a lot for their role in mood disorders:

• Dopamine. Dopamine is important for the sensitivity of the reward system in the brain. Researchers belief that dopamine levels might be lowered in depression. For bipolar disorders, researchers belief that the dopamine receptors might be overly sensitive.

• Serotonin. Researchers belief that people vulnerable to depression may have less sensitive serotonin receptors. The same is believed for people with bipolar disorder.

• Norepinephrine.

5.2.2. How does the brain function?

Many of the brain structures involved in experiencing and regulating emotion seem to be changed during episodes of MDD. The following brain structures have been studied the most:

• Amygdala; helps determine the emotionally importance of a stimulus. Activity is elevated in MDD when watching negative stimuli.

• Anterior cingulate; this structure shows greater activation in MDD while watching negative stimuli.

• Dorsolateral prefrontal cortex; this structure shows diminished activation when watching negative stimuli.

• Hippocampus; this structure also shows diminished activation when watching negative stimuli.

• Striatum; people with MDD show a diminished activation in this structure during exposure to emotional stimuli, especially when receiving positive feedback.

The same is true for people with bipolar disorder, except the striatum. Activation of this structure is high.

5.2.3. What is the involvement of the neuroendocrine system?

The main stress hormone is cortisol. In times of stress, cortisol is released. This increases the activity of the immune system, so that the body can prepare for threats.

The levels of cortisol are often poorly regulated in people with depression, meaning the body is not functioning well in decreasing the levels of cortisol. If high levels of cortisol are present in the body for too long, it will harm the body.

The same is true for people with a bipolar disorder.

5.2.4. What are the social factors in depression?

There is a strong correlation between interpersonal problems and depression, but it is not immediately clear what causes what. Depression can cause interpersonal problems, because depressive people tend to withdraw, finds no enjoy in being in contact with others, etc. There are also factors that precede and predict the onset of depressive episodes, such as: difficult life events, criticism from family, adversity in childhood, etc.

Lack of social support may also be an important factor. This may worsen the individual’s ability to handle stressful life events. Vice versa, social support seems to protect against severe stressors.

A family member’s critical comments toward or emotional overinvolvement with the person with depression is defined as expressed emotion (EE).

5.2.5. What are the psychological factors in depression?

Neuroticism is a personality trait that involves the tendency of an individual to experience frequent and intense negative feelings. Longitudinal research shows that this trait predicts the onset of depression. It also explains at least part of the genetic vulnerability to depression.

In cognitive theories, the pessimistic thoughts and self-critical thoughts a person can have, can be seen as major causes of depression. Three cognitive theories will be described next:

• Beck’s theory. Aaron Beck linked depression to a negative triad. The negative triad consists of negative views of the self, their world and the future. Cognitive biases are often present. These are tendencies to process information in negative ways.

• Hopelessness theory. The most important trigger of depression is hopelessness, according to this theory. Hopelessness is defined as by the belief that desirable outcomes will not occur and that there is nothing a person can do to change this. Important to this theory is attributions. Attributions are the explanations a person forms about why a stressor has occurred. Two dimensions here are emphasized: stable (permanent) versus unstable (temporary) causes and global versus specific causes. Someone is more likely to become depressed if his attributional style makes him feel hopeless, because he believes that negative life events are due to stable and global causes.

• Rumination theory. Rumination may increase the risk of depression according to this theory. A tendency to dwell on sad experiences and thoughts is how rumination is defined.

5.2.6. What are the social and psychological factors in bipolar disorder?

Research suggests that two factors may predict increases in manic symptoms over time:

• Reward sensitivity. Mania is due to a disturbance in the reward system according to this model. Patients might be highly reward sensitive.

• Sleep deprivation. There is a relation between mania and disruptions in sleep.

5.3. What is the treatment for mood disorders?

5.3.1. What is the psychological treatment of depression?

The following treatments have shown to be effective in treating depression:

• Interpersonal psychotherapy (IPT).

• Cognitive therapy. This theory focuses on negative schema’s and cognitive biases.

• An adaption of cognitive therapy is mindfulness-based cognitive therapy (MBCT) which focuses on preventing relapse.

• Behavioral Activation (BA) therapy. The goal in this therapy is to increase participation in positively reinforcing activities, so negative spiral of depression, withdrawal and avoidance can be disrupted.

• Behavioral Couples therapy. This therapy helps with relieving depression when a person with depression also experiences marital distress.

5.3.2. What is the psychological treatment of bipolar disorder?

The following is necessary and/or very helpful in the treatment of bipolar disorder:

• Medication.

• Psychoeducational approaches.

• Cognitive therapy.

• Family-focused therapy.

5.3.3. What is the biological treatment of mood disorders?

Drugs and electroconvulsive therapy (ECT) are the two major biological treatments used to treat depression and mania. ECT involves deliberately causing a momentary seizure. This treatment is controversial, but more powerful than antidepressant. The treatment is used when other treatments have failed.

For depression, drugs are the most used and best-researched treatments. There are three major categories: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs).

The best chances of recovering from a depression is to combine psychotherapy and antidepressant medications. Medication is most helpful for immediate relief. Psychotherapy is needed to protect against recurrent episodes.

Mood-stabilizing medications are medications that reduce manic symptoms. Lithium is an example of such medication. It has to be prescribed and used very carefully due to possible serious side effects. Furthermore, two other classes of medications have been approved: anticonvulsant medications and antipsychotic medications.

5.4. What is suicide?

Behaviors that are intended to cause death and do so, are named suicide. Behaviors that are intended to cause bodily harm, but are not meant to cause death, are named nonsuicidal self-injury.

5.4.1. What is the epidemiology of suicide and suicide attempts?

Studies suggest the following:

• Suicidal ideation occur at least once in a lifetime for about nine percent of people worldwide.

• In areas where more people own guns, suicide rates are higher.

• Suicide is four times more likely for men than for women.

• Suicide attempts that do not result in death are more likely among women than among men. This probably due to the use of less lethal methods among women.

• Rates of suicide are higher in old age.

• More and more children and adolescents commit suicide.

• Suicide risks elevates four- or fivefold for divorced people or widowed people.

5.4.2. What are the risk factors for suicide?

Suicide is a very complex and multifaceted behavior.

About 50 percent of the people attempting suicide is depressed and about 90 percent of the people attempting suicide has some form of psychological disorder. If a disorder comorbids with depression within an individual, suicide is most likely.

The heritability for suicide attempts is about 48 percent.

Other influences of suicide rates are economic and social events. Media reports of suicide is often followed with an increase in suicides.

People can have many different reasons to choose suicide:

• To induce guilt in others.

• To get love from others.

• Making amends for wrongs.

• To get rid of unacceptable feelings.

• To escape emotional pain.

• To rejoice a deceased loved one.

Some researchers link suicide to poor problem-solving skills. Poor problem-solving skills can make people more vulnerable to hopelessness. Feelings of hopelessness is strongly related to suicidality. Suicide actions might be driven by factors such as impulsivity.

5.4.3. How do we prevent suicide?

It helps to talk about suicide openly and matter-of-factly. This may relieve a person of a sense of isolation.

Most people who kill themselves have a form of psychological disorder. Successfully treating the disorder reduces the risk of suicide. The use of medications in mood disorders also reduces the risk.

The most promising therapies for reducing suicidality are the cognitive behavioral approaches. These treatments include strategies to decrease the risk of suicide. It is important to help patients understand the emotions and thoughts that triggers the need to commit suicide. Together with clinicians, patients need to challenge their negative thoughts and need to find effective ways to tolerate emotional distress. Clinicians also help clients solve the problems they are having. The goal is to reduce feeling of hopelessness by improving problem-solving skills and improving social support.

What are anxiety disorders? - Chapter 6 (13)

In anxiety disorders, both anxiety and fear are key elements. Dread over an expected problem is the definition of anxiety. A reaction to immediate danger is called fear. The difference is in the words “expected” and “immediate”. It is an important contrast.

Both anxiety and fear are adaptive behaviors. Fear makes it possible for humans to fight or flight by activating the sympathetic nervous system. In anxiety disorders the activation happens when there is no danger.

Taken together, anxiety disorders are the most common kind of psychological disorder.

6.1. What are the clinical descriptions of the anxiety disorders?

There is a lot of overlap in the DSM-5 definitions of anxiety disorders. A diagnosis can only be made if the following criteria are met. This is true for all the anxiety disorders.

• Symptoms interfere with important areas of functioning or cause marked distress.

• Symptoms are not caused by a drug or a medical condition.

• Symptoms persist for at least 6 months or at least 1 month for panic disorder.

• The fears and anxieties are distinct from the symptoms of another anxiety disorder.

6.1.1. What are specific phobias?

In a specific phobia, the disproportionate fear is caused by a specific situation or object. Even though the person realizes the fear is disproportionate, he still does a lot to avoid the situation or object. Specific phobias are comorbid with each other.

DSM-5 Criteria for Specific Phobia

• Marked and disproportionate fear consistently triggered by specific objects or situations.

• The object or situation is avoided or else endured with intense anxiety.

6.1.2. What is social anxiety disorder?

A persistent, unrealistically intense fear of social situations that may involve being scrutinized by unfamiliar people is the key aspect of social anxiety disorder. These leads to avoidance of social situations. The manifestations and outcomes of the disorder differ a lot and the severity varies greatly between patients. The disorder commonly starts during adolescence.

DSM-5 Criteria for Social Anxiety Disorder

• Marked and disproportionate fear consistently triggered by exposure to potential social scrutiny.

• Exposure to the trigger leads to intense anxiety about being evaluated negatively.

• Trigger situations are avoided or else endured with intense anxiety.

6.1.3. What is panic disorder?

The key features of panic disorder is recurrent panic attacks not linked to a specific situation and worrying about having more of such attacks. A sudden attack of intense apprehension and terror, accompanied by at least four other symptoms, like: physical symptoms, depersonalization, derealization and/or certain fears (e.g., losing control or fear of dying). To diagnose a panic disorder, the word “unexpected” is important. The panic attacks must be unexpected, expected panic attacks are much more likely caused by a phobia. The response is also important in diagnosing this disorder. According to the DSM, the person must either worry about the attacks or change his behavior because of the attacks.

DSM-5 Criteria for Panic Disorder

• Recurrent unexpected panic attacks.

• At least 1 month of concern or worry about the possibility of more attacks occurring or the consequences of an attack, or maladaptive behavioral changes because of the attacks.

6.1.4. What is agoraphobia?

Anxiety about anxiety occurring in situations in which it would be difficult to escape or in which it would be embarrassing to experiencing the anxiety, is the key feature of agoraphobia. People with this disorder often do not leave their house, or do this with enormous distress. About 50 percent or more of the patients do not experience panic attacks and this fact makes agoraphobia a separate disorder instead of a subtype of panic disorder.

DSM-5 Criteria for Agoraphobia

• Disproportionate and marked fear or anxiety about at least two situations where it would be difficult to escape or receive help in the event of incapacitation, embarrassing symptoms, or panic-like symptoms, such as being outside of the home alone; traveling on public transportation; being in open spaces such as parking lots and marketplaces; being in enclosed spaces such as shops, theaters, or cinemas; or standing in line or being in a crowd.

• These situations consistently provoke fear or anxiety.

• These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety.

6.1.5. What is generalized anxiety disorder?

Worry is the key element of generalized anxiety disorder. Because the individual can not settle on a solution, the worry continues.

DSM-5 Criteria for Generalized Anxiety Disorder

• Excessive anxiety and worry at least 50 percent of days about a number of events or activities (e.g., family, health, finances, work and school).

• The person finds it hard to control the worry.

• The anxiety and worry are associated with at least three (or one in children) of the following:

  • restlessness or feeling keyed up or on edge.

  • easily fatigues.

  • difficulty concentrating or mind going blank.

  • irritability.

  • muscle tension.

  • sleep disturbance.

6.1.6. What comorbids with anxiety disorders?

A lot of people with an anxiety disorder also meet the criteria of another anxiety disorder at some point in their life. Anxiety disorders comorbid with many other disorders, such as major depression, substance abuse and personality disorders. Comorbidity is linked with greater severity and poorer outcomes.

6.2. What are gender and cultural factors in the anxiety disorders?

6.2.1. What are the gender factors?

Women are more likely than men to develop an anxiety disorder. Several reasons for why this is the case are:

• Women may report their symptoms more often or more easily.

• Social factors, such as gender roles.

• Women and men might have different life circumstances, like sexual assault.

• It is likely that they react differently to stress biologically.

6.2.2. What are the cultural factors?

Culture and environment influence what people come to fear, but in every culture you can find people with anxiety disorders.

The prevalence of anxiety disorders differ among cultures, but this might be due to whether it is acceptable to have a mental disorder in a particular culture.

6.3. What are common risk factors across the anxiety disorders?

6.3.1. What is fear conditioning?

Mowrer’s two-factor model of anxiety disorders continues to influence thinking from a behavioral perspective. According to Mowrer, there are two steps in developing an anxiety disorder:

• An individual learns to fear a neutral stimulus that is linked to an intrinsically aversive stimulus. Thus an individual learns fear via classical conditioning.

• By avoiding the aversive stimulus, an individual can feel relief. The avoidance is maintained because it gets reinforced. This happens via operant conditioning.

Classical conditioning can occur in different ways:

• Direct experience.

• Modeling.

• Verbal instruction.

Research shows that people with an anxiety disorder acquire fears more easily than people without the disorder and those fears go slower extinct.

6.3.2. What are the genetic factors?

A heritability of 20-40 percent is suggested for social anxiety disorder, generalized anxiety disorder and specific phobias. Furthermore, twin studies suggests about 50 percent heritability for panic disorder. Some genes may increase the risk of developing anxiety disorder. Other genes may increase the risk of developing a specific type of anxiety disorder.

6.3.3. What are the neurobiological factors?

The fear circuit is a set of brain structures that is activated when people feel anxious of fearful. Some structures in the fear circuit are linked to anxiety disorders:

• Amygdala: involved in assigning emotional significance to stimuli.

• Medial prefrontal cortex: helps regulating the activity of the amygdala.

• Hippocampus.

6.3.4. What are the personality factors?

Behavioral inhibition is a trait seen in some infants. It is a tendency to become agitate when faced with novel toys, people or other stimuli. It may set the stage for the development of an anxiety disorder later in life.

Neuroticism is a personality trait and defined by the tendency to experience frequent or intense negative emotions. People who have high levels of neuroticism are much more likely to develop an anxiety disorder.

6.3.5. What are the cognitive factors?

People with anxiety disorders tend to keep having negative beliefs about the future. It is important for clinicians to find out how these beliefs are sustained. People tend to engage in safety behaviors to protect themselves from the feared consequences. These safety behaviors might be the reason the unhelpful beliefs are sustained.

People with an anxiety disorder often experience little sense of control over their surroundings. This is often caused by a serious life event over which someone had no control. Furthermore, a lack of control over the environment can promote anxiety, as is shown in animal studies.

People with anxiety disorders tend to pay more attention to negative cues in their surroundings than people without such disorders do. This heightened attention happens automatically and very quickly.

6.4. What is the etiology of specific anxiety disorders?

6.4.1. What is the etiology of specific phobias?

The two-factor model by Mowrer is the main model of phobias. According to this model, a threatening experience causes a specific phobia that is seen as a conditioned response. The phobia is sustained by avoidance behavior. About half of the people with a specific phobia report not remembering a conditioning experience. Proponents of the model argue that memory gaps are common and the simple surveys asking about the experience of people therefore is not very reliable.

According to the two-factor model, it is possible to be conditioned to fear all types of stimuli. Though people with phobias tend to fear certain stimuli. Researcher propose that evolution “made” our fear circuit react strongly to stimuli that could be life-threatening. This is called prepared learning.

6.4.2. What is the etiology of social anxiety disorder?

The behavioral perspective on the causes of social anxiety disorder is also based on the two-factor conditioning model. The use of safety behaviors , to not feel the anxiety, might create other problems, because other people tend to disapprove of these kind of behaviors.

Social anxiety might be intensified by cognitive processes in several ways:

• It seems that people with social anxiety disorders have unrealistically negative beliefs about the consequences of their social behaviors.

• More than other people, people with this disorder pay more attention to how they are doing in social situations and pay more attention to their internal sensations. This focus on the self might interfere with the ability to perform well in social contacts.

• Research shows that people with this disorder evaluate their social performance overly negative.

• It appears that people with social anxiety disorder attend less to external cues than to internal cues.

6.4.3. What is the etiology of panic disorder?

The locus coeruleus is a brain area in the fear circuit that plays an important role in panic disorder. It is a major source of norepinephrine, a neurotransmitter, in the brain. When stressed, there are surges of norepinephrine. These surges are linked to increased activity of the sympathetic nervous system. Certain drugs can increase activity in the locus coeruleus, which in turn can trigger panic attacks. There are also drugs that decrease activity and therefore decrease the risk of panic attacks.

6.4.4. What are the behavioral factors?

It has been suggested that interoceptive conditioning is the type of classical conditioning of panic attacks. In interoceptive conditioning, a person experiences somatic signs of anxiety, following an individual’s first panic attack; the attacks then become a conditioned response to somatic signs of anxiety.

According to cognitive perspectives, people with panic disorder have a catastrophic misinterpretation of somatic changes. People interpret the changes as signs of upcoming doom. A vicious circle is created, because such thoughts lead to more anxiety, and more anxiety leads to more bodily sensations.

Anxiety Sensitivity Index is a scale that measures the extent to which people respond fearfully to their bodily sensations. The index can predict the onset of panic attacks.

6.4.5. What is the etiology of agoraphobia?

The risk of agoraphobia seems to be linked to genetic vulnerability and life events. The main model for the etiology in this disorder is the fear-of-fear hypothesis. This model suggests that negative thoughts about the consequences of experiencing anxiety in public drive agoraphobia.

6.4.6. What is the etiology of generalized anxiety disorder (GAD)?

There is high comorbidity between GAD and other anxiety disorders. In a few important ways, this disorder differs from the other disorders:

• People who meet the criteria for GAD are more likely to experience episodes of major depressive disorder.

• People seem to have a general tendency to experience general stress, instead of a specific fear.

• People with GAD might be avoiding emotions.

• They have a kind of intolerance to uncertainty.

6.5. What are the treatments of the anxiety disorders?

6.5.1. What are commonalities across psychological treatments?

Exposure therapy is an effective treatment for all the anxiety disorders. It is common practice to make an exposure hierarchy in exposure therapy. In an exposure hierarchy, a graded list of triggers is made. First the client needs to expose himself to the less challenging triggers and move his way up to the most challenging triggers.

A few key principles seem to be important in preventing the patient from relapsing:

• Exposure should include as many aspects of the feared object as possible.

• Exposure should occur in as many different contexts as possible.

Extinction of fear involves learning instead of forgetting. This is the case, because the fear will not be entirely erased from the brain. It is important for people to learn new associations with the feared object, so that the new associations can inhibit activation of the fear.

According to the cognitive perspective of exposure theory, exposure helps people correct their incorrect beliefs that they are not able to cope with the stimulus. Exposure helps people experience people that they can cope and nothing bad happens.

6.5.2. What are psychological treatments of specific anxiety disorders?

With phobias, exposure treatment involves in vivo exposure to the feared object.

Exposure therapy with social anxiety disorders often begin with practicing with the clinicians before exposing the client to more public situations. Safety behaviors tend to interfere with the extinction of the anxiety. Stopping safety behaviors is therefore necessary.

With panic disorder, exposure happens by deliberately eliciting bodily sensations associated with panic, followed by practicing coping tactics. The patient can also be helped by challenging the disfunctional thoughts about the sensations.

Exposure therapy in agoraphobia is often done with a graded hierarchy.

6.5.3. What medications reduce anxiety?

Anxiolytics are the type of drugs that reduce anxiety. Two types are most often used: benzodiazepines and serotonin-norepinephrine reuptake inhibitors (SNRIs). Medications offers relief from the anxiety, but only during the time when they are taken. People often relapse when they stop taking the drugs.

What are obsessive-compulsive-related and trauma-related disorders? - Chapter 7 (13)

7.1. What are obsessive-compulsive and related disorders?

In this chapter three disorders will be discussed: obsessive-compulsive disorder, body dysmorphic disorder and hoarding disorder.

Obsessive-compulsive disorder is defined by repetitive thoughts and obsessions (urges), and repetitive behaviors or mental acts (compulsions). The symptoms of repetitive thoughts and behaviors are shared with the other two disorders. These symptoms are for people with any of these three disorders distressing, they feel uncontrollable, and take a lot of time. The disorders often co-occur.

7.1.1. What are the clinical descriptions of the obsessive-compulsive and related disorders?

7.1.1.1. What is obsessive-compulsive disorder?

The presence of either obsessions or compulsions is necessary for the diagnosis of obsessive-compulsive disorder. Most people experience both.

Persistent and uncontrollable impulses, thoughts or images that are intrusive and recurring is what is called obsessions. These impulses, thoughts and images often appear irrational the person themselves. A lot of the time these obsessions involve fear of contamination from germs or illnesses.

When a person feels the need for repetitive and clearly excessive behavior and mental acts to decrease the anxiety caused by obsessive thoughts or to prevent some terrible event from happening, we talk about compulsions. It is hard for patients to stop, even though they realize their behavior is illogical.

DSM-5 Criteria for Obsessive-Compulsive Disorder

• Obsessions and/or compulsions.

• Obsessions are defined by:

  • Recurrent, intrusive, persistent, unwanted thoughts, urges, or images.

  • The person tries to ignore, suppress, or neutralize the thoughts, urges or images.

• Compulsions are defined by:

  • Repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a dreaded event.

  • The person feels driven to perform the repetitive behaviors or thoughts in response to obsessions or according to rigid rules.

  • The acts are excessive or unlikely to prevent the dreaded situation.

• The obsessions or compulsions are time consuming (e.g., at least 1 hour per day) or cause clinically significant distress or impairment.

7.1.1.2. What is body dysmorphic disorder?

When an individual is preoccupied with one or more imagined or exaggerate defects in his appearance, he is likely to suffer from body dysmorphic disorder (BDD).

People with BDD find it very hard to stop thinking (obsessing) about their concerns. For a third of the patients, the insight is low, and therefore they are convinced that others will see them as grotesque. This preoccupation with appearance can interfere with many contexts of life. If the focus of the patient is only on shape and weight, clinicians should consider an eating disorder.

DSM-5 Criteria for Body Dysmorphic Disorder

• Preoccupation with one or more perceived defects in appearance.

• Others find the perceived defect(s) slight or unobservable.

• The person has performed repetitive behaviors or mental acts (e.g., mirror checking, seeking reassurance, or excessive grooming) in response to the appearance concerns.

• Preoccupation is not restricted to concerns about weight or body fat.

7.1.1.3. What is hoarding disorder?

The need to acquire in people with hoarding disorder is excessive and only part of the problem. Another part of the problem is their hatred to parting with their objects. Patients are often unaware of the severity of their behavior.

DSM-5 Criteria for Hoarding Disorder

• Persistent difficulty discarding or parting with possessions, regardless of their actual value.

• Perceived need to save items.

• Distress associated with discarding.

• The symptoms result in the accumulation of a large number of possessions that clutter active living spaces to the extent that their intended use is compromised unless others intervene.

7.1.2. What is the prevalence and comorbidity of the obsessive-compulsive and related disorders?

The prevalence estimates for OCD and BDD are about 2 percent, for hoarding disorder it is about 1,5 percent. All three disorder tend to comorbid with depression and anxiety disorders.

7.1.3. What is the etiology of the obsessive-compulsive and related disorders?

Genes play a moderate role in these three disorders.

Some of the same brain regions seem to be involved in the three disorders: the orbitofrontal cortex, the caudate nucleus and the anterior cingulate.

The main goal of cognitive behavioral theory is to understand why a patient with OCD keeps showing behaviors or thoughts well after the perceived threat is gone. Researches argued that previous functional responses for threat become habitual for patients with OCD and therefore have trouble overriding the behaviors once the threat is gone.

A cognitive model suggests that people with OCD have a yedasentience that does not work well. That is the feeling of knowing that you have thought enough, studied enough, done enough to prevent chaos from low-level threats in the environment.

A cognitive model suggests that people with OCD may try harder to suppress their obsessions and by doing so, worsening their situation. Research shows they are indeed more likely to attempt thought suppression. It is difficult to suppress a thought, because people often keep thinking the thought, to remind themselves to suppress that thought.

Patients with BDD are often detail oriented. This effects the way they look at facial features. They consider one feature at a time, and by doing so, it is more likely they become engrossed while considering a flaw. Being attractive is more important to these patients than people without this condition.

Many theorists take an evolutionary perspective when considering hoarding. The cognitive behavioral model suggests a few factors might be involved:

• Poor organizational skills.

  • They have problems with attention.

  • They have difficulty with categorizing their objects and making decisions about them.

• Unusual beliefs about possessions.

  • They often have an extreme emotional attachment to their objects.

• Avoidance behaviors.

7.1.4. What is the treatment of the obsessive-compulsive and related disorders?

The most often used medications for these disorders is antidepressants.

Exposure and response prevention (ERP) is the most often used form of psychological treatment in these kind of disorders. The response prevention component of ERP is often used in treating OCD, because people with this disorder believe that their compulsive behavior will prevent terrible things from happening. In this kind of treatment, patients find themselves in situations that elicit their compulsive behaviors and have to refrain from performing those kind of behaviors. The thought behind this:

• The person will feel the full force of the anxiety, because they are not performing their compulsive behaviors.

• The anxiety will become less because of exposure.

Research has shown positive effects of ERP for body dysmorphic disorder.

With hoarding disorder ERP is a bit adapted. Getting rid of their object is the exposure element of treatment, because they fear that situation the most. Stopping the behaviors that patients use to reduce their anxiety, is the response prevention part. First patients need to get some insight in the severity of their problems.

7.2. What is posttraumatic stress disorder and what is acute stress disorder?

These are the only psychological disorders that have diagnosis based on the cause. The diagnosis will only be made when symptoms develop after a traumatic event.

7.2.1. What is the clinical description and epidemiology of posttraumatic stress disorder and acute stress disorder?

An extreme response to a severe stressors is what posttraumatic stress disorder (PTSD) entails. To consider diagnosis, a set of symptoms should be present:

• Reexperiencing the traumatic event in an intrusively version.

• Stimuli linked to the event are avoided.

• Development of other signs of negative mood and thought after the event.

• Symptoms of arousal and reactivity are increased.

Sometimes the symptoms develop years after the traumatic event.

A diagnosis for acute stress disorder (ASD) is included in the DSM-5. It is diagnosed when symptoms develop after a trauma, but the duration is shorter than the duration of the symptoms in PTSD (3 days to a month). Short-term reactions to serious trauma could get stigmatize with a diagnosis of ASD, even though such reactions are common. Another concern with the ASD diagnosis is that people developing PTSD did not meet the criteria for ASD in the first four weeks after the traumatic event.

PTSD comorbid highly with other disorders, such as: major depression, anxiety disorders, conduct disorder and substance abuse.

7.2.2. What is the etiology of posttraumatic stress disorder?

Many risk factors of PTSD overlap with the risk factors for anxiety disorders. The focus will be on risk factors uniquely linked to PTSD next.

Whether or not an individual develops PTSD is influenced by the severity of the trauma and the nature of the trauma. PTSD develops more often after a trauma caused by humans than caused by natural disasters.

The function of the hippocampus seems to be uniquely linked to PTSD. The volume seems smaller for those with the disorder than for those without it. This can contribute to psychological vulnerability, because:

• Even in a safe context, the risk that an individual will react to reminders of the trauma could increase due to deficits in the hippocampus.

• Interference may occur with organizing coherent narratives about the trauma due to deficits in the hippocampus.

7.2.3. What treatment is available for posttraumatic stress disorder and acute stress disorder?

The SSRI’s, a type of antidepressant, seems to be very helpful in treating PTSD. People often relapse, if they stop taking the medication.

The most commonly used psychological treatment of PTSD is exposure therapy. There a different types of exposure:

• Reminders of the traumatic event.

• Imaginal exposure.

• Exposure via virtual reality technology.

Cognitive behavioral approaches, including exposure, appear to prevent the development of PTSD in patients with ASD.

DSM-5 Criteria for Posttraumatic Stress Disorder

A. Exposure to actual of threatened death, serious injury or sexual violence, in one or more of the following ways: experiencing the event personally, witnessing the event in person, learning that a violent or accidental death or threat of death occur to a close other, or experiencing repeated or extreme exposure to aversive details of the event(s) other than through the media.

B. At least 1 of the following intrusion symptoms:

• Recurrent, involuntary, and intrusive distressing memories of the trauma(s), or in children, repetitive play regarding the trauma themes.

• Recurrent distressing dreams related to the event(s).

• Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma(s) were recurring, or in children, reenactment of trauma during play.

C. At least 1 of the following avoidance symptoms:

• Avoids internal reminders of the trauma(s).

• Avoids external reminders of the trauma(s).

D. At least 2 of the following negative alterations in cognition and mood began after the event:

• Inability to remember an important aspect of the trauma(s).

• Persistent and exaggerated negative beliefs or expectations about one’s self, others or the world.

• Persistently negative emotional state, or in children younger than 7, more frequent negative emotions.

• Markedly diminished interest or participation in significant activities.

• Feeling of detachment or estrangement from others, or in children younger than 7, social withdrawal.

• Persistent inability to experience positive emotions.

E. At least 2 of the following changes in arousal and reactivity:

• Irritable or aggressive behavior.

• Reckless or self-destructive behavior.

• Hypervigilance.

• Exaggerated startle response.

• Problems with concentration.

• Sleep disturbance.

F. The symptoms began or worsened after the trauma(s) and continue for at least one month.

G. Among children younger than 7, diagnosis requires criteria A, B, E and F, but only 1 symptom from either category C or D.

What are dissociative disorders and somatic symptom-related disorders? - Chapter 8 (13)

Experiencing disruptions of consciousness is seen in dissociative disorders. Individuals with a somatic-symptom-related disorder complains of bodily symptoms. Those symptoms suggest a physical defect. These kind of disorders tend to comorbid.

8.1. What are dissociative disorders?

8.1.1. What is a depersonalization/derealization disorder?

A sense of being detached from one’s self is depersonalization, and a sense of being detached from one’s surroundings is derealization. The trigger is often stress.

DSM-5 Criteria for Depersonalization/Derealization Disorder

• Depersonalization: Experiences of detachment from one’s mental processes or body, as though one is in a dream, or

• Derealization: Experiences of unreality of surroundings.

• Symtpoms are persistent or recurrent.

• Reality testing remains intact.

• Symptoms are not explained by substances, another dissociative disorder, another psychological disorder, or by a medical condition.

8.1.2. What is dissociative amnesia?

DSM-5 Criteria for Dissociative Amnesia

• Inability to remember important autobiographical information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness.

• The amnesia is not explained by substances, or by other medical or psychological conditions.

• Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently purposeful wandering.

The period of amnesia may last for several hours or several years, and everything in between. It can begin and end very suddenly. The amnesia can cause some disorientation. Severe stress can cause this kind of memory loss.

8.1.3. What is dissociative identity disorder (DID)?

DSM-5 Criteria for Dissociative Identity Disorder

• Disruption of identity characterized by two or more distinct personality states (alters) or an experience of possession. These disruptions lead to discontinuities in the sense of self or agency, as reflected in altered cognition, behavior, affect, perceptions, consciousness, memories or sensory-motor functioning. This disruption may be observed by others or reported by the patient.

• Recurrent gaps in memory for events or important personal information that are beyond ordinary forgetting.

• Symptoms are not part of a broadly accepted cultural or religious practice.

• Symptoms are not due to drugs or a medical condition.

• In children, symptoms are not better explained by an imaginary playmate or by fantasy play.

It is possible that the primary alter is not aware of the existence of other alters and may have no memory of the time one of the other alters are in control. This primary alter is most often the one seeking treatment.

The posttraumatic model and the sociocognitive model are two major models for explaining DID. The first model suggests that the key element for developing DID is the use of dissociation to cope with trauma. According to the second model, it is very likely that alters appear in response to suggestions by clinicians, media or cultural influences in people who have been abused and seek explanations for their symptoms. This means that DID could be iatrogenic, which in turn means that it could have been created by treatment.

It is possible that people can roll play the symptoms of DID. Research supports this idea.

8.1.3.1. What treatment is used for DID?

The patient should be convinced that splitting into multiple personalities is no longer necessary in dealing with traumas. It is helpful to learn the patient effective ways to deal with stress.

Antidepressants have no effect on DID, but can be necessary in the treatment of anxiety and depression, which often comorbid with DID.

8.2. What are somatic symptom and related disorders?

Excessive concerns about physical symptoms or health define somatic symptom and related disorders. People with such disorders tend to pay frequent visits to a medical doctor, and often have a negative opinion about their doctors, because no medical explanation can be found.

There are several reasons to criticize the criteria for diagnosis:

• The conditions are particularly varied.

• The criteria are too subjective: what is too much concern e.g.?

• Patients often think the diagnosis stigmatizes too much.

The disorders often develop in early adulthood and often comorbid with other disorders.

8.2.1. What is the clinical description of somatic symptom disorder?

Excessive anxiety, energy or behavior centered around somatic symptoms is the key characteristic of somatic symptom disorder. It can be diagnosed, whether the symptoms can be explained medically or not. Some conflict or stress may cause or intensify the somatic symptoms.

DSM-5 Criteria for Somatic Symptom Disorder

• At least one somatic symptom that is distressing or disrupts daily life.

• Excessive thought, distress, and behavior related to somatic symptom(s) or health concerns, as indicated by at least one of the following:

  • Health-related anxiety.

  • Disproportionate and persistent concerns about the seriousness of symptoms.

  • Excessive time and energy devoted to health concerns.

  • Duration of at least 6 months.

• Specify if predominant pain.

8.2.2. What is the clinical description of illness anxiety disorder?

Preoccupation with fears of having a serious disease, even though there are no significant somatic symptoms, is the key characteristic of illness anxiety disorder. This disorder comorbid often with anxiety and mood disorders. Not a lot of people meet the criteria for this diagnosis, because not a lot of people are completely free of somatic symptoms.

DSM-5 Criteria for Illness Anxiety Disorder

• Preoccupation with and high level of anxiety about having or acquiring a serious disease.

• Excessive illness behavior (e.g., checking for signs of illness, seeking reassurance) or maladaptive avoidance (e.g., avoiding medical care).

• No more than mild somatic symptoms are present.

• Not explained by other psychological disorders.

• Preoccupation lasts at least 6 months.

8.2.3. What is the clinical description of conversion disorder?

The key feature is conversion disorder is the sudden development of neurological symptoms, despite having nothing wrong with the bodily organs and nervous system. Clinicians have to make sure there is no neurological basis for the complaint. In the DSM-5 clinicians can find guidelines about how to assess whether symptoms might be medically unexplained. The symptoms of the disorder often develop in adolescence or early adulthood.

DSM-5 Criteria for Conversion Disorder

• One or more symptoms affecting voluntary motor or sensory function.

• The symptoms are incompatible with recognized medical disorder.

• Symptoms cause significant distress or functional impairment or warrant medical evaluation.

8.2.4. What is the etiology of somatic symptom-related disorders?

Heritability seems not to be a factor in these disorders.

Finding the reason why some people are more aware of and distressed by somatic symptoms is the key issue in understanding somatic symptom disorders. The focus lies on brain regions that are activated by unpleasant body sensations in neurobiological models of somatic symptom-related disorders. Heightened activity in the anterior insula, anterior cingulate cortex and somatosensory cortex is linked to greater propensity for somatic symptoms.

Pain and somatic symptoms can be increased by anxiety, depression and stress hormones.

The focus with cognitive behavioral models lies with mechanisms that could contribute to the major focus on and fear over health concerns.

Research results give evidence for automatically focusing on hints of physical health problems in people with excessive distress about their somatic symptoms.

Two behavioral reinforcers might be given to the person having an excessive fear about their somatic symptoms:

• The person might take the role of being ill and the avoidance behaviors that might follow this, can intensify symptoms, because it limits healthy behaviors.

• The person may seek reassurance and this behavior can be reinforced if the person receives attention or sympathy because of the behavior.

There are more possible reinforcers for somatic symptoms.

In conversion disorders, the role of the unconscious seems to be clear, therefore the disorder has a central place in psychodynamic theories. According to these theories an unconscious psychological conflict causes the physical symptom. Patients may also have an unconscious motivation for having certain symptoms.

DSM-5 Criteria for Factitious Disorder

• Fabrication or induction of physical or psychological symptoms, injury or disease.

• Deceptive behavior is present in the absence of obvious external rewards.

• In Factitious Disorder Imposed on Self, the person presents himself or herself to others as ill, impaired, or injured.

• In Factitious Disorder Imposed on Another, the person fabricates or induces symptoms in another person and then presents that person to others as ill, impaired or injured.

The symptoms of conversion disorders seem to be shaped by social and cultural factors.

8.2.5. What is the treatment of somatic symptom and related disorders?

People with such a disorder usually want medical care and not psychological treatment. This is one of the major obstacles to treatment. A gentle reminder of the mind-body connection might help to get patients to consider mental health care.

People first go to their general practitioners with their complaints about somatic symptoms. It is therefore important that general practitioners can tailor care for people with somatic symptom-related disorders.

To help people with somatic symptom-related disorders, cognitive behavioral clinicians have applied different techniques:

• By identifying and changing the emotions that trigger the patient’s concerns.

• Change their cognition about their symptoms.

• Changing the behaviors that come with playing the role of a sick person.

• Gaining more reinforcement for engaging in different social interactions.

Because these disorders often comorbid with anxiety and depression, it is not surprising that somatic symptoms are reduced if anxiety and depression are successfully treated.

When pain is the focus of somatic symptom disorder, multiple techniques can be helpful:

• Cognitive behavioral techniques.

• Hypnosis.

• Acceptance and commitment therapy.

• Antidepressants.

What is schizophrenia? - Chapter 9 (13)

The psychological disorder schizophrenia is characterized by:

• Disordered thinking.

• Faulty perception and attention.

• A lack of emotional expressiveness.

• Disturbances in behavior.

The way someone thinks, feels and behaves are invaded by the symptoms of schizophrenia.

9.1. What are the clinical descriptions of schizophrenia?

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

• Positive symptoms.

• Negative symptoms.

• Disorganization.

DSM-5 Criteria for Schizophrenia

• Two or more of the following symptoms for at least 1 month; one symptom should be either 1, 2, or 3;

1. Delusions.

2. Hallucinations.

3. Disorganized speech.

4. Disorganized (or catatonic) behavior.

5. Negative symptoms (diminished motivation or emotional expression).

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

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

9.1.1. What are positive symptoms?

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

9.1.1.1. What are delusions?

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

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

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

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

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

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

9.1.1.2. What are hallucinations and other disturbances of perception?

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

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

9.1.2. What are negative symptoms?

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

9.1.2.1. What is avolition?

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

9.1.2.2. What is asociality?

Asociality refers to severe impairments in social relationships.

9.1.2.3. What is anhedonia?

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

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

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

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

9.1.2.4. What is blunted affect?

A lack of outward expression of emotion is referred to as blunted affect. This concept refers not to the patient’s inner experience of emotion.

9.1.2.5. What is alogia?

A significant reduction in the amount of speech is referred to as alogia. If this symptom is present, the person does not talk much.

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

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

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

9.1.3. What are disorganized symptoms?

9.1.3.1. What is disorganized speech?

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

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

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

9.1.3.2. What is disorganized behavior?

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

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

9.1.4. How is schizophrenia included in the DSM-5?

In the DSM-IV-TR you could find subtypes of schizophrenia. They were removed, because they had:

• Questionable usefulness,

• Poor reliability,

• Poor predictive validity.

The chapter entitled “Schizophrenia Spectrum and Other Psychotic Disorders in the DSM-5 includes:

• Schizophrenia.

• Schizophreniform disorder.

• Brief psychotic disorder.

• Schizoaffective disorder.

• Delusional disorder.

9.2. What is the etiology of schizophrenia?

9.2.1. Are there genetic factors?

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

9.2.1.1. What does behavior genetics research show?

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

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

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

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

9.2.1.2. What does molecular genetics research show?

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

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

9.2.2. What is the role of neurotransmitters?

9.2.2.1. What is the dopamine theory?

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

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

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

Other neurotransmitters that seem to have a role in the disorder are:

• Serotonin.

• GABA.

• Glutamate.

9.2.3. What is known about the brain structure and function in people with schizophrenia?

9.2.3.1. Are the ventricles in the brain of someone with the disorder enlarged?

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

9.2.3.2. Is the prefrontal cortex of particular importance in schizophrenia?

A variety of evidence suggests that this is the case:

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

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

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

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

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

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

9.2.4. What is known about the connectivity in the brain?

There are three types of connectivity in the brain:

• Structural connectivity: how different structures of the brain are connect via white matter.

• Functional connectivity: the connectivity between brain regions based on correlations between their blood oxygen level dependent (BOLD) signal measured with fMRI.

• Effective connectivity: combines both types of connectivity in that it not only reveals correlations between BOLD activations in different brain regions but als the direction and timing of those activations.

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

9.2.5. What environmental factors may contribute to schizophrenia?

The following environmental factors possibly contribute to schizophrenia:

• Delivery complications.

• Maternal infections during pregnancy.

• Cannabis use among adolescents.

9.2.6. What are psychological factors?

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

The highest rates of schizophrenia are found in people with the lowest socioeconomic status (SES), but schizophrenia can be found among all levels of SES.

• Socio genic hypothesis: is the stress associated to lower socioeconomic status contributing to the development of schizophrenia?

• Social selection hypothesis: or do people with disorder end up with a lower socioeconomic status due to the disorder.

Scientific evidence seem to support the social selection hypothesis.

9.2.7. What are the developmental factors?

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

• Lower IQs

• Were more often delinquent.

• Were more often withdrawn.

• Boys were rated more disagreeable.

• Girls were rated more passive.

• Poorer motor skills.

• More expressions of negative emotions.

In a more recent prospective study, it was found that children who eventually developed the disorder had signs of a cognitive deficit beginning at age 7 that remained stable through adolescence.

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

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

• Having a biological relative with schizophrenia.

• A recent decline in functioning.

• High levels of positive symptoms.

• High levels of social impairment.

9.3. What is the treatment for schizophrenia?

Treatment is often a combination of:

• Short-term hospital stays.

• Medication.

• Psychosocial treatment.

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

9.3.1. What medications are used?

Drugs that are widely used in the treatment of schizophrenia are antipsychotic drugs. There are first-generation and second-generation antipsychotic drugs (e.g., clozapine and risperidone). Medications alone are not a completely effective treatment, but do help a lot.

Research keeps being done to find new and more effective drug therapies for schizophrenia.

9.3.2. What are the psychological treatments?

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

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

• Family therapies: these therapies have numerous characteristics in common:

  • Education about schizophrenia.

  • Information about antipsychotic medication.

  • Blame avoidance and reduction.

  • Communication and problem-solving skills within the family.

  • Social network expansion.

  • Hope.

• Cognitive behavior therapy.

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

• Psycho education.

• Case management.

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

What are substance use disorders? - Chapter 10 (13)

In the hope of changing mood, reducing pain or changing states of consciousness, people have used several substances. The root of substance use disorder is probably the pleasing effects of substances.

10.1. What are the clinical descriptions, prevalence and effects of substance use disorders?

In contrast to the DSM-IV-TR, the DSM-5 contains categories for specific substances in substance use disorder. Gambling disorder is also included in the DSM-5.

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

Tolerance and withdrawal are most of the time part of a severe substance use disorder. Tolerance stands for either (a) to keep getting the desired effect, larger doses are needed or (b) if the usual amount is taken, the effects become less. When a person stops taking the drugs or reduces the amount, it is possible the person develops negative physical and psychological effects. This is called withdrawal.

Multiple factors can contribute to the development of substance use disorder:

• An individual’s neurobiology.

• Social setting.

• Culture.

• Other environmental factors.

DSM-5 Criteria for Substance Use Disorder

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

• Failure to meet obligations.

• Repeated use in situations where it is physically dangerous.

• Repeated relationship problems.

• Continued use despite problems caused by the substance.

• Tolerance.

• Withdrawal.

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

• Efforts to reduce or control use do not work.

• Much time spent trying to obtain the substance.

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

• Craving to use the substance is strong.

10.1.1 What is alcohol use disorder?

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

Alcohol use disorder often comorbids with other drug use.

What is known about alcohol users:

• College-age adults use alcohol most frequent.

• The consequences of binge drinking can be very serious, e.g., death.

• More men than women tend to have problems with alcohol.

• African American adolescents and adults are less likely to binge drink than European American and Hispanic adolescents and adults do.

• The disorder comorbids with several other psychological disorders.

10.1.1.2. What are the short-term effects of alcohol?

What the effects of alcohol use are, depends on:

• Amount of alcohol consumption.

• Person’s weight.

• Presence of food in the stomach.

• Person’s body fat.

Effects of alcohol are there, because it interacts with multiple neural systems in the brain:

• It stimulates GABA-receptors.

• It increases levels of serotonin and dopamine.

• It inhibits glutamate receptors.

10.1.1.3. What are the long-term effects of prolonged alcohol abuse?

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

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

10.1.2. What is tobacco use disorder?

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

10.1.2.1. What is the prevalence and are the health consequences of smoking?

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

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

10.1.2.2. What are the health consequences of secondhand smoke?

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

• Lung damage.

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

10.1.2.3. What are E-cigarettes?

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

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

10.1.3. What is marijuana?

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

10.1.3.1. What are the effects of marijuana?

People who smoke marijuana often report feeling relaxed and sociable after use. The kind of effects are dependent on the dosage. Effects appear more or less after 30 minutes, as a consequence smokers tend to get much higher than intended.

Marijuana use can interfere with cognitive functioning, as indicated by scientific evidence. If this is also the case when a smoker is not using at the moment, is not clear. Better research must be done to answer this question.

Short-term physical consequences include the following:

• Bloodshot and itchy eyes.

• Dry mouth and throat.

• Increased appetite.

• Raised blood pressure.

• Reduced pressure within the eye.

Lung structure and function can become impaired with long-term use of marijuana.

Smokers can become tolerant to marijuana, but it is not clear whether a user will experience withdrawal symptoms when he / she stops using.

There is a lot of debate on whether marijuana use should become legal, because of its therapeutic benefits.

10.1.4. What are opiates?

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

10.1.4.1. What are the psychological and physical effects?

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

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

10.1.5. What are stimulants?

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

10.1.5.1. What are amphetamines?

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

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

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

10.1.5.2. What is cocaine?

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

• Pleasurable states.

• Increased sexual desire.

• Produced feelings of self-confidence.

• Produced feelings of well-being.

• Produced feelings of indefatigability.

Chronic use can cause:

• Heightened irritability.

• Impaired social relationships.

• Paranoid thinking.

• Disturbances in eating and sleeping.

Not all, but some users develop tolerance. It seems that stopping with cocaine causes severe withdrawal symptoms.

10.1.6. What are hallucinogens, ecstasy and PCP?

10.1.6.1. What is LSD and other hallucinogens?

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

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

10.2. What is the etiology of substance use disorder?

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

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

2. Start experimenting with using it.

3. Begin using it regularly.

4. Use it heavily.

5. Finally become dependent on it.

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

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

10.2.1. What are the genetic factors?

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

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

10.2.2. What are the neurobiological factors?

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

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

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

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

10.2.3. What are the psychological factors?

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

• The effects of drugs on mood.

• People’s expectations about the effects on behavior.

• Personality traits.

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

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

Some personality traits appear to be important in predicting the development of substance use disorders:

• High levels of neuroticism.

• Persistent desire for arousal.

• Cautious behavior, harm avoidance and conservative moral standards.

10.2.4. What are the sociocultural factors?

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

Another sociocultural factor is the ready availability of the substance. It seems that greater availability of a particular drug is related to greater use of that drug.

Other contributing factors include:

• Family (e.g., unhappy marriage).

• Social settings.

• Friends who use.

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

10.3. What is the treatment of substance use disorder?

10.3.1. What is the treatment of alcohol use disorder?

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

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

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

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

Controlled drinking is based on two assumptions:

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

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

10.3.2. What are the treatments for smoking?

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

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

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

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

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

• Nicotine gum.

• Nicotine patches.

10.3.3. What is the treatment of drug use disorder?

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

Some somewhat helpful psychological treatments are:

• The antidepressant medication desipramine.

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

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

• Motivational enhancement therapy.

• Self-help residential homes.

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

10.4. What is prevention of substance use disorder?

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

• Increasing taxes on cigarettes.

• Restricting tobacco advertising.

• Public education campaigns.

• Creating smoke-free environments.

• Graphic images of the ill effects placed on packages.

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

• Peer-pressure resistance training.

• Correction of beliefs and expectations.

• Inoculation against mass media messages.

• Peer leadership.

What are eating disorders? - Chapter 11 (13)

11.1. What are the clinical descriptions of eating disorders?

11.1.1. What is anorexia nervosa?

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

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

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

The disorder frequently comorbids with other psychological disorders.

These are some of the physical consequences of Anorexia Nervosa:

• Blood pressure often falls.

• The slowing of the heart rate.

• The development of kidney and gastrointestinal problems.

• Decline of bone mass.

• The drying out of the skin.

• Nails become brittle.

• The change of hormone levels.

• Mild anemia may occur.

• Some people lose hair from the scalp.

• Some people may develop lanugo.

Mostly after a few years, about 50-70 percent of the patients recover. Death rates are high, because of physical complications and suicide.

DSM-5 Criteria for Anorexia Nervosa

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

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

• Body image disturbance.

DSM-5 severity ratings for Anorexia Nervosa

• Mild: BMI range ≤ 17

• Moderate: BMI range 16 – 16.99

• Severe: BMI range 15 – 15.99

• Extreme: BMI range

11.1.2. What is bulimia nervosa?

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

• Vomiting.

• Fasting.

• Excessive exercise.

A binge is defined with two characteristics:

• Eating an excessive amount of food.

• Having a feeling of losing control over eating.

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

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

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

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

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

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

DSM-5 Criteria for Bulimia Nervosa

• Recurrent episodes of binge eating.

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

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

DSM-5 severity ratings for Bulimia Nervosa

• Mild: 1 – 3 compensatory behaviors/week

• Moderate: 4 – 7 compensatory behaviors/week

• Severe: 8 – 13 compensatory behaviors/week

• Extreme: 14 or more compensatory behaviors/week

11.1.3. What is binge eating disorder?

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

Binge eating disorder comorbids with several other psychological disorders.

Risk factors for developing the disorder include:

• Low self-concept.

• Depression.

• Childhood obesity.

• Critical comments about being overweight.

• Weight-loss attempts in childhood.

• Childhood physical or sexual abuse.

Physical consequences of the disorder include:

• Increased risk of type 2 diabetes.

• Cardiovascular problems.

• Chronic back pain.

• Headaches.

• Sleep problems.

• Anxiety.

• Depression.

• Irritable bowel syndrome.

DSM-5 Criteria for Binge Eating Disorder

• Recurrent binge eating episodes.

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

• Eating more quickly than usual.

• Eating until over full.

• Eating large amounts even if not hungry.

• Eating alone due to embarrassment about large food quantity.

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

• No compensatory behavior is present.

DSM-5 severity ratings for Binge Eating Disorder

• Mild: 1 -3 binges/week

• Moderate: 4 – 7 binges/week

• Severe: 8 – 13 binges/week

• Extreme: 14 or more binges/week

11.2. What is the etiology of eating disorders?

11.2.1. What are the genetic factors?

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

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

11.2.2. What are the neurobiological factors?

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

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

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

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

11.2.3. What are the cognitive behavioral factors?

The fear of fatness and body-image disturbance is in cognitive behavioral theories of anorexia nervosa emphasized as the motivating factors that reinforce weight loss.

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

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

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

11.2.4. What are the sociocultural factors?

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

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

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

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

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

Eating disorders are more seen in:

• Women than men.

• White women than black women.

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

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

When evaluating the personalities of people with anorexia and bulimia, one needs to keep in mind that severe restriction of food intake can have powerful effects on personality and behavior, as is shown in research.

Among the changes are:

• Preoccupation with food.

• Increased fatigue.

• Poor concentration.

• Lack of sexual interest.

• Irritability.

• Moodiness.

• Insomnia.

According to research, the following personality characteristics may play a role:

• Perfectionism.

• Body dissatisfaction.

• A propensity to experience negative emotions.

11.3. What is the treatment of eating disorders?

11.3.1. Are medications helpful?

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

11.3.2. What is the psychological treatment of anorexia nervosa?

Therapy for anorexia nervosa has two goals:

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

• Long term maintenance of weight gain.

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

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

11.3.3. What is the psychological treatment of bulimia nervosa?

Cognitive behavior therapy is the most effective psychological treatment for bulimia nervosa. The overall goal in this therapy is to reestablish normal eating patterns, but it also involves changing a patient’s beliefs and thinking about:

• Thinness.

• Being overweight.

• Dieting.

• Restriction of food.

For binge eating disorder is CBT also an effective treatment.

11.3.4. What are preventive interventions for eating disorders?

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

• Psycho educational approaches.

• De-emphasizing sociocultural influences.

• Risk factor approach.

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

What are sexual disorders? - Chapter 12 (13)

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

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

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

12.1. What are sexual norms and behavior?

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

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

12.1.1. What is the relation of gender with sexuality?

Genders tend to differ in sexuality in a few ways:

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

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

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

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

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

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

12.1.2. What is the sexual response cycle?

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

1. Desire phase, refers to sexual interest or desire.

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

3. Orgasm phase, sexual pleasure peaks.

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

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

12.2. What are sexual dysfunctions?

12.2.1. What are the clinical descriptions of sexual dysfunctions?

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

• Those involving sexual desire, arousal, and interest.

• Orgasmic disorders.

• A disorder involving pain.

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

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

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

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

12.2.1.1. What are disorders involving sexual interest, desire and arousal?

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

DSM-5 Criteria for Female Sexual Interest/Arousal Disorder

Diminished, absent, or reduced frequency of at least three of the following:

• Interest in sexual activity.

• Erotic thoughts or fantasies.

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

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

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

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

DSM-5 Criteria for Male Hypoactive Sexual Desire Disorder

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

DSM-5 Criteria for Erectile Disorder

On at least 75 percent of sexual occasions:

• Inability to attain an erection, or

• Inability to maintain an erection for completion of sexual activity, or

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

12.2.1.2. What are orgasmic disorders?

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

DSM-5 Criteria for Female Orgasmic Disorder

On at least 75 percent of sexual occasions:

• Marked delay, infrequency, or absence of orgasm, or

• Markedly reduced intensity of orgasmic sensation.

DSM-5 Criteria for Premature Ejaculation

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

DSM-5 Criteria for Delayed Ejaculation

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

12.2.1.3. What are sexual pain disorders?

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

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

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

• Inability to have vaginal/penetration during intercourse.

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

• Marked fear or anxiety about pain or penetration.

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

12.2.2. What is the etiology of sexual dysfunctions?

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

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

• Previous sexual abuse.

• Lack of sexual knowledge.

• Relationships problems.

• Psychological disorders.

• Negative cognitions about sexuality.

• Negative attitudes about sexuality.

12.2.3. What are the treatments for sexual dysfunctions?

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

• Anxiety reduction and psycho eduction.

• Procedures to change attitudes and thoughts.

• Communication training.

• Directed masturbation.

• Other physical treatments.

• Medications.

  • Antidepressant drugs.

  • PDE-5 inhibitors (e.g., Viagra).

12.3. What are the paraphiliac disorders?

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

12.3.1. What is fetishistic disorder?

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

DSM-5 Criteria for Fetishistic Disorder

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

• Causes significant distress or impairment in functioning.

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

12.3.2. What are pedophilic disorders and incest?

Pedophilic is diagnosed, according to the DSM, when:

• Adults derive sexual gratification through sexual contact with prepubertal children, or

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

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

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

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

DSM-5 Criteria for Pedophilic Disorder

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

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

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

12.3.3. What is voyeuristic disorder?

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

DSM-5 Criteria for Voyeuristic Disorder

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

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

12.3.4. What is exhibitionistic disorder?

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

DSM-5 Criteria for Exhibitionistic Disorder

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

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

12.3.5. What is frotteuristic disorder?

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

DSM-5 Criteria for Frotteuristic Disorder

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

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

12.3.6. What are sexual sadism and masochism disorders?

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

DSM-5 Criteria for Sexual Sadism Disorder

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

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

DSM-5 Criteria for Sexual Masochism Disorder

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

• Causes marked distress or impairment in functioning.

12.3.7. What is the etiology of paraphiliac disorders?

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

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

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

Another important factor in the paraphiliac disorders are cognitive distortions and attitudes.

12.3.8. What are the treatments for the paraphiliac disorders?

Because many sex offenders lack the motivation to change their illegal behavior, strategies to enhance their motivation are an important part of treatment.

For countering the distorted thinking, cognitive procedures are often used.

Other helpful treatments might be:

• Empathy training.

• Relapse prevention.

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

What are disorders of childhood? - Chapter 13 (13)

13.1. How does classification and diagnosis of childhood disorders work?

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

Childhood disorders are often divided into two broad domains:

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

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

13.2. What is Attention-Deficit/Hyperactivity Disorder?

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

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

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

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

• Adults only need to show symptoms in five domains.

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

• Predominantly inattentive.

• Predominantly hyperactive-impulsive.

• Combined.

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

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

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

• To be viewed more negatively by peers.

• To be more anxious and depressed.

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

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

DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder

Either A or B:

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

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

• Several of the above present before age 12.

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

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

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

13.2.2. What is the etiology of ADHD?

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

• Dopamine receptor genes: DRD4 and DRD5.

• Dopamine transporter gene: DAT1.

• SNAP-25.

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

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

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

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

13.2.3. What is the treatment of ADHD?

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

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

Some promising psychological treatments are:

• Parent training.

• Changes in classroom management.

• Intensive behavioral therapies.

13.3. What is conduct disorder?

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

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

A specifier of conduct disorder in the DSM-5 is “limited prosocial emotions”, for children who have what are referred to as callous and unemotional traits.

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

DSM-5 Criteria for Conduct Disorder

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

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

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

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

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

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

13.3.2. What is the etiology of conduct disorder?

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

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

Neuropsychological deficits are also found:

• Poor verbal skills.

• Difficulty with executive functioning.

• Problems with memory.

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

Causally related to aggressive behavior is rejection by peers.

13.3.3. What is the treatment for conduct disorder?

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

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

• The adolescent

• The family

• The school

• In some cases also the peer group.

The uniqueness with this therapy lies in emphasizing:

• Individual and family strengths.

• Identifying the social context for the conduct problems.

• Using present-focused and action oriented interventions.

• Treatment is in “ecologically valid” settings, such as the home and the school.

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

13.4.1. What is depression in children?

Children and adolescents ages 7 to 17 and adults both show the following symptoms in major depressive disorder:

• Depressed mood.

• Inability to experience pleasure.

• Fatigue.

• Concentration problems.

• Suicidal ideation.

Children and adolescents differ however in:

• Showing more guilt.

• Lower rates of early-morning wakefulness.

• Lower rates of early-morning depression.

• Lower rates of loss of appetite.

• Lower rates of weight loss.

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

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

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

Some forms of treatments are possible:

• Antidepressants.

• Cognitive behavioral therapy.

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

13.4.2. What is anxiety in children?

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

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

Other types of anxiety disorders found in children are:

• Social anxiety disorder.

• Symptoms of posttraumatic stress disorder.

• Obsessive compulsive disorder.

Genetics play a role, but they do their work via the environment.

Treatment is for the most part the same as treatment for adults.

DSM-5 Criteria for Separation Anxiety Disorder

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

• Repeated and excessive distress when separated.

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

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

• Refusal or reluctance to sleep away from home.

• Nightmares about separation from attachment figure.

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

13.5. What is a specific learning disorder?

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

13.5.1. What are the clinical descriptions?

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

• Specific learning disorder.

• Communication disorders.

• Motor disorders.

DSM-5 Criteria for Specific Learning Disorder

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

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

13.5.2. What is the etiology of specific learning disorder?

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

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

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

Research results suggests that any genes linked to dyscalculia are also linked to mathematics ability.

13.6. What is intellectual disability?

Intellectual disability was named mental retardation in the DSM-IV-TR. Due to the stigma linked to the old term, most mental health professionals stopped using it.

13.6.1. How does the diagnosis and assessment of intellectual disability work?

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

• Deficits in intellectual functioning.

• Deficits in adaptive functioning.

• An onset during development.

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

• Conceptual.

• Social.

• Practical.

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

DSM-5 Criteria for Intellectual Disability

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

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

• Onset during child development.

13.6.2. What is the etiology of intellectual disability?

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

13.6.3. Are there genetic chromosomal abnormalities?

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

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

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

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

• HIV.

• Herpes simplex.

• Toxoplasmosis.

• Cytomegalovirus.

• Rubella.

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

13.6.4. What is the treatment of intellectual disability?

Some treatments of intellectual disability are available:

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

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

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

• Computer-assisted instruction. Some benefits of computer-assisted instruction are:

  • Computers can help to maintain the attention of distractible students because of visual and auditory components.

  • It can ensure successful experiences, because the level of the material can be geared to the person using the computer.

  • The need for numerous repetitions of material can be met.

13.7. What is autism spectrum disorder?

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

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

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

• Fusiform gyrus.

• Other regions in the temporal loves.

• Amygdala.

Children with this disorder have some communication deficits:

• Babbling is less frequent in infants with ASD.

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

• Pronoun reversal.

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

Children with this disorder might become obsessed with something, e.g., continually lining up toys.

They may also show stereotypical behavior, peculiar ritualistic hand movements and other rhythmic movements.These activities are often described as self-stimulatory.
Some children with the disorder can become obsessed with and form strong attachments to simple inanimate objects and to more complex mechanical objects.

ASD often comorbids with intellectual disability and anxiety.

13.7.2. What is the etiology of autism spectrum disorder?

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

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

13.7.3. What is the treatment of autism spectrum disorder?

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

DSM-5 Criteria for Autism Spectrum Disorder

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

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

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

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

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

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

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

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

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

C. Onset in early childhood.

D. Symptoms limit and impair functioning.

What are late life and neurocognitive disorders? - Chapter 14 (13)

14.1. What issues come with aging?

Because people reach many different ages above the age of 65, gerontologists often split these people into three groups:

• In the first group the ages are between 65 and 74 and are called the young-old.

• In the second group the ages are between 75 and 84 and are called the old-old.

• The third group are the ages above 85 and are called the oldest-old.

More people are reaching this old age and therefore a lot of clinicians work with older adults. Surprising is the fact that many of these clinicians say not to have had any formal training about late-life issues.

14.1.1. What are the myths about late life?

There are many myths about late life and all of these have been debunked, examples of these are:

• Old people are unhappy. Studies reveal that this is not the case. Elderly people experience less negative emotions than young people. The elderly also seem to be more skilled at regulating their emotions.

• Old people are lonely. With old people there is a phenomenon called social selectivity. Social selectivity means that the interests lies with a few social relationships that are considered most important, instead of being interested in seeking new social interactions.

There are many stereotypes about the elderly. Most of them are false. A major concern is that those stereotypes are often learned young and persist through life and can become negative self-perceptions as people become old.

14.1.2. What are the problems experienced in late life?

The elderly have the most problems when it comes to their physical health. They also experience stress due to social problems, like losing loved ones and stigmatizing attitudes from younger people. All these problems have effect on their mental health.

With age, there is a decline in the quality and depth of sleep. If chronic sleep deficits stay untreated, it can worsen psychological, physical and cognitive problems. The risk of mortality can even increase. It seems that psychological treatment can be of some benefit.

14.1.3. Which research methods are used in the study of aging?

Researches must be careful when they attribute differences between age groups solely to the effects of aging, because other factors related to age may influence findings.

• Age effects are the effects of being a certain age.

• Cohort effects are the consequences of growing up during a certain time period, e.g. W.W.II.

• Time-of-measurement effects. A variable that is being studied can be influenced by events at a particular point in time.

To assess developmental change, researchers often use one of two major research designs:

• Cross-sectional. In these kind of studies the researcher compares different age groups at the same time on a particular variable.

• Longitudinal studies. The investigator retests a group of people over a number of years using the same measure.

A disadvantage of longitudinal studies is selective mortality. This means that some people are no longer available for follow-up because of death.

14.2. What is known about psychological disorders in late life?

The DSM-5 criteria are the same for all ages. The elderly have more medical conditions and use more medications than younger people. This should be considered when diagnosing the elderly, because if the symptoms can be accounted for by a medical condition or by medication, the psychological disorder should not be diagnosed. It should also be considered that physical and psychological health interact with each other.

Studies show that people older than 65 have the lowest prevalence of psychological disorders of all age groups. This defies the myths and stereotypes of unhappiness and anxiety in late life.

There might be other reasons than better health of coping styles, for why the prevalence estimates are so low:

• The elderly seem to feel uncomfortable discussing symptoms.

• Cohort effects may play a role.

• People with psychological disorders have higher risks of dying before the age of 65.

14.3. What are neurocognitive disorders in late life?

14.3.1. What is dementia?

Dementia is a term used to describe the decline in cognitive abilities to the point that function becomes impaired.

There are different types of dementia, with different causes and symptoms. The most common symptom of dementia is decline in memory. Depending on the cause, dementia can be progressive, static or remitting. Mild cognitive impairment is the term used for early signs of decline that have been noted before functional impairment is present. It is difficult to tell where mild cognitive decline ends and dementia begins. According to the DSM-5 the difference lies with the interference of the symptoms with the ability to live independently. The symptoms in mild cognitive decline do not necessarily progress into dementia.

14.3.1.1. What is Alzeheimer’s disease?

With Alzheimer’s disease brain tissue progressively deteriorates. A patient with this disease usually dies within twelve years after the onset of symptoms. Memory loss is the most known and common symptom in Alzheimer’s disease. At first the memory loss might be overlooked, but will eventually interfere with daily function. The disease is progressive which means the symptoms get worse with time. Both the range and severity of these symptoms increase.

There are more beta-amyloid plaques and neurfibillary tangles found in the brain of patients with Alzeheimer's disease than people of the same age without the disease. People with the disease often either produce major amounts of beta-amyloid or have impairments in the mechanisms that clear-up the beta-amyloid. The plaques are mostly found in the frontal cortex. The tangles are mostly found in the hippocampus. The plaques and tangles spread through the brain as the disease worsens.

The immune system reacts to the plaques, which leads to inflammation, and that triggers a number of changes in the brain over time. In the beginning there seems to be a loss of synapses from different kind of neurons. Neurons begin to die, which make different parts of the brain shrink.

Genes play a role in Alzheimer’s, but so do lifestyle factors. Some factors might protect against cognitive decline, such as regular exercise and intellectual activities. The protective aspects of intellectual activities led to the idea of cognitive reserve. Cognitive reserve is the idea that some people may be able to compensate for the disease by using alternative neural networks or cognitive strategies.

14.3.2. What is frontotemporal dementia?

A loss of neurons in the frontal and temporal lobes is seen in frontotemporal dementia (FTD). It is a progressive disease that develops quickly. In contrast to Alzeimer’s disease is memory in FTD not severely impaired. There a different types of FTD. To meet the criteria for the most common one, there must be deterioration in at least three of the following contexts and should lead to impairments in daily living: empathy, executive function, ability to inhibit behavior, compulsive or perseverate behavior, hyperorality and apathy.

FTD damage social relationships more often than Alzheimer’s disease, due to deficits in the regulation of emotions, in combination with changes in personality and lack of insight.

14.3.3. What is vascular dementia?

Cerebrovascular disease causes vascular dementia. When circulation of blood is impaired, neurons die. Often this is caused by strokes. Strokes can occur in any area of the brain, therefore the symptoms between people can differ a lot.

14.3.4. What is Dementia with Lewy Bodies (DLB)?

Lewy bodies are protein deposits in the brain. They can cause cognitive decline. Most people with Parkinson’s disease will develop this form of dementia, though it is still possible to develop DLB if Parkinson’s disease is not present. The symptoms are similar to the symptoms of Parkinson’s. People with DLB often have intense dreams. It often seems as though they are acting out their dreams.

14.3.5. What treatments exist for dementia?

No cure for dementia is available. Some medication is used as treatment. Medications do not restore memory in Alzheimer’s disease, but do seem to slow down the decline. Medication is more often used for the treatment of psychological symptoms, which often co-occur with dementia.

Some psychological and lifestyle treatments seem to have beneficial effects, e.g.: supportive psychotherapy, increase exercise, cognitive training programs and learning new behavioral strategies.

14.3.6. What is delirium?

The term delirium implies being “off-track”; it is more often described as a clouded state of consciousness. ‘Extreme trouble focusing attention’ and ‘profound disturbances in the sleep/wake cycle’ are the most common symptoms. Disturbances in perception is also often seen in delirium. Fast shifts in activity and mood occur too. Deliriums are most common among children and older adults, but is also seen in other age groups. When a delirium goes untreated, the outcomes are severe: increased risk of death, and more cognitive decline. If the delirium is treated, complete recovery is possible.

What are personality disorders? - Chapter 15 (13)

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

15.1. What is the DSM-5 approach to classification?

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

Cluster A: odd or eccentric behavior.

Cluster B: dramatic, emotional or erratic behavior.

Cluster C: anxious of fearful behavior.

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

15.1.1. How are the DSM-5 personality disorders assessed?

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

15.1.2. What problems are in the DSM-5 approach to personality disorders?

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

15.1.2.1. Are personality disorders stable over time?

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

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

• Even after remission, many problems with functioning exist.

• The possibility of relapse stays high.

15.1.2.2. Are personality disorders highly comorbid?

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

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

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

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

Some of the key advantages of this model are:

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

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

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

15.3. What are common risk factors across the personality disorders?

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

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

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

15.4.1. What is paranoid personality disorder?

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

The DSM-5 Criteria for Paranoid Personality Disorder:

Presence of 4 or more of the following signs of distrust and suspiciousness from early adulthood across many contexts:

• Unjustified suspiciousness of being harmed, deceived or exploited.

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

• Reluctance to confide in others because of suspiciousness.

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

• Bears grudges for perceived wrongs.

• Angry reactions to perceived attacks on character or reputation.

• Unwarranted suspiciousness of the partner’s fidelity.

15.4.2. What is schizoid personality disorder?

The DSM-5 Criteria for Schizoid Personality Disorder:

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

• Lack of desire for or enjoyment of close relationships.

• Almost always prefers solitude to companionship.

• Little interest in sex.

• Few or no pleasurable activities.

• Lack of friends.

• Indifference to praise or criticism.

• Flat affect, emotional detachment, or coldness.

15.4.3. What is schizotypal personality disorder?

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

The DSM-5 Criteria for Schizotypal Personality Disorder:

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

• Ideas of reference.

• Odd beliefs or magical thinking.

• Unusual perceptions.

• Odd thought and speech.

• Suspiciousness or paranoia.

• Inappropriate or restricted affect.

• Odd or eccentric behavior or appearance.

• Lack of close friends.

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

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

15.5.1. What is antisocial personality disorder and what is psychopathy?

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

15.5.1.1. What is antisocial personality disorder?

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

The DSM-5 Criteria Antisocial Personality Disorder:

• Age at least 18.

• Evidence of conduct disorder before age 15.

• Pervasive pattern of disregard for the rights of others since the age of 15 as shown by at least three of the following:

  • Repeated law breaking.

  • Deceitfulness, lying.

  • Impulsivity.

  • Irritability and aggressiveness.

  • Reckless disregard for own safety and that of others.

  • Irresponsibility as seen in unreliable employment or financial history.

  • Lack of remorse.

15.5.1.2. What is psychopathy?

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

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

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

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

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

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

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

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

15.5.1.4. What are the psychological risks?

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

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

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

15.5.2. What is Borderline Personality Disorder?

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

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

The DSM-5 Criteria Borderline Personality Disorder:

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

• Frantic efforts to avoid abandonment.

• Unstable sense of self.

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

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

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

• Marked mood reactivity.

• Chronic feelings of emptiness.

• Recurrent bouts of intense or poorly controlled anger.

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

A lot of risk factors may contribute to the onset of BPD.

Neurobiological factors: BPD patients show an increased activation of the amygdala to emotional pictures, which is relevant to the emotion dysregulation. Patients show deficits in the prefrontal cortex and this might contribute to impulsivity; they also show a disrupted connectivity between the amygdala and the prefrontal cortex.

Social factors: high estimates of heritability are seen in the BPD population, besides high rates of childhood abuse or neglect. It is not clear yet, which of these two factors sets the disorder in motion.

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

15.5.3. What is Histronic Personality Disorder?

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

The DSM-5 Criteria Histronic Personality Disorder

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

• Strong need to be the center of attention.

• Inappropriate sexually seductive behavior.

• Rapidly shifting and shallow expression of emotions.

• Use of physical appearance to draw attention to self.

• Speech that is excessively impressionistic and lacking in detail.

• Exaggerated, theatrical emotional expression.

• Overly suggestible.

• Misreads relationships as more intimate than they are.

15.5.4. What is Narcissistic Personality Disorder?

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

The DSM-5 Criteria Narcissistic Personality Disorder

Presence of five or more of the following signs of grandiosity, need for admiration, and lack of empathy from early adulthood across many contexts:

• Grandiose view of one’s importance.

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

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

• Extreme need for admiration.

• Strong sense of entitlement.

• Tendency to exploit others.

• Lack of empathy.

• Envious of others.

• Arrogant behavior or attitudes.

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

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

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

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

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

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

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

15.6.1. What is Avoidant Personality Disorder?

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

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

The DSM-5 Criteria Avoidant Personality Disorder

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

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

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

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

• Preoccupation with being criticized or rejected.

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

• Views self as socially inept, unappealing or inferior.

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

15.6.2. What is Dependent Personality Disorder?

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

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

The DSM-5 Criteria Dependent Personality Disorder:

An excessive need to be taken care of, as shown by the presence of at least five of the following from early adulthood across many contexts:

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

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

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

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

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

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

• Urgently seeking new relationship when one ends.

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

15.6.3. What is Obsessive-Compulsive Personality Disorder?

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

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

The DSM-5 Criteria Obsessive-Compulsive Personality Disorder:

Intense need for order, perfection, and control, as shown by the presence of at least four of the following from early adulthood across many contexts:

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

• Extreme perfectionism interferes with task completion.

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

• Inflexibility about morals and values.

• Difficulty discarding worthless items.

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

• Miserliness.

• Rigidity and stubbornness.

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

15.7. What is the treatment for personality disorders?

15.7.1. What are general approaches to the treatment of personality disorders?

Psychotherapy is often the first choice for the treatment of personality disorders. Most of the time this is supplemented with medications.

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

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

15.7.2. What is the treatment for borderline personality disorder?

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

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

The cognitive behavioral aspect involves four stages:

1. Dangerously impulsive behaviors are addressed. The goal is greater control of self.

2. In this stage the focus lies with learning to modulate the extreme emotionality.

3. During this stage the focus is on improving relationships and self-esteem.

4. In this stage the focus is on connectedness and happiness.

What are legal and ethical issues in psychopathology? - Chapter 16 (13)

Criminal commitment is a procedure that confines a person in a mental or forensic hospital either for determination of competency to stand trail or after acquittal by reason of insanity. Those who have broken the law or are alleged to have done so and have a psychological disorder are subject to criminal commitment.

A person can be deprived of liberty and placed in a hospital if he/she is deemed mentally ill and dangerous, even though has not broken any laws. The set of procedures by which this can happen, is called civil commitment.

16.1. What is criminal commitment?

A disordered mind is referred to as insanity. This is not a psychological concept, but a legal one. Most of the time, insanity defense results in a greater denial of liberties than they would otherwise experience, even though it was intended to protect people’s rights.

16.1.1. What is the insanity defense?

A lawyer could argue that his client should not be held responsible for an illegal act because it can be attributed to a psychological disorder or intellectual disability that interferes with rationality. This is called the insanity defense.

Someone can be held fully responsible for a crime, even if that person has a diagnosis of a psychological disorder. It is also possible that someone commits the most horrendous crime without having a psychological disorder. Therefore, crime and psychological disorders do not go hand in hand.

The current insanity pleas:

• Not guilty by reason of insanity (NGRI): nobody argues that a person did commit the crime, but the defense lawyer argues that the person should not be held responsible due to to the person’s insanity at the time of the crime.

• Guilty but not mentally ill (GBMI): with this deal an accused person can be found legally guilty of a crime and has the possibility for psychiatric judgment on how to deal with the convicted person if he or she is considered to have been mentally ill when the act was committed.

16.2. What is civil commitment?

Civil commitment is a procedure whereby an individual (even against his or her will) can be legally considered mentally ill and hospitalized.

The procedures usually fit into one of the next categories:

• Formal, which is by order of a judge.

• Informal, this is an emergency commitment of people with a psychological disorder. This can be done without initially involving a judge.

16.2.1. What is preventive detention?

It is not true that people with psychological disorders account for a significant proportion of the violence that happens in society, it is about 3 percent in the USA.

It is usually against family members or friends when people with a psychological disorders do act aggressively. The incidents tend to occur at home. Violence from people with psychological disorders seldom affect the general public.

Under the following conditions, violence prediction is most accurate as is suggested by research:

• Repeatedly violent behavior in the recent past.

• Violence can be expected when the individual was incarcerated because of a very serious act in the distant past and he or she is released without a change in the individual’s predetention personality and physical abilities and if the individual is going back to the same environment in which he or she was previously violent.

• Violence can be predicted if the individual is judged to be on the brink of a violent act, even with no history of violent behaviors.

An arrangement whereby an individual is ordered by the court to receive treatment on an outpatient basis is called assisted outpatient treatment (AOT). This is a way of increasing medication compliance. If medication compliance is increased, reduction of violence can be expected.

Some issues and trends that revolve around the protections of people with psychological disorders are:

• The principle of the least restrictive alternative. This means that mental health professionals have to provide the treatment that restricts the individual’s freedom the least while remaining workable.

• Right to treatment. The state needs to provide treatment if an individual is deprived of liberty because he or she has a psychological disorder and is a danger to self or others.

• Right to refuse treatment.

16.3. What are ethical dilemmas in therapy and research?

Numerous international codes of ethics for the conduct of scientific research have been developed, as response to the many instances of harm done to research participants. Reevaluation and revision of those codes are continually done, because new challenges are continually posed to the research community.

Institutional review boards review the research proposals of behavioral researchers for safety and general ethical propriety.

Informed consent is a key component of ethical research. People must be able to decide whether they want to be in a study or not based on the information given by the researcher. It is important that there is no coercion in obtaining informed consent. It is also important that participants understand that they can withdraw from the study at any point.

By professional ethics codes, people are assured that what is said and done in a therapeutic session will remain confidential. This means that nothing will be revealed to a third party, with the exception of other professionals and those intimately involved in the treatment.

A privileged communication is communication between people in a confidential relationship that is protected by law. The person’s right of privileged communication has important limits:

• The therapist is being accused of malpractice by the patient.

• When the therapist has reason to believe that the patient of 16 years old or younger has been a victim of a crime.

• A patient has initiated therapy in hopes of evading the law for having committed a crime or for planning a crime.

• The person is a danger to self or others and disclosure of information is needed to ward off such danger. The therapist is the judge of this.

Abnormal Psychology - Kring et al. - 13th edition - BulletPoints

What is psychopathology? - BulletPoints 1

• Psychopathology is the study of the nature, development, and treatment of psychological disorders.

• The best definition of psychological disorder has seven aspects:

  • The individual has the disorder within himself.

  • There are difficulties in thinking, feeling and/or behaving that are of clinical significance.

  • It often involves a kind of personal distress.

  • There is impairment in processes that support mental functioning, such as: psychological, developmental, and/or neurobiological.

  • The problems are not a culturally specific reaction to an event.

  • The problems are not only a result of conflict with society.

• In Europe there were a lot of hospitals for patients with leprosy until the fifteenth century. The old leprosy hospitals were turned into asylums, when the attention shifted from leprosy to psychological disorders due to dissapearance of leprosy in Europe. Asylums were buildings used to give housing and care to people with psychological disorders.

• Francis Galton was one of the first to ascribe many behavioral characteristics to heredity as a result of his studies with twins in the late 19th century. He talked about differences in nature (genetics) and nurture (environment). Some researchers became interested in the idea of heritability in psychological disorders and started studying it.

• Freud theorized that psychopathology is caused by unconscious conflicts in the individual. This is often referred to as psychoanalytic theory. He divided the psyche into three main parts: id, ego and superego. The id wants immediate gratification of it basic urges. Also known as the pleasure principle. Tension is produced when the urges of the id are not satisfied. The contents of the ego are mainly conscious. It needs to deal with reality and thus is driven by the reality principle. The ego mediates between the demands of the id and the demands of reality. The superego can be seen as a person’s conscience. It incorperates the values of the parents to receive the pleasure of the parents’ approval and avoind the pain of disapproval.

• Observable behavior is the center of behaviorisme rather than that consciousness of mental functioning.The behaviorist approach was influenced by three types of learning: classical conditioning, operant conditioning and modeling.

• Cognitive therapy emphasizes the idea that a major determinant in psychological disorders is how people see themselves and the world.

What are the current paradigms in psychopathology? - BulletPoints 2

• A paradigm is a conceptual framework or approach within which a scientist works – that is, a set of basic assumptions, a general perspective, that defines how to conceptualize and study a subject, how to gather and interpret relevant data, even how to think about a particular subject.

• Throughout the life span, the environment shapes how our genes are expressed, and our genes also shape our environments.

• An important term that will be used throughout this summary is heritability. This refers to the extent to which variability in a particular behavior in a population can be accounted for by genetic factors.

• Behavior genetics is the study of the degree to which genes and environmental factors influence behavior.

• Gene expression involves particular types of DNA called promoters. These promoters are recognized by particular proteins called transcription factors. Promoters and transcription factors are the focus of much research in molecular genetics and psychopathology.

• According to the neuroscience paradigm psychological disorders are linked to abnormal processes in the brain.

• The writers want to caution against reductionism, which refers to the view that whatever is being studies can and should be reduced to its most basic parts. Most things, disorders, humans are more than the sum of their parts. The danger is that certain phenomena will be missed by researchers who focus only on the molecular level, because the phenomena only emerges at certain other levels of analysis.

• The idea that problem behavior is likely to continue if it is reinforced is one of the important influences from behaviorism. Generally, four possible consequences is seen as reinforcements of problem behavior: getting attention, escaping from tasks, generating sensory feedback and gaining access to desirable things or situations. Treatment can be tailored to change the consequence of the problem behavior, when the source of reinforcement is known.

• Within cognitive behavior therapy the focus is on private events, such as thoughts, perceptions, judgments, etc. Changing a pattern of thought is called cognitive restructuring.

• The term used to describe the different kinds of mental processes is cognition.

• The focus with cognitive science lies on how people structure their experiences, how they make sense of their experiences and how people relate their past experiences to current ones.

• Emotions can be studies from multiple perspectives and thus cuts across the paradigms.

• Not one of the stated paradigm is adequate enough on its own to explain or treat the psychological disorders, because the disorders are much too diverse. Because of this, the diathesis-stress paradigm was introduced. This paradigm links genetic, neurobiological, psychological and environmental factors together and therefore is an integrative paradigm.

What is diagnosis and assessment? - BulletPoints 3

• The consistency of measurement is called reliability. Good reliability means the measurement measures the same thing everytime.The degree to which two independent observers agree on what has been observed is called interrater reliability. The extent to which people being observed several times receive similar scores is measured by test-retest reliability. Both interrater reliability and test-retest reliability are important to assessment and diagnosis.

• Validity is complex. If a test has good validity it means that the tests measures what it is suppose to measure.

• DSM stands for Diagnostic and Statistical Manual of Mental Disorders. It is the diagnostic system used by many mental health professionals. The DSM-5 is the latest issue of the manual.

• In psychopathological assessment, clinicians use both structured and less structured interviews. A difference to a casual conversation is the way the clinician pays attention to the individual’s response.

• Stress is defined as the subjective experience of distress in response to perceived problems in the environment. Stress is a major aspect of many different disorders, that makes it a very important thing to measure. The assessment widely used to study life stressors is the Bedford college life events and difficulties schedule (LEDS).

• Behavioral assessment is mostly done through observation. A direct observation of behavior can be done, for example, or self-observation (often referred to as self-monitoring). Reactivity is the term used for the phenomenon wherein behavior changes because it is being observed.

• The idea that different psychological functions rely on different areas of the brain forms the basis for neuropsychological tests. These tests are often used besides the brain-imaging techniques.

• People working in psychophysiology are interested in bodily changes that are linked to psychological events. Sensitivity of psychophyiological assessments is not strong enough to be used for diagnosis. It does give important information about an individual and it is useful when a someone wants to compare individuals.

• A measure that is created for one culture or ethnic group may not be as reliable and valid with a different cultural or ethnic group. This notion is refered to as cultural bias.

What are the research methods in psychopathology? - BulletPoints 4

• Science is trying to gain knowledge via observation. A theory is formed and then tested by systematically gathering data.

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

• Both statistical and clinical significance should be considered. Statistical significance means that the observed correlation is unlikely to have occured by chance. Clinical significance means that the relationship between the variables is large enough to matter.

• There is a major disadvantage to the use of the correlation method, namely: no conclusions can be drawn about the causation of the relationship. It is not known if one variable causes the other. It is also possible that a third variable has caused the relationship between the two variables. This is known as the third-variable problem.

• To determine a casual relationship between two variables the experiment is the best tool to use. Participants of an experiment will be randomly assigned to different conditions. An independent variable will be manipulated and a dependent variable will be measured.

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

• In randomized controlled trials (RCT) clients are randomly assignted to treatment group or control group. The independent variable is the received treatment and the clients’ outcome is the dependent variable.

• It is not always possible to use the experimental method due to ethical reasons. To still take advantage of the benefits of the experimental method, researchers can use an analogue experiment. In an analogue experiment researchers try to create or observe a phenomenon related to the one they actually want to test. This phenomenon is then the analogue.

What are mood disorders? - BulletPoints 5

• In mood disorders disabling disturbances in emotion are seen. On the one hand there is extreme sadness in depression and on the other hand there is the extreme elation of mania.

• The inability to experience pleasure and/or experiencing extreme sadness are the key features of depression. Symptoms in depression vary.

• Major Depressive Disorder (MDD) is an episodic disorder. This means that symptoms tend to be present for a certain period of time and then clear. Eventhough it clears, the episodes are likely to recur. The chance of getting a new episode goes up after every episode.

• The DSM-5 distinguishes three types of bipolar disorder. The key features of these disorders are manic symptoms. A state of intense elation, irritability or activation is called a mania.

• It is unlikely that there is one single gene that explains mood disorders, because the symptoms patients can experience differ tremendously. Researchers therefore think a set of genes is responsible.

• The levels of cortisol are often poorly regulated in people with depression, meaning the body is not functioning well in decreasing the levels of cortisol. If high levels of cortisol are present in the body for too long, it will harm the body.

• There is a strong correlation between interpersonal problems and depression, but it is not immediately clear what causes what. Depression can cause interpersonal problems, because depressive people tend to withdraw, finds no enjoy in being in contact with others, etc. There are also factors that precede and predict the onset of depressive episodes, such as: difficult life events, criticism from family, adversity in childhood, etc.

• Neuroticism is a personality trait that involves the tendency of an individual to experience frequent and intense negative feelings. Longitudinal research shows that this trait predicts the onset of depression. It also explains at least part of the genetic vulnerability to depression.

• Drugs and electroconvulsive therapy (ECT) are the two major biological treatments used to treat depression and mania. ECT involves deliberately causing a momentary seizure. This treatment is controversial, but more powerful than antidepressant. The treatment is used when other treatments have failed.

• Behaviors that are intended to cause death and do so, are named suicide. Behaviors that are intended to cause bodily harm, but are not meant to cause death, are named nonsuicidal self-injury.

• About 50 percent of the people attempting suicide is depressed and about 90 percent of the people attempting suicide has some form of psychological disorder. If a disorder comorbids with depression within an individual, suicide is most likely.

• The most promising therapies for reducing suicidality are the cognitive behavioral approaches. These treatments include strategies to decrease the risk of suicide. It is important to help patients understand the emotions and thoughts that triggers the need to commit suicide. Together with clinicians, patients need to challenge their negative thoughts and need to find effective ways to tolerate emotional distress. Clinicians also help clients solve the problems they are having. The goal is to reduce feeling of hopelessness by improving problem-solving skills and improving social support.

What are anxiety disorders? - BulletPoints 6

• In anxiety disorders, both anxiety and fear are key elements. Dread over an expected problem is the definition of anxiety. A reaction to immediate danger is called fear. The difference is in the words “expected” and “immediate”. It is an important contrast.

• A persistent, unrealistically intense fear of social situations that may involve being scrutinized by unfamiliar people is the key aspect of social anxiety disorder. These leads to avoidance of social situations. The manifestations and outcomes of the disorder differ a lot and the severity varies greatly between patients. The disorder commonly starts during adolescence.

• The key features of panic disorder is recurrent panic attacks not linked to a specific situation and worrying about having more of such attacks.

• Anxiety about anxiety occuring in situations in which it would be difficult to excape or in which it would be embarrassing to experiencing the anxiety, is the key feature of agoraphobia.

• Worry is the key element of generalized anxiety disorder. Because the individual can not settle on a solution, the worry continues.

• Mowrer’s two-factor model of anxiety disorders continues to influence thinking from a behavioral perspective. According to Mowrer, there are two steps in developing an anxiety disorder:

  – An individual learns to fear a neutral stimulus that is linked to an intrinsically aversive stimulus. Thus an individual learns fear via classical conditioning.

  – By avoiding the aversive stimulus, an individual can feel relief. The avoidance is maintained because it gets reinforced. This happens via operant conditioning.

• The fear circuit is a set of brain structures that is activated when people feel anxious of fearful. Some structures in the fear circuit are linked to anxiety disorders.

• People with anxiety disorders tend to keep having negative beliefs about the future. It is important for clinicians to find out how these beliefs are sustained. People tend to engage in safety behaviors to protect themselves from the feared consequences. These safety behaviors might be the reason the unhelpfull beliefs are sustained.

• Exposure therapy is an effective treatment for all the anxiety disorders. It is common practice to make an exposure hierarchy in exposure therapy. In an exposure hierarchy, a graded list of triggers is made. First the client needs to expose himself to the less challenging triggers and move his way up to the most challenging triggers.

• Anxiolytics are the type of drugs that reduce anxiety. Two types are most often used: benzodiazepines and serotonin-norepinephrine reuptake inhibitors (SNRIs). Medications offers relief from the anxiety, but only during the time when they are taken. People often relapse when they stop taking the drugs.

What are obsessive-compulsive-related and trauma-related disorders? - BulletPoints 7

• Obsessive-compulsive disorder is defined by repetitive thoughts and obsessions (urges), and repetitive behaviors or mental acts (compulsions). The symptoms of repetitive thoughts and behaviors are shared with the other two disorders. These symptoms are for people with any of these three disorders distressing, they feel uncontrollable, and take a lot of time. The disorders often co-oocur.

• The presence of either obsessions or compulsions is necessary for the diagnosis of obsessive-compulsive disorder. Most people experience both.

• When an individual is preoccupied with one or more imagined or exaggerate defects in his appearance, he is likely to suffer from body dysmorphic disorder (BDD).

• The need to acquire in people with hoarding diorder is excessive and only part of the problem. Another part of the problem is their hatred to parting with their objects. Patients are often unaware of the severity of their behavior.

• Some of the same brain regions seem to be involved in the three disorders: the orbitofrontal cortex, the caudate nucleus and the anterior cingulate.

• Exposure and response prevention (ERP) is the most often used form of psychological treatment in these kind of disorders. The response prevention component of ERP is often used in treating OCD, because people with this disorder believe that their compulsive behavior will prevent terrible things from happening.

• An extreme response to a severe stressos is what posttraumatic stress disorder (PTSD) entails. To consider diagnosis, a set of symptoms should be present:

  • Reexperiencing the traumatic event in an intrusively vesion.

  • Stimuli linked to the event are avoided.

  • Development of other signs of negative mood and thought after the event.

  • Symptoms of arousal and reactivity are increased.

• Whether or not an individual develops PTSD is influenced by the severity of the trauma and the nature of the trauma. PTSD develops more often after a trauma caused by humans than caused by natural disasters.

• The most commonly used psychological treatment of PTSD is exposure therapy. There a different types of exposure:

  • To reminders of the traumatic event.

  • Imaginal exposure.

  • Exposure via virtual reality technology.

What are dissociative disorders and somatic symptom-related disorders? - BulletPoints 8

• Experiencing disruptions of consciousness is seen in dissociative disorders. Individuals with a somatic-symptom-related disorder complains of bodily symptoms. Those symptoms suggest a physical defect. These kind of disorders tend to comorbid.

• A sense of being detached from one’s self is depersonalization, and a sense of being detached from one’s surroudings is derealization. The trigger is often stress.

• The posttraumatic model and the sociocognitive model are two major models for explaining DID. The first model suggests that the key element for developing DID is the use of dissociation to cope with trauma. According to the second model, it is very likely that alters appear in response to suggestions by clinicians, media or cultural influences in people who have been abused and seek explanations for their symptoms. This means that DID could be iatrogenic, which in turn means that it could have been created by treatment.

• The patient should be convinced that splitting into multiple personalities is no longer necessary in dealing with traumas. It is helpful to learn the patient effective ways to deal with stress.

• Excessive concerns about physical symptoms or health define somatic symptom and related disorders. People with suchs disorders tend to pay frequent visits to a medical doctor, and often have a negative opinion about their doctors, because no medical explanation can be found.

• Excessive anxiety, energy or behavior centered around somatic symptoms is the key characteristic of somatic symptom disorder. It can be diagnosed, whether the symptoms can be explained medically or not.

• Preoccupation with fears of having a serious disease, eventhough there are no significant somatic symptoms, is the key characteristic of illness anxiety disorder.

• The key feature is conversion disorder is the sudden development of neurological symptoms, despite having nothing wrong with the bodily organs and nervous system. Clinicians have to make sure there is no neurological basis for the complaint.

• Finding the reason why some people are more aware of and distressed by somatic symptoms is the key issue in understanding somatic symptom disorders. The focus lies on brain regions that are activated by unpleasant body sensations in neurobiological models of somatic symptom-related disorders. Heightened activity in the anterior insula, anterior cingulate cortex and somatosensory cortex is linked to greater propensity for somatic symptoms.

• To help people with somatic symptom-related disorders, cognitive behavioral clinicians have applied different techniques:

  • By identifying and changing the emotions that trigger the patient’s concerns.

  • Change their cognitions about their symptoms.

  • Changing the behaviors that come with playing the role of a sick person.

  • Gaining more reinforcement for engaging in different social interactions.

What is schizophrenia? - BulletPoints 9

• The psychological disorder schizophrenia is characterized by:

  • Disordered thinking.

  • Faulty perception and attention.

  • A lack of emotional expressiveness.

  • Disturbances in behavior.

• Beliefs that are contrary to reality and are firmly held in spite of disconfirming evidence are called delusions. Delusions are common positive symptoms in this disorder.

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

• Behavioral deficits in motivation, pleasure, social closeness and emotion expression is what make up the negative symptoms in schizophrenia.

• A lack of motivation and a seeming absence of interest in or an inability to persist in what are usually routine activities is referred to as avolition or apathy.

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

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

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

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

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

• Drugs that are widely used in the treatment of schiozphrenia are antipsychotic drugs. There are first-generation and second-generation antipsychotic drugs (e.g., clozapine and risperidone). Medications alone are not a completely effective treatment, but do help a lot.

What are substance use disorders? - BulletPoints 10

• Tolerance and withdrawal are most of the time part of a severe substance use disorder. Tolerance stands for either (a) to keep getting the desired effect, larger doses are needed or (b) if the usual amount is taken, the effects become less. When a person stops taking the drugs or reduces the amount, it is possible the person develops negative physical and psychological effects. This is called withdrawal.

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

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

• People who smoke marijuana often report feeling relaxed and sociable after use. The kind of effects are dependent on the dosage. Effects appear more or less after 30 minutes, as a consequence smokers tend to get much higher than intended.

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

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

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

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

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

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

• Detoxification is the first step in treatment for substance use disorders. Withdrawal can be difficult on both physical as psychological levels.

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

What are eating disorders? - BulletPoints 11

• Bulimia Nervosa is characterized by episodes of rapid consumption of a large amount of food, followed by compensatory behavior to prevent weight gain.

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

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

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

• The fear of fatness and body-image disturbance is in cognitive behavioral theories of anorexia nervosa emphasized as the motivating factors that reinforce weight loss.

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

• When evaluating the personalities of people with anorexia and bulimia, one needs to keep in mind that severe restriction of food intake can have powerful effects on personality and behavior, as is shown in research.

• Therapy for anorexia nervosa has two goals:

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

  • Long term maintenance of weight gain.

• Cognitive behavior therapy is the most effective psychological treatment for bulimia nervosa. The overall goal in this therapy is to reestablish normal eating patterns, but it also involves changing a patient’s beliefs and thinking about:

  • Thinness.

  • Being overweight.

  • Dieting.

  • Restriction of food.

What are sexual disorders? - BulletPoints 12

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

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

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

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

  1. Desire phase, refers to sexual interest or desire.

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

  3. Orgasm phase, sexual pleasure peaks.

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

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

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

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

• Recurrent sexual attraction to unusual objects or sexual activities lasting at least six months are defined by the DSM-5 as paraphilic disorders.

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

• Pedophilic is diagnosed, according to the DSM, when:

  • Adults derive sexual gratification through sexual contact with prepubertal children, or

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

• The intense and recurrent desire to obtain sexual gratification by watching unsuspecting other in a state of undress or having sexual relations is the key characteristic of voyeuristic disorder.

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

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

• Inflicting pain or psychological suffering on someone else is the focus of desire in sexual sadism disorder. Being the one subjected to pain or humiliation as the focus of desire is called sexual masochism disorder.

• Because many sex offenders lack the motivation to change their illegal behavior, strategies to enhance their motivation are an important part of treatment.

What are disorders of childhood? - BulletPoints 13

• In the field of developmental psychopathology it is important to consider what is typical for a particular age.

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

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

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

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

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

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

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

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

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

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

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

What are late life and neurocognitive disorders? - BulletPoints 14

• Because people reach many different ages above the age of 65, gerontologists often split these people into three groups:

  • In the first group the ages are between 65 and 74 and are called the young-old.

  • In the second group the ages are between 75 and 84 and are called the old-old.

  • The third group are the ages above 85 and are called the oldest-old.

• The elderly have the most problems when it comes to their physical health. They also experience stress due to social problems, like losing loved ones and stigmatizing attitudes from younger people. All these problems have effect on their mental health.

• The DSM-5 criteria are the same for all ages. The elderly have more medical conditions and use more medications than younger people. This should be considered when diagnosing the elderly, because if the symptoms can be accounted for by a medical condition or by medication, the psychological disorder should not be diagnosed. It should also be considered that physical and psychological health interact with each other.

• Dementia is a term used to describe the decline in cognitive abilities to the point that function becomes impaired.

• With Alzheimer’s disease brain tissue progressively deteriorates. A patient with this disease usually dies within twelve years after the onset of symptoms. Memory loss is the most known and common symptom in Alzheimer’s disease. At first the memory loss might be overlooked, but will eventually interfere with daily function. The disease is progressive which means the symptoms get worse with time. Both the range and severity of these symptoms increase.

• A loss of neurons in the frontal and temporal lobes is seen in frontotemporal dementia (FTD). It is a progressive disease that develops quickly. In contrast to Alzeimer’s disease is memory in FTD not severely impaired.

• Cerebrovascular disease causes vascular dementia. When circulation of blood is impaired, neurons die. Often this is caused by strokes. Strokes can occur in any area of the brain, therefore the symptoms between people can differ a lot.

• No cure for dementia is available. Some medication is used as treatment. Medications do not restore memory in Alzheimer’s disease, but do seem to slow down the decline. Medication is more often used for the treatment of psychological symptoms, which often co-occur with dementia.

• The term delirium implies being “off-track”; it is more often described as a clouded state of consciousness. ‘Extreme trouble focusing attention’ and ‘profound disturbances in the sleep/wake cycle’ are the most common symptoms. Disturbances in perception is also often seen in delirium.

What are personality disorders? - BulletPoints 15

• The personality disorders are defined by enduring problems with forming a stably positive identity and with sustaining close and constructive relationships.

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

  • Cluster A: odd or eccentric behavior.

  • Cluster B: dramatic, emotional or erratic behavior.

  • Cluster C: anxious of fearful behavior.

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

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

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

• Defining aspects of schizotypal personality disorder include eccentric thoughts and behavior, interpersonal detachment and suspiciousness.

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

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

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

• Overly dramatic and attention-seeking behavior are the key aspects in histronic personality disorder.

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

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

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

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

• Psychotherapy is often the first choice for the treatment of personality disorders. Most of the time this is supplemented with medications.

What are legal and ethical issues in psychopathology? - BulletPoints 16

• Criminal commitment is a procedure that confines a person in a mental or forensic hospital either for determination of competency to stand trail or after acquittal by reason of insanity.

• A person can be deprived of liberty and placed in a hospital if he/she is deemed mentally ill and dangerous, eventhough has not broken any laws. The set of procedures by which this can happen, is called civil commitment.

• A disordered mind is referred to as insanity. This is not a psychological concept, but a legal one.

• A lawyer could argue that his client should not be held responsible for an illegal act because it can be attributed to a psychological disorder or intellectual disability that interferes with rationality. This is called the insanity defense.

• An arrangement whereby an individual is ordered by the court to receive treatment on an outpatient basis is called assisted outpatient treatment (AOT). This is a way of increasing medication compliance. If medication compliance is increased, reduction of violence can be expected.

• Informed consent is a key component of ethical research. People must be able to decide whether they want to be in a study or not based on the information given by the researcher.

• By professional ethics codes, people are assured that what is said and done in a therapeutic session will remain confidential. This means that nothing will be revealed to a third party, with the exception of other professionals and those intimately involved in the treatment.