College aantekeningen psychopathology

College 1: 15-09-21

Introduction

Sexual dysfunction is everything that is not ‘normal’. To be a disorder, it needs to be stressful for the person and not necessarily for the couple. Sexual arousal can be very high when you're young and new in a couple. It can be totally different for an old man/woman.  It changes with age, phase, state, etc.

There are predisposing factors, precipitants and maintaining factors (see table on the slides)

The exam is about a case that you need to evaluate and not just learning the DSM.

What are sexual dysfunctions?

It is very hard to talk about sexual problems. It is easier to talk about it, when everything is going great.

Arousal disorder and sexual disorders are now combined in the DSM, it wasn’t earlier.

Sexual desire and sexual arousal are overlapping constructs since both depend on the ability of an individual to process sexual information during sexual activity. 

What can cause/maintain sexual dysfunction?

Every system in your body and your brain needs to work in synchrony. The hormones need to be there, for sexual tasks and pleasure. Good blood flow is needed for the erection or the ‘gevoeligheid’ from the vagina. 

Phases of sexual activity:

The main critic of this model is that in general our human sexual response is not really dislinear. If there is a physical task, you can skip the first state of excitement. It is also possible to skip the orgasm face. 

The sexual tipping point model (see figure on the slides). 

Dysfunctions to learn: 

• delayed ejaculation= a marked difficulty or inability to achieve desired ejaculation. More common in men over 50 years of age. It is a problem with arousal. Often it is mistakenly diagnosed as erectile disorder. 3 common factors associated with DE: higher frequency of masturbation, idiosyncratic masturbatory style, disparity between the reality of sex with his partner compared to his preferred sexual fantasy during masturbation.

• erectile disorder= failure to obtain or maintain erection during partnered sexual activities. There is a marked decrease in erectile rigidity and it is more common in men over 50 years of age. Most problems remit without professional intervention. 

• male hypoactive sexual desire disorder= persistent deficient or absent sexual thoughts, fantasies or desires. Many men are often treated for different sexual diagnoses while they are suffering from MHSDD. When it’s limited to a single partner, it is not SD but a relationship problem.

• premature ejaculation= persistent or recurrent pattern of ejaculation during partnered sexual activity within 1 minute following penetration or before an individual wishes it.

• female orgasmic disorder= delay, infrequency or absence of orgasm or reduced intensity of orgasm sensation. 10% of women do not report the experience of orgasm. Likelihood of not having orgams problems related to:

1. manual genital caressing

2. self-use vibrator

3. perception that sex is important

4. early age of first orgasm

5. cunnilingus (beffen)

6. orgasm by penile motion

• Female sexual interest/arousal disorder= absent or reduced interest/arousal related to sexual activities, thoughts, cues, etc. Persistent problem for relationships.

• Genito-pelvin pain/penetration disorder(GPPPD)= difficulties with vaginal penetration during intercourse, pain during intercourse, fear or anxiety about pain or penetration or contraction of pelvic floor muscles during sex. They experience more disgust towards sexual things like vagina fluid. The disgust is difficult to unlearn.

• Substance/medication induced sexual dysfunction. Don’t take 6 months to get a diagnosis.

• Other specified sexual dysfunction

• Unspecified sexual dysfunction

Long term relationships - sexual pleasure - cohesion in LTRs

It is not the destination that matters in sex. The process is important.

In summary: there are 10 diagnostic labels, 7 have same time criteria, 2 clusters of symptoms not fitting in the drawer and 9 labels are mosaic of the symptoms. 

Don’t run to conclusions, you need to have all the criteria to make a conclusion. Otherwise write your thoughts down and ask questions. 

Treatment→ communication is very important. Also sensate focus is a very old treatment that is still used.

College 2: 17-09-21

Introduction

More than half of the women believe they are too fat.1 out of 5 women have once a month a binge, 10% of them vomit after a binge. This is so common that it is hard to speak of psychopathology.

Feeding and eating disorders: pathology

Feeding disorders

• Pica= persistent eating of nonnutritive substances over a period of at least 1 month. For example a battery, a rock or a knife.

• Rumination disorder= repeated regurgitation of food over a period at least 1 month. A history in the medical field, but it’s psychological. They vomit their food up, to eat it up again. It is very bad for your stomach.

• Avoidant-restrictive food intake disorder(AFRID)= physical, psychological and social problem. They avoid eating or drinking with others or in a specific place. Sometimes they are obse (only eating fast food), but 

mostly they are losing weight. 

Eating disorders (body shape weight and control of it)

• Anorexia nervosa= significantly low body weight. Intense fear of gaining weight or persistent behavior that interferes with gaining weight. They are not able to get to a normal weight. Disturbance in the way that they look at themselves. A part of this group is denying that they have this disorder, so they don’t seek treatment.

There is a restricting type(control food intake) and the purging/binging type(eat but vomit after). 

Not in the DSM is the starvation syndrome, which is pretty common in anorexia nervosa. The criteria for this syndrome are on the slide.

• Bulimia nervosa= recurrent episodes of binge eating (you experience a lack of control while eating a lot). Recurrent inappropriate compensatory behaviors in order to prevent weight gain. At least once a month for 3 months. Not exclusively during episodes of anorexia nervosa.

• Binge-eating disorder= recurrent episodes of binge eating. They don’t compensate for it, so you grow in weight. Marked distress regarding binge eating is present. 

• Other specified= nog diagnostic criteria. Residual category for eating disorders of clinical severity. For example the night eating syndrome. 

• Unspecified

Obesity

It is not a psychiatric diagnosis, but a medical disorder. It has a lot to do with environmental factors. Binge eating can lead to being overweight, ofcourse. Interventions could be based on CBT. 

Diagnose

Preoccupation with body image and weight sometimes is not explicit. Expected development is to be kept in mind.

PARDI (child and adult version) is an interview to see if someone is checking the criteria. On the subscales sensitivity, lack of interest and fear.

There are different variations of the same disorder. There are sex differences as well, so you need to keep that in mind.

It is most in girls and less in boys. The prevalence lifetime is on the slide.

You can also have a lack of eating due to depression or other things that are going on, so it’s not always a disorder of eating/feeding.

Transdiagnostic processes. Similarity instead of differences between disorders: 

• attention

• reasoning

• thinking style

• memory processes

• behavioral processes

Meanwhile in society there are storms of eating disorders: number, severity, complexity.

College 3: 22-09-21

Introduction

Many types of clinical disorders can be described as cyclops. It’s a fixation, uncontrollable, automatic. 

Addiction

Is it reasonable to judge someone on an addiction? It is a difficult question. Because there is a discussion about the choice/free will from the addict. It is a disease. 

Substance use disorder

Tolerance= The more you use, you get fewer effects. So you have to use more, to get to that same level. There is a desire. 

Withdrawal= ‘afkicken’. The same substance is taken to relieve or avoid the symptoms. 

Addiction as dyscontrol

Substance use dyscontrol: drug usage becomes a substance use disorder when persons are significantly impaired in their control of this usage. 

1. substance used more than intended

2. unsuccessful efforts to cut down

3. strong desire

“Normal” people have free choice to choose what they want to do. Addicted people have a constrained choice to choose for the drug instead of something else to do.

Change is extremely difficult, but not impossible (‘dus niet verslaafd meer raken’). This is demonstrated by a famous case of Leroy Powell. In the morning he had to go to court for $20 intoxication and he drank one drink, but not more. He could control it on that specific morning. 

“I’ve never come across a single person who wants to be addicted”. 

College 4: 24-09-21

What is sleep?

We sleep ⅓ of our lives. In a baby there is a lot of REM-sleep, when you get older it decreases. Without a good sleep, you are not able to make good food choices and don’t go to the gym. 

Sleep is a behaviour: a period of physical rest with an elevated arousal threshold, but it is possible to wake up, and its posture is species-specific. It is not a constant state. 

Stages when going to sleep:

• Non-rem stage 1

• Non-rem stage 2

• Non-rem stage 3

• REM(rapid-eye movement)-sleep

If you wake up from REM-sleep, you can often tell a nicce coherent story(a dream). But sleepwalking can only happen during Non-rem sleep. The longer you are awake, the deeper you sleep. Process S= the need for sleep is a homeostatically,regulated process (sleep need). 

See slides for physiology of the stages!

Two process model

Sleep is a rhythmic behaviour. It is regulated by a biological clock(process C) in the hypothalamus. On the place where the optic nerves reach the brain. The function of this clock is that it gives your body a time structure. With this information, your body can anticipate. Like increasing the heart rate or etc. In the morning your body prepares yourselves for activity instead of laying down. It is synchronized by light. The timing of sleep is controlled by interaction between S and C.

Each cell has a rhythm of 24 hours, they should communicate the same 24 hour schedule. 

Functions of sleep

1. Waste processing

During sleep 60% increase in space between cells. This increases the removal rate of degradation products, including amyloid(protein). Process involved in neurodegenerative diseases, including Alzheimer's disease. You can develop dementia faster, when you sleep less. 

2. Learning and memory

There is a change in the activity in the synapses. The more deep sleep there is, the more little synapses removed and the big ones strengthened. You can not keep all the information that you got during the day. 

3. Emotional regulation (REM-sleep)

During sleep, the emotional part is removed from the memory. 

What can go wrong: classification of sleep disorders

Insomnia

Has a high prevalence and is the most common sleep disorder. Women have it more, which could be correlated to hormones. Having problems with falling asleep, staying asleep or waking up. Things that happen during the day may affect your sleep, but when you get stressed about going to sleep it is bad. 

The most successful treatment is CBT-I(cognitive behavioural therapy)= education, restriction, stimulus control, cognitive therapy, sleep hygiene, relaxation therapy. CBT-I improves depression. It is much more effective than taking drugs. 

Sleep related breathing disorders

Central disorder of hypersomnolence

Circadian rhythm sleep-wake disorders

Chronic/recurring pattern of disrupted sleep due to changes in the circadian system or by misalignment between the endogenous circadian rhythm and the sleep-wake rhythm required by the physical or social environment. 

• Delayed sleep phase syndrome= persistent/recurrent delayed sleep phase, causing severe problems falling asleep and rising at the required time of the day. Late bedtimes, but normalisation of total sleep time. Bedtime depends on your age. During puberty, you go to bed most late and then it goes down again. In males the peak is later. During each age group, there is still a difference in people. 

Parasomnias

Sleep related movement disorders

College 5: 29-09-21

Soma is the Greek word for body. It’s basically the approach between body and mind.

The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition and are not fully explained by. The symptoms must cause clinically significant distress or impairment in social, occupational or other areas of functioning.

Proof that something is not wrong (DSM 4), is now changed to proof that something is present (DSM 5). 

Pathogenesis means what is the origin of suffering. Not only the symptoms are important, but also what they come from. The consequences/coping with the symptoms are the motor of psychological problems. 

The way of dealing with symptoms are important:

• proximal factors= somatic symptoms, misinterpretation, emotional response, extreme behaviour.

• distal factors= intolerance of uncertainty, anxiety sensitivity, resilience, social support, cultural socialisation. 

Pain model of Vlaeyen et al.

If you don’t catastrophize, you interpret in a non fearful way. You just carry on then. 

Cognitive behavioural model of anxiety (hypochondriac) → see slides

DSM-5:

Illness anxiety disorder= preoccupation with having or acquiring a serious illness (example with the movie from Woody Allen).

Functional neurological symptom disorder (conversion disorder)= one or more symptoms of altered voluntary motor or sensory function. So there is nothing wrong with your body, but still you  can’t properly use it. It is a response from your body to some stress. 

psychological factors affecting other medical conditions= a medical symptom or condition, other than a mental disorder, is present.

Factitious disorder= falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. So you really believe you have a disorder, but you have not. 

Other specified somatic symptom and related disorder

Unspecified somatic symptom and related disorder

Conclusion: 

• Somatic symptom and related disorders are a heterogeneous and controversial category

• In the DSM-5 various disorder categories have been reconsidered, but the general principle has hardly improved.

• Biopsychosocial perspective has greater explanatory value

• Despite diagnostic ambiguity, all these disorders are difficult to diagnose and to treat

• The corona pandemic puts this topic on the map as never before!

Having good health simply means you’re dying at the slowest possible rate.

College 6: 1-10-21

Personality

Enduring pattern in which people think, feel and behave. It’s stabilizing with age. Most personality traits are not pathological. 

What is personality disorder?

There must be psychopathology (extreme and out of the range) connected with personality. Connected to a part of character/temperament. It’s a dysfunction in normal life. Other people have a serious problem with their behaviour. 

It probably starts in adolescence. 

In the DSM5 it says: ‘extreme variance of normal personality, so quantitative.’ You start with looking at the general criteria  and after you specify. Manifested in at least 2 of the following: cognition, affectivity, interpersonal functioning, impulse control. 

Biopsychosocial model:

3 criteria for a personality disorder:

• Pathological (outside normal range, associated with dysfunctioning)

• Persistent (often already manifest in adolescence)

• Pervasive (manifest in most situations, rigid)

If one meets the criteria for a general personality disorder, there are three clusters to look further in(A, B and C). 

Cluster A= odd, eccentric behaviour. 

• paranoid personality disorder= pervasive distress and suspiciousness. They don't trust anybody. 

• schizoid personality disorder= pervasive pattern of detachment from social relationships. They feel very lonely. From the outside it looks like they don’t have emotions. A lack of color in everything. There are just a few things to care about. It overlaps a little with depression, but then without any emotion.  

• schizotypal personality disorder= pervasive pattern of social and interpersonal deficits. Reduced capacity to start a social relationship and show eccentric or odd behaviour. These people are more vulnerable for distress.  Is it a psychosis or a pattern of the years? Highly paranoid, especially around other people. 

Cluster B= emotional, dramatic

• borderline personality disorder= pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity. They don’t know who they are. They switch from I am such a person to the other. It’s difficult to follow them, for the people around them. 

• narcissistic personality disorder= Has a grandiose sense of self-importance. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). Requires excessive admiration. They are not interested in other people, they lack empathy.  They feel like they don’t need to follow the rules. 

• histrionic personality disorder= Is uncomfortable in situations in which he or she is not the center of attention. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. They shift their behaviour in a snip. Other people should admire you. 

• antisocial personality disorder= the only one which starts before 18 years of age really. Pervasive pattern of disregard for and violation of the rights of others. They think it’s normal for them to break rules. Other people are weak in their eyes. Some of them are very clever and manipulate others. Therefore it’s difficult to treat. They don’t regret it, it’s not a problem for them how they behave. 

Cluster C= anxious, worrying, fearful

• avoidant personality disorder= Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. They are unwilling to get involved in social activities. They only do it when they are sure you like them. It’s a disaster to get rejected. They can not stand negative feelings. 

• dependent personality disorder= pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts. They themselves can’t survive without other people. The other people are really competent then. They need constant reassurance. They avoid having a conflict, because they can’t lose other people. They feel themselves as weak and helpless. 

• obsessive compulsive personality disorder= Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). They exclude other activities.

More prevalent in women: Borderline, histrionic, dependent PD

More prevalent in men: Schizoid, schizotypal, narcissistic, antisocial PD

There is also a bias with diagnosing by the therapist.

In summary: psychopathology associated with personality, extreme variance of normal personality: quantitative, PPP, general + 3 clusters: specific PD and addendum: research.

College 7: 06-10-21

Affective disorders

Dysthymic disorder

Depressive disorder, unipolar= depressed mood and anhedonia (loss of pleasure/interest). 

Depressive disorder, recurrent

Bipolar I disorder

Bipolar II disorder

Cyclothymic 

Adjustment disorder= maladaptive reaction to an identified stressor (within 3 month, no longer than 6 months duration as a whole). So an extreme response because of something that happened, for example a car accident.

Symptoms of a depressed mood, cry and feeling of hopelessness. 

When there is grief, you still can have the diagnosis of a depressive disorder. 

The trigger for depression is that you have experienced a life event. 

If it doesn't impact your normal life, you don’t have a thing in the DSM.

Epidemiology

Prevalence 7-12% a depression once

Suicide attempt 20 x higher during a depressive episode

15% die because of suicide

The treatment for bipolar disorder are mood stabilisers (medication) and no psychological factors. 

Difference between dysthymic and persistent is the number of symptoms. 

Relapse prevention: antidepressant. This is the most used strategy, but there is no evidence when to stop. Whether it is safe to stop.

College 8: 08-10-21 

Obsessive-compulsive disorder=  obsessions and compulsions. This can be with thoughts, cleaning, washing, counting, etc. The solution is to not suppress it but let the thought come and then expose yourself. 

Body dysmorphic disorder= they think that they look unnormal. 

Hoarding disorder= having difficulty throwing stuff away. Excessive excuitsition. 

Trichotillomania (hair-pulling disorder)

Excoriation (skin-picking) disorder

Intrusion (=indringing):

• Intrusive anxious predictions

• Egodystone obsessions that go against personal values/norms/identity

Compulsion (=drang/obsessie)

College 9: 13-10-21

Firesetters

Three clusters for fire-setters:

1. abreaction of emotions

• pure firesetters, the recidivism is high. 

• the motivation for treatment is high

• impersonal public objects (bv. art, carbage can, a shelter)

2. personal anger

• a well known victim, there is anger but not revenge

• acting alone

• high impulsiveness

• the motivation for treatment is low

3. intentional 

• behavioural problems in youth

• personality disorders

• resistance therapy

• different intentions (bv. cry for help / attention / revenge)

Treatment program:

1. motivation and self-image

2. offense analysis

3. fire interest

4. communication and social functioning

5. self-regulating

6. relapse prevention

Most of the firesetters do have their internal scripts. Like fire is exciting and intrinsically regarding, fire is a means of controlling your tensions, fire as a weapon, fire is controllable. 

People tend to repeat their drama’s. 

Treatment phase:

• Individual psychotherapy

• Arts therapy= working with materials.

• Systems therapy= een vorm van psychotherapie en wordt ook wel relatie- en gezinstherapie genoemd

• Labour therapy

Paraphilia & perversions

Paraphilia is the experience of intense sexual arousal to atypical objects, situations, fantasies, behaviors, or individuals. It is a variation in desire. There is a link with sub-optimal attachment (Rich). There is less regard to commitment and mutuality. Control over another person, that's lacking in normal life, 

The forming of sexual desires: a chance combination of stimulus and arousal. 

Disorders:

• voyeurism

• exhibitionism

• rubbing

• sexual-masochism

• sexual sadism

• paedophilia (more in man)= de slachtoffers zijn onder de 16 en de persoon is 5 jaar ouder dan het kind. 

• fetishism

• cross dressing 

Not all sex offenders do have a paraphilia and not all paraphilics commit sex offenses. 

Perversion is the sexualisation as a defence mechanism from fear and aggression in an intimate relation. 

College 10: 15-10-21

Psychosis:

• delusions

• hallucinations

• disorganized thinking (speech)

• disorganized or abnormal motor behaviour (catatonia)

• negative symptoms= the ones that are absent

Clusters = labels= diagnosis

Schizophrenia= two (or more) of the key features are present: delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behaviour and negative symptoms. 

Schizophreniform disorder= the duration of the symptoms is shorter than schizophrenia. Episodes last 1 month till less than 6 months. Schizophrenia light.

Brief psychotic disorder= Schizophrenia light light. 

Schizoaffective disorder= Schizophrenia but with emotions. Uninterrupted period of illness with major mood episodes (either mania or major depression). Part of the time you also have the symptoms of a mood disorder. It is important to distinguish bipolar or depressive. 

Delusional disorder= behaviour and functioning is not really impaired. For example: at your work you might believe someone wants to poison you, but at home you're feeling fine. 

Specifying the type of delusion and of the delusion is bizarre. 

Substance-induced= presence of delusions or hallucinations. Occur after substance intoxication/withdrawal and this substance is capable of giving this symptom. Specify when it happened (during drug intake or withdrawal).

Medical condition= specify severity(ernst) and predominant symptom.

Catatonia= at least 3 symptoms present: stupor, mutism, negativism, posturing, mannerism, grimacing, echolalia, etc.  

Overlap personality→ personality disorder college

College 11: 20-10-21

Background of ADHD

There is too much information for your head to process and therefore there is a filter. It works with neurotransmitters. It’s blocking voices, images, etc. that you don’t need at that moment. It can also mute such a stimulus. 

With ADHD attention deficit hyperactivity disorder) the filter isn't working that well. You don’t have the control to give attention to certain stimuli and not to others. People feel like their head is full and they're thinking a lot. There are too many stimuli in the head. 

Core symptoms

Before 1980 it was called minimal brain disorder/dysfunction. 

In the DSM5 the core symptoms are:

• inattention = concentration problem

Maybe more like divided attention, they have too much attention.

Attention is interest and concentration is bundling of attention / full focus. 

• hyperactivity = restlessness

Too much energy vs. unrest/restlessness. Too many stimuli leads to unrust in the head, verbal unrest and physical unrest. 

• impulsivity = only when extravert

No notice of consequence, no inhibition of behaviour and difficulty suppressing direct needs. There is verbal and behavioural impulsivity. This core symptom is only possible when you are an extravert. 

If there are not a lot of stimuli, it doesn’t matter if the filter is working or not. Reducing the stimuli is then a part of the solution. To get the ADHD diagnosis, you need the core symptom of inattention. 

Without hyperactivity almost never exists, because when it's not observable it can be in the head. So ADD does not exist. 

The symptoms need to be present before the age of 12, in two or more settings. It has to have a negative impact on life. 

Subtypes in the DSM5

Combined presentation

Inattentive presentation (which is meant by ADD)

Hyperactive / impulsive presentation

ADHD-NOS

Symptoms that are not in the DSM5

1. Hyperfocus

You forget everything around you and focus on one thing. Het zuigt je concentratie helemaal op.

2. Sleep disorders 

3. Problems receiving physical stimuli 

4. Discharges (crying / temper tantrum)

It’s only the druppel die de emmer doet overlopen. Your head is full so you cry because it's just too much. 

5. Weak sense of time

6. Low self-esteem

They get a lot of negative reactions. Like sit still and listen to me. They get the signals that they are not good the way they are.

Diagnosing

Anamnese= het verhaal dat een patiënt (of de familie of naasten van de patiënt) aan een arts vertelt, vaak geleid door diagnosticerende vragen, over het verloop van zijn gezondheidstoestand.

Observation

Questionnaires (AVL, VVGK / GVK, SEV, ASEBA)

Intelligent-test: disharmonisch profile

Attention-test

D2 test.

Take home message

• ADHD= to many stimuli because of filterproblems

• Core symptom= concentration problem

• Difference ADHD vs ADD is personality or stage of life (there is no real ADD, its only called that way in the ‘volksmond’.

• Every ADHDér is hyperactive (in head)

• Impulsivity= information comes too late

College 12: 22-10-21

Symptoms

Autism spectrum criteria:

1. Persistent deficits in social communication and interaction, including 

- social-emotional reciprocity.

- nonverbal communicative behaviours.

- difficulty starting, maintaining and understanding relationships.

2. Restricted, repetitive patterns of behaviour, interest or activities. Including

- repetitive movements, object use or speech.

- insistence on sameness, so that you have to do something in a specific routine. 

- restricted, fixated interests.

- hyper- or hypo reactivity to sensory input.

The symptoms are significantly impairing in functioning and are present in early development (may be masked or not seen directly). 

The three functional levels of autism

Theory of mind is a social cognitive skill. Understanding other points of view and thereby the emotions and actions. A famous one is the Sally-Anne test. Joint attention is necessary. It starts with reciprocity (back and forth). 

There are children with and without intellectual disability. It can also be that the person doesn’t have autism, but just has struggles to communicate due to the low level of intelligence. 

Categories of autism disorder

• Asperger’s syndrome

If you got diagnosed with de DSMIV, you get your label. If you get diagnosed with the DSMV today, you get autism with requiring support. These people have, most of the time, a high level of intelligence.

• PDD-nos

Meant for the children who didn’t meet the full criteria for autism. There are traits, but they are not that present. 

Heller's syndrome is childhood disintegrative disorder. It is not in the DSM anymore.

Rett syndrome is a rare condition in which there is a genetic mutation on the X chromosome. A boy will not survive this mutation. A girl will have autistic features, but may grow out of it. Specific for this syndrome is motor impairment/seizures. It is not in the DSM anymore. 

Girls with autism

There is a diagnostic gender bias, because they tend to get diagnosed later. They sometimes get misdiagnosed before. Their quality of life would improve if it is done earlier. They will understand themselves better.

Male : female ratio = 3 : 1 

They can mask their ability better and it isn’t less strange if they have a specific hobby that they are enthusiastic about.

Media portrayal

Sometimes it is pictured as cute, but that is not really the truth in all cases.

Early signs of autism

After 6 month of age it is first visible: decline in eye contact, fewer vocalizations, less social smiling, lower social responsiveness (joint attention and reciprocity). 

Screening and diagnostic assessment

Screening is to determine who needs further diagnostic assessment. Tools are the following tests:

< 2: CHAT (checklist for autism in toddlers)

0-4: CoSoS (communication en sociale ontwikkelings signalen)

> 4: SRS-2 (social responsiveness scale) and SCQ (social communication questionnaire). 

To diagnose the following tools are used: ADI-R, AVZ-R, DISCO, Auti-R, ADOS-G. Only to be used by professionals who received additional training. The official diagnosis is done by the psychiatrist or GZ psychologist. 

Support/treatment

Under the age of then it is focused on the parents (psycho-education). There is an evidence based video interaction training (VIPP-AUTII), this focus on parental sensitivity providing structure/routines and creating a predictable environment. 

When he/she is a little older the pivotal response treatment is used. This is focused on motivation, response to cues and social initiations. Or floorplay/floortime is used, to use a child's interest to connect. 

Education

In schools there is a preference for mainstream education (inclusive). If things don’t go well, special education is the solution. The teacher-student relationship can be difficult, because they have more people to teach. 

Autistic savants (‘knowing’)

It's an extremely rare condition where a person has extraordinary abilities that do not match their overall functioning. Not all people with ASD are savants and not all savants have ASD. There are different types:

• splinter skills= have a special talent. No one taught them to. Like calendar calculation and sport trivia.

• talented savant= music or art.

• prodigious savant= a genius (extremely rare)

College 13: 27-10-21

Trauma

A traumatic event is an exposure to actual or threatened death, serious injury, or sexual violence. Directly experiencing, witnessing in person, learning that they happened to someone close or experiencing repeated exposure. 

Childhood neglect is a reactive attachment disorder and disinhibited social engagement disorder. Traumatic incidents are PTSD and acute stress disorder. An unspecified stressor is the adjustment disorder. 

Therapy for PTSD:

• coping skills to calm emotions, activate resources

• identify triggers, stop avoidance

• exposure to triggers extinguish reaction

• confront negative cognitions and feelings

• integrate event in autobiography, acceptance

• make plans for bright future

PTSD or acute stress disorder is a traumatic event AND diagnostic criteria.

Adjustment disorder is a traumatic event with symptoms not meeting PTSD criteria OR PTSD symptoms following a non-traumatic event. 

Dissociative

Often embarrassment and confusion about the symptoms desire to hide them. 

Potentially disrupt every area of psychological functioning. 

Dissociative amnesia has to be specified with dissociative fugue, this is apparently purposeful travel or bewildered wandering. 

The five symptom clusters for dissociative disorders are:

1. dissociative amnesia

2. depersonalization

3. derealization

4. identity confusion

5. identity alteration

Differential Diagnosis

• Bipolar Disorder II: rapid shifts in mood commonly

reported across dissociative states, sometimes

accompanied by fluctuation in levels of activation

• PTSD: 1) amnesia for everyday (i.e., nontraumatic)

events, 2) disruptive intrusions unrelated to traumatic

material by dissociated identity states into the

individual’s sense of self and agency

• Psychotic Disorders: symptoms caused by alternate

identities, no delusional explanations for the phenomena,

and often describe the symptoms in a personified way

• Factitious disorder and malingering

Non-traumatic purposes:

• drug use

• anesthesia

• panic disorders

• early-onset anxiety symptoms

• psychosocial stress

College 14: 29-10-21

Introduction

Fear vs. anxiety, they shouldn’t be used as the same term. Fear is an emotional response to real or perceived imminent threat. Anxiety is anticipation of future threat. The adaptive side is that it increases chances of survival. 

1 in 5 people will develop an anxiety disorder in their life. Women are more likely to develop an anxiety disorder.

PTSD and OCD moved out to their own chapter in the DSMV. 

Characteristics of different anxiety disorders?

The object of fear categorises this. 

Fobias

With all disorders the fear must be out of proportion and the duration is 6 months or longer.

With specific phobia the fear is out of proportion. 

A lot of people just noticed their fear when they got kids. They coped with it before, but then they find out it isn’t normal. They don’t want to pass it on to their kids. 

When you get anxious, it is more unlikely to faint. Because you're blood pressure is going up. 

With social anxiety disorder the fear is out of proportion as well. They are afraid of social rejection. They often won’t see that their beliefs are not reliable, even not after exposure. People with social anxiety overestimate visibility of anxious symptoms, underestimate their own social skills, have a bias towards social threatening information and negatively interpreting ambiguous social information. 

With panic disorder the fear is out of proportion. The feeling is a little bit the same as the exercise with the head between legs and then go up. At least 1 month of worrying about new attacks or consequences. If you misinterpret the symptoms that you get out of anxiety, avoidance and safety behaviours will occur. 

With generalized anxiety disorder you find it difficult to control worry. Worry about worry. 

With agoraphobia you are afraid of not getting out/away.

Why does a phobia persist?

When you have a fear, you will avoid this. Then there is relief. When you keep avoiding, you never test the belief that something is dangerous. 

DSMV

Pros:

• insurance

• once you got a label, other people could understand you better.

• it’s a universal guide for all therapists. A language that everyone speaks. 

Cons:

• not a perfect fit with reality. You don’t always fit into a category. 

• it describes and doesn’t explain anything

• stigma to labelling

Symptoms vary on a continuum of severity. The cut-off is arbitrary. The differences are quantitative rather than qualitative. 

People can have psychotic experiences/symptoms, but it doesn't automatically mean you have a psychotic disorder.

The network perspective

The current view: symptoms caused by underlying factors. Measure it by the symptoms, but the disorder isn’t something touchable. Disorder result from a causal interplay between the symptoms. 

How do we define abnormality?

It is also relying on social norms (culture). It is not a matter of asking who is right or wrong. What we perceive als normal or abnormal depends on social and cultural norms. Social norms vary by place and over time (cultural and historical contexts).