Lecture notes with Clinical Psychology at the University of Groningen - 2014/2015

Lecture 1

Establishment of Clinical Psychology

The roots for clinical psychology go back to the Second World War when many soldiers returned traumatised after fighting in the war. The clinicians to that time have not had a clear treatment guidelines, but did what “felt right”. The need of finding ways to treat those people finally led to the establishment of the Journal of Clinical Psychology in 1945. Shortly afterwards, application of the scientist-practitioner started, so that empirical findings were used in clinical practice. Carl Roger stressed the importance of finding ways in which treatment can become more effective. According to Roger, therapies should be studied more in detail in order to become more knowledgeable about how it can be improved.

Clinical Psychology

Clinical psychology (psychopathology) has two different components. It includes the symptoms of the psychological disorders on the one hand, and the scientific study of those symptoms on the other hand. Abnormal psychology is used as a synonym for clinical psychology. When using the term “abnormal”, it is important to define when behaviour is normal versus abnormal. Several factors are taken into account in defining abnormal behaviour. Firstly, “abnormal” involves the deviation from a statistical norm, implying that abnormal behaviour is unusual and can be quantified. However, this criterion can be problematic since comparing normal versus abnormal behaviour usually involves subjective judgment. Furthermore, not all behaviour that deviates from the norm is considered negative: if a great pianist plays the piano every time he is able to do so, for example, this behaviour is not considered to fall into the category of “abnormal psychology”.

Another aspect when considering abnormality is the cultural context of that behaviour. There are no universal standards in the diagnosis of abnormal behaviour. One behaviour might be considered normal in one culture, but abnormal in another one. As a result, people may not receive treatment for specific disorders in some countries. An example which shows the importance of the cultural background is the pseudo-scientific disorder drapetomania: in the past, slaves who ran away from their employers were considered to have this “mental illness”.

Furthermore, abnormality also depends on the individual’s functioning in society. Abnormal behaviour may represent itself by disfunction in daily living. However, not all dysfunctional behaviours are caused by psychopathology: the fact that people spend more time sleeping in winter than in summer can for example better be explained by evolution.

A further criterion of “abnormal” behaviour is that it is distressing or disabling the person. This definition is independent of culture. However, it requires the person to be aware of the negative consequences of the behaviour. That is not the cause for every disorder. Anorexic individuals, for example, think favourably about the results of losing weight. Furthermore, the distress might be explained by other factors than psychopathology. Situational factors, like the death of a loved one, might also cause the experienced distress.

The Diagnostic and Statistical Manual of Mental Disorders (DSM)

The DSM applies the 3D Model for diagnosing psychological disorders. According to this model, abnormal behaviour is determined by Deviance, Dysfunction, Distress and Disability. The forensic system also uses the criteria of Danger (to oneself or the environment).

The DSM is currently in its fifth edition. The current edition is different from its previous form in several aspects. The fourth edition presented a categorical approach to psychopathology: the criteria for diagnosis was determined by how many symptoms were present. In the fifth edition, however, a dimensional approach was added. This allows the clinician to place a disorder on a continuum depending on its severity. The definition of a mental disorder were also renewed. The problem with the older definition was that it assumed disorders to depend on social norms. However, it is not known whether the psychological disorders or social norms existed first. That is why the fifth edition assumes that a psychobiological dysfunction rather than a deviance of social norms is reflected in mental disorders.

There are debates, however, about whether abnormality can be viewed as a medical illness. Proponents say that many psychological disorder come as a result of medial diseases. A simple infection, for example, can result in an inability to sleep. Opponents criticise the implied biological reductionism: one cannot explain disorders completely in terms of its biological properties; social aspects also need to be taken into account. Identifying biological factors may also lead to the stigmatisation of “abnormal” people to be “internally different”. Furthermore, there are only a few conditions with medical bases and medical testing is still limited.

Despite these limitations and controversies, the DSM is widely used. It provides a common approach of diagnosing mental disorders.

Contemporary Theories of Psychopathology

Contemporary theories in clinical psychology consider an integrative perspective, including biological, psychological and social factors for explaining psychopathology. This combined approach is called the biopsychosocial model. It implies a relationship between the brain, the mind, and the environment. It is, however, very difficult to study these factors in combination. Therefore, models often focus on either the biological, psychological or social aspect.

Why Research in Clinical Psychology?

Research in clinical psychology provides the basis for building theories and related intervention techniques. It can also be used to review whether the interventions are effective. Therefore, clinical psychologists are scientist-practitioners: they use empirical findings to gain knowledge about diagnosis and treatment. Tanks to scientistic research, old theories are continually challenged and replaced by better ones.

Research Designs

A case study involves the extensive examination of a single individual. This might be useful for generating new hypotheses or challenging old ones. It is, however, difficult to generalise the individual’s result to the general public.

Despite that, Dr. Mark Williams succeeded in establishing external validity to a case study. He studied a case of a person who suffered both from depression and an over-general memory. Consequently, he started conducting research about the relationship between depression and general memories and found a significant correlation: the higher the depression, the more general are the memories. To measure the specificity of memory, he developed a standardised measure called the Autobiographical memory test (AMT). In this test, participants are asked to state five events where they felt a specific emotion. People with over-general memory are not able to give specific examples for such emotional events. So Williams’ case study provided a starting point for forming a theory and developing a standardised measure.

Another research design is the correlational study. Fortunately, it solves the problem of external validity and is highly replicable. However, it is limited by the fact that possible confounds can bias the results.

One challenge in clinical psychology is to disentangle the cause and effect of a disorder. A possible solution might be to conduct an experiment involving high-risk people. It can be tested whether an increase in the causal variable (X: the independent variable) precede the effects (Y: the dependent variable). In an experiment, subjects are randomly assigned into the experimental or control group. If research participants and / or the research are unknown (“blind”) about the experiment’s real purpose, bias is reduced. But even if researchers in experiments have more control than in other research designs, variables that are not controlled for may still exist. Another disadvantage is that psychopathological experiments can often not be conducted due to ethical reasons.

An experiment where people are randomly allocated to different treatment groups is called a randomised controlled trial (RCT) and is often viewed as the “gold standard” for a clinical trial. However, critics say that this method can falsely yield effective results. One reason for that might be limitations in the study design. Possible bias may result from a limited sample size, un-blinded subjects or researchers, multiple outcome measures or if drop-outs are ignored. Other reasons for false positive results include patient expectancies or the commitment of the research staff to the treatment of the publication strategy.

Experimental psychopathology can, however, overcome the cause-effect problem by conducting an experiment where a disorder is “caused”. The assumption that psychopathology exists on a continuum allows the researcher to cause milder forms of a psychological disorder to a participant to draw conclusion about the general illness. When conducting research in post-traumatic stress disorder (PTSD), for example, a “mini-trauma” can be induced by showing violent scenes. It can then be tested to what extent the participant experiences intrusive memories in form of recurrent thoughts. It has been found that occupying the brain during exposure to traumatic experience can prevent these negative consequences.

Lecture 2

Diagnosing Psychopathology

Assessment Procedure

The assessment procedure in psychopathology is aimed at collecting information about the patients. In order to do so, many different tools are available. Which tool clinicians use depends on their frame of reference: a behavioural therapist, for example, uses assessment tools to assess behaviour, whereas cognitive therapists use alternative tools for gathering information about the client’s thought process.

The variants of diagnostic tools are diverse. Intake assessments can be open or (semi)structured. They can also take the form of anamnesis, where the goal is to find out about the person’s past by asking this person or relatives about previous experiences. Additional diagnostic tools are observation, interviews, questionnaires, neuropsychological tests or projective procedures.

Diagnostics / Classification

There are different principles of classification. One can place psychological disorders on dimensions or into categories. When using an unidimensional approach, a cut-off point needs to be identified that determines the degree upon which a person is diagnosed for having a disorder. Multidimensional classification gives information about several symptoms; it can be added up to reach one dimensions. A further principle of classification is the distinction between the monothetic and polythetic approach. In monothetic classification, only one symptom can be significant enough to sort a person into a certain category of mental disorders. Anorexic individuals, for example, are identified when they lost so much weight that they have less than 85% of their expected weight. Alternatively, a polythetic classification is used for other types of disorders. Polythetic classification include a large amount of symptoms that can be present in the individual. In panic attacks, for example, a person is diagnosed when showing six out of thirteen different symptoms. So the symptoms here can be completely different in several clients with the same disorders.

In order to know whether the assessment methods are adequate, it is important to check whether they have reliability and validity. Reliability refers to whether the results are consistent and validity is concerned with whether the assessment really measures what it is supposed to measure.

Classification System: the DSM

There are two main modern diagnostic classification system, namely the Diagnostic and Statistical Manual of Mental Disorder (DSM) and the International Classification of Diseases (ICD). Whereas the ICD is used for general diagnoses of diseases, the DSM deals with the psychiatric assessment.

The DSM, which is now in its fifth edition, changes across cultures and with time. Homosexuality, for example, was still defined as a disease in the second edition. Over the of time, a huge increase in diagnoses can be seen in the DSM which is aimed at becoming more specific about the disorders. For each disorder, several symptoms are listed. Since the disorders are labelled with numerical codes, international use is possible. The DSM now presents a system that describes behaviour without trying to explain it. In that way, it eliminates cultural bias and it allows research to discover possible causes.

In the DSM-4, there were 5 axes, including clinical disorders, personality conditions, physical disorders, contributing psychosocial and environmental factors as well as global assessment of functioning. However, there were difficulties to distinguish between Axis I and Axis II. Whereas the first Axis was considered to be more specific to acute symptoms, the second axis’ chronic symptomology were thought of as relating to the person’s personality. However, it was difficult to find a clear cut between the two axes. When the new edition was discussed, the axis about personality disorders still did not reach a consensus. Due to the difficulties of finding personality dimensions, this axis still uses the categorical approach.

In the DSM, personality disorders are described as enduring and interfering with the person’s functioning .There are three cluster: cluster A, the “bizar” cluster, involves paranoid, schizoid and schizotypal disorders. Cluster B includes more dramatic disorders such as antisocial, borderline, histrionic and narcissistic personality disorders. Cluster C deals with anxious personality disorders such as avoidant, dependent and obsessive-compulsive ones.

One benefit of the DSM is that it allows clinicians and researchers to have a common language about disorders. However, the DSM can only be used to describe rather than explain mental illnesses. False positive and false negatives are also of great concern. Furthermore, the distinction between normal and abnormal remains arbitrary. Another problem is the lack of knowledge about the pattern of varied symptoms. Controversy and debates continue to exist about the DSM.

Diagnostic Tools

In clinical psychology, observation can either be used for the registration of behaviour or cognition. Cognitions can be assessed by the use of self-reports or diaries. Behavioural therapist try to measure three thing: the antecedents of behaviour (A), the behaviour itself (B), and the consequences of behaviour (C). In the classroom, a teacher may rate the frequency of various of the child’s behaviours. Alternatively, coding forms provide a very organised way of observation.

An interview can be open or (semi)structured. SCID is an example of a semistructured interview form. Its advantage is that it seems like a normal conversation but nevertheless assesses the disorder.

Alternative diagnostic tools include questionnaires (for example Beck Depression Inventory), neuropsychologists test and intelligence testing. The Wechsler Adult Intelligence Test (WAIS) is the most commonly used intelligence test in clinical psychology. It provides four major indexes, namely verbal comprehension, perceptual reasoning, working memory and processing speed.

Projective tests, such as the Rorschach Inkblot test or the Thematic Apperception Test (TAT) may be used as a starting point of assessment but should not be used as the only diagnostic tool.

Routine outcome monitoring is used to check whether the client makes progress in therapy. It is aimed at improving the quality of the organisation.

Treating Psychopathology

Psychological Treatments

There are a number of psychological treatments. The frame of reference determines which approach the clinician applies. In the psychodynamic approach, a disorder is thought to be caused by unresolved unconscious conflicts. Therefore, common tools of assessment include dream analysis or free association. The humanistic perspective views disordered people as being unable to function optimally. In therapy, they should become more aware of themselves. Therefore, the client talks most of the time in the therapy sessions. Behavioural psychologists argue that mental illness result from maladaptive behaviour patterns. They look at the context in which the behaviour happens. The cognitive perspective focuses on the meaning the person gives to events. It is suggested that these thoughts determine how the person act. So the aim of this approach is to change maladaptive thought processes.

Psychodynamic Therapy

Psychodynamic therapies involve various concepts. The client’s resistance to change needs to be overcome. Transference means that a past experience of the patient transfers to the current client-therapist relationship. Counter-transference, in contrast, occurs when the therapist has specific expectations about the client.

Humanistic Therapy

Whereas Sigmund Freud is the father of psychodynamic therapies, Carl Roger is famous for establishing humanistic therapies. The basic idea behind the humanistic approach is that everybody is unique. People are viewed in a very positive light, arguing that everyone deserves to develop who he or she really is. A key concept in humanistic therapies is unconditional positive regard. It means that the therapist accepts everything that the patient is saying. In contrast to the psychodynamic approach, therapists in the humanistic approach are also encouraged to self-disclose. The aim of humanistic therapies is that the persons think positively about themselves and accept who they are.

Behavioural Therapy

In behavioural therapy, the goal is to change behaviour. In individual therapy, the client is supposed to engage in new behaviour experiences. It is suggested that one experiences more reinforcement by being active. In meditation therapy, parents learn how to reinforce the desired behaviour of their child at home. Behavioural therapy consists of two phases. The first step is to understand and explain the disorder. Then, treatment can follow. In order to explain behaviour, the ABC concept is used. It is important to understand the Antecedents (triggers), the Behaviour itself and its positive as negative Consequences. In the example of binge-eating, the antecedents might be that the child is bullied for being overweight. When this child comes home and is also alone, binging behaviour may result. Most behaviour is followed by positive and negative consequences. Binge-eating might be positive for the person since the food tastes good and is soothing. However, negative consequences include weight gain and low self-esteem. It may be used as a way to avoid the conflict (for example the interpersonal conflict of being bullied). Behavioural and cognitive aspects are often mixed in therapy

After this initial description of behaviour, a treatment plan should be established. Part of the treatment could be cue exposure to food so that the person may regain control over binging. The first step in treatment is to explain the symptoms. The cues (e.g. being bullied) that lead to the maladaptive behaviour (e.g. binging) should be identified in collaboration with the client. After the cues have been identified, the client can be exposed to them and has to accept them without engaging in the old behaviour. In that way, treatment tries to break the chain of the events.

Cognitive Therapy

In cognitive therapy, more focus is placed on the meaning the client gives to situations. The treatment involves identifying whether these types of thought are really true. Therapies might involve testing the evidence of the thoughts. A person who is afraid of dogs can for example be exposed to a dog and might realise that there is no evidence that every dog bites.

Biological Intervention

An alternative treatment tool is a biological intervention. Pharmacology provides different kinds of drugs for various types of symptoms, such as anxiolytics for anxiety disorders. If a person is resistant to pharmacotherapy, more drastic interventions are considered, such as electroconvulsive therapy or transcranial magnetic stimulation.

Lecture 3

The Role of Psychiatrists

Psychiatrists are primary in charge of medical issues. Whereas they are responsible for drug prescriptions, psychologists are more trained in communication sills. The American Psychological Association (APA) argues that a client’s therapeutic help should be considered as a whole process in which psychologists and psychiatrists work complementary rather than exclusively. Even if psychiatrists prescribe the medication, a psychologists should be able to give advice about possible problems of medication usage. Therefore, the APA considers following guidelines:

APA Guideline 1

Psychologists should have a good knowledge about various topics; they should not only be conscious about what they know, but also about they do not know. It is important that they have a basic knowledge about pharmacology.

APA Guideline 4

Psychologists should keep up their level of knowledge to the current knowledge base, including the knowledge about pharmacotherapy.

Psychopharmacology

Psychopharmacology is the study of how drugs alter mood, thinking, and behaviour. It also studies how medication can be effectively used in psychopathology. Drugs can be distinguished between natural (i.e. herbal drugs) and artificial (i.e. synthetic drugs) sources.

The basic concepts in psychopharmacology include pharmacodynamics, what the drug “does” to the body, and pharmacokinetics, what the body “does” to the drug. The drug’s effects can be seen in three phases: the pharmaceutical phase, the pharmacokinetic phase, and the pharmacodynamic phase.

The Pharmaceutical Phase

In this phase, a psychologists might talk about wether a patient really takes the medication every day. When a drug is taken, the body continually metabolises and clears it. When as much of the drug is removed as has been taken in, a “steady state” is reached. The time of this state depends on the half-life of the given medication: the steady state is attained after approximately four half-times. A half-time is defined as the time it takes for the body to metabolise half of the dose.

Different processes take place in the pharmaceutical phase. The first one is the absorption of the drug. It involves the route of administration, which is usually orally. Formulation can differ in that some medications are taken in capsules, while others are taken as tablets. The state of the gut of the patient can have an impact on the medication as well. Furthermore, drug-food interactions should be considered since some food can become toxic in combination with drugs. Another process is the drug’s distribution, so the way of the drug from the blood to the brain. This process can be altered by protein molecules.

Pharmacogenetics

This process is characterised by the medication’s metabolism. During the transformation, the drug changes chemically. It can either become inactive, active or toxic in the body. One thing to keep in mind is that even if medication might not be toxic itself, it can become toxic due to the interaction with the body. People seem to differ in how well they are able to metabolise antidepressants. One can distinguish between Poor Metabolisers (PM), which are likely to have a lot of side-effects, and Good Metabolisers (UM), who hardly have any side-effects. The large variety of drugs allows to take into account those individual differences: if a patient does not react well to a drug, he or she might be able to change to another subtype. With increasing age, people need longer to metabolise medications.

Drug Action and Drug Effect

Before a drug can exert its effects,it needs to bind to its receptor (drug action). Drugs differ in their potency and efficacy. Considering the drug’s effect, it is useful to take the ED50 value into account. This value represents the dose at which 50% of the drug’s maximum response is reached. A drug is more potent than another drug if it reaches the same response given a lower dose. The margin of safety illustrates the difference between the drug effect and unintended effects.

APA Guideline 5

Psychologists should not only consider the patient’s side-effects, but also possible adverse effects. Adverse effects may result from excessive dosages, or a particular reaction by the patient to the medication. A person, for example, might have liver problems and therefore cannot handle a particular drug. Polypharmacy defined as the description of multiple medication at the same time, should be considered with the family doctor.

APA Guideline 9

A psychologist should make sure that the medication can become as effective as it should be. Adherence (compliance) refers to the degree to which the patient correctly follows treatment advice. If a patient forgets to take the medication, the therapeutic invention may remain ineffective. However, sometimes side-effects make patients stop taking the medications. Then, patients should go back to the psychiatrist in order to change the kind of drug. Five different dimensions may influence the patient’s adherence, namely the social and economic situation, the health care system as well as condition-related, therapy-related or patient-related issues.

Guideline 10:

Improving treatment adherence can be achieved by building a good therapeutic relationship since this provides a secure basis for the discussion of psychopharmacology. Then, psychologists could address personal opinions about medication use. The therapist, however, should remain neutral to this topic by avoiding to state his or her own opinion.

Guideline 11:

In total, psychologists should take a biopsychosocial approach to treatment. A combination of biological, psychological and interpersonal factors play a role in the intake, assessment and treatment of psychopathology. 

Lecture 4

Depression

A depressive disorder is characterised by emotional symptoms (e.g. depressed mood), cognitive symptoms (e.g. guilt and worthlessness) as well as behavioural symptoms (e.g. appetite changes). Additional criteria for depression include that the sufferer experiences significant distress and that there is no medical reason, such as medications, for these feelings. In contrast to the DSM-4, feeling depressed as a result of losing a loved one now accounts as a criteria in the DSM-5. The DSM-5 also assesses suicided risk on a dimension of severity. Major depressive disorder can occur in a single episode or as recurrent episodes. Note that half of the patients who had a single depressive episode relapse after recovery, and 80 percent of those who had more than one episode. Depart from the major depression, there are alternative forms of depression, such as persistent depressive disorders (i.e. dysthymic depression and double depression), disruptive mood dysregulation disorder and premenstrual dysphoric disorder. Dysthymic depression refers to a state of mild, chronic depressive mood over at least two years. Double depression occurs when a person with a mild depression relapses into a major depressive state. Disruptive mood dysregulation disorder relates to children who have a lot of outburst; it helps to identify people who are at risk for bipolar disorder in adulthood. Premenstrual dysphoric disorder means that women report irritability and mood switches a week before their mestruation.

The major neurotransmitter involved in depression is serotonin. On average, depressed people have lower serotonin levels. Tryptophan, which is received through food-intake, is metabolised in the body to form serotonin. There has been a lot of arguments about whether serotonin has really been involved in depression. The best evidence comes from tryptophan depletion studies. In the experimental method of these studies, participants do not receive tryptophan throughout their diet. Women have lower serotonin levels than men on average. Results of the studies show a decrease in serotonin in both sexes after tryptophan depletion, but a more significant decrease in women. Serotonin seems to play a role especially in patients who already had depression: for them, tryptophan depletion is highly correlated with relapse. For an individual who is at risk of depression (e.g. if it runs in the family), serotonin depletion also yields significant effects.

Considering the genetics of depression, a polymorphism in promotor of serotonin transporter gene has been identified. Either a shorter (S/S) or a longer (L/L) version of the promoter is present. The shorter genotype seem to be correlated with depressive disorders. Comparing people with and without a family history of depression shows that a S/S genotype can put an individual at a higher risk of depression even without a history of depression. On the contrary, people with a history of depression and a L/L gene have low risks of becoming depressed. So both the genotypes and the family history moderate the risk for depression. Depressed family members may trigger depressive symptoms in their offsprings since they are not able to provide the care and love their offsprings need. Evidence from monkey studies show that monkeys whose mothers have been absent exhibit depressive symptoms independent of age. This relationship, however, again depends on the type of serotonin transporter gene the monkey has. It can be concluded that depression involves both genetic and environmental factors.

One environmental factor is light exposure. When light exposure (e.g. in winter) is lower, people have a higher risk of becoming depressed. This refers to Seasonal Affective Disorder (SAD), which is much more common in the Northern U.S. or Canada than in the Southern regions. Research about light exposure in depression showed mood worsening when tryptophan depleted individuals had to read in dim light, but no effect on mood when they read in bright light. So the bright light seems to account for the tryptophan depletion, and therefore has a positive effect on the serotonin levels. Bright light therapy is a common treatment method both for seasonal and some non-seasonal depressive disorders. In more than half the patients, effects are already experienced over the time of one week. However, relapse rates are high and there is a risk of (hypo)mania following treatment.

Biological interventions for depression include antidepressants such as MAOIs, SSRIs, tricyclics, and also tryptophan from the food store. Alternative interventions are physical exercise, electroconvulsive therapy (ECT) and experimental therapeutics. Experimental therapeutics like deep-brain stimulation, however, do not have a lot of empirical evidence evaluating its effectiveness yet.

Suicide

Suicide is a worldwide phenomenon that is committed by one million people each year. The number of people who attempt to commit suicide is even 10 to 20 times higher. A significant gender differences has been observed, namely that whereas women attempt to commit suicide more often, more men succeed in doing so. About 90 per cent of the people committing suicide have a psychological disorder - usually depression or bipolar disorder - at the time of their death.

In order to predict suicidal behaviours, various predisposing factors have been identified. There are distal risk factors, which can predispose people to have suicidal thoughts, and proximal risk factors, which often lead to the suicide attempt itself. Distal risk factors include family history of suicide and genetic factors, early-life adversity, epigenetic factors as well as personality traits (e.g. hostility and impulsivity) and chronic substance use (e.g. alcoholism). Factors that are usually involved in the attempt itself are recent negative life events (e.g. loss of health), psychopathology (e.g. depression), suicidal ideation (i.e. thinking one is better off when dead) and hopelessness.

A seasonal pattern in the suicide prevalence rates has also been identified: the end of winter is the time where most suicides occur, probably because those people had a long and severe depressive episode over the course of the winter and become more active in implementing their suicidal thoughts at the beginning of spring.

People who commit suicide or have suicidal thoughts usually have a decreased serotonin synthesis in their brain. Assessing suicidal thoughts can be done by explicit methods, such as questionnaires, as well as implicit tests like the Implicit Association Test (IAT). Suicide Prevention methods attempt to decrease overall symptoms, such as the related psychological disorder, by biological and/or psychological interventions. An immediate intervention is given by infusing ketamine, which reduces suicidality within 24-hours. However, it is not an effective prevention in the long term. Problem-solving therapy can reduce hopelessness, which is one of the main cognitive predictors of suicide attempts. Suicide Hotlines are also available.

Bipolar Disorder

Bipolar Disorder occurs when people switch between depressive episodes and mania. Whereas the DSM-4 did not specified different forms of bipolar disorders, the DSM-5 now distinguished between Bipolar I disorder, Bipolar II disorder, and Cyclothymic disorder. Bipolar I disorder is characterised by manic episodes which involve elevated, expansive and irritable mood, whereas Bipolar II encompasses hypomania, a milder form of mania. Cyclothymic disorder is a milder version of both depression and mania, which are present over a period of at least 2 years. Overall, major depression is four times as common as bipolar disorder. Whereas women are twice as likely as men to become depressed, there are no gender differences in the prevalence of bipolar disorder. Bipolar disorder can also be seasonal, so that a sufferer may have a depressive episode during winter and a manic episode during spring.

Many questions still need to be answered about bipolar depression. The comorbidity of bipolar disorder with other psychological disorders such as addiction problems and post-traumatic stress disorder, for example, is still not understood. Factors that precede the disorder are also largely unknown. A debate is also going on about whether bipolar disorder is distinct from major depressive disorder.

Biological studies have shown some abnormalities in brain structure and neurotransmitter activity in bipolar patients. Evidence suggests a tyrosine depletion in manic patients, which seem to lower dopamine synthesis. The overall activity of the brain seems to be higher in manic patients, but we do not know whether this is the cause or the effect of this episode. Genetic factors also seem to be significant in bipolar individuals.

Pharmacological treatment of bipolar disorder typically involves the prescription of lithium, which is a mood stabiliser of both depression and mania. It may improve receptor functioning, but how it works exactly is still unknown. Lithium is frequently combined with other drugs such as antipsychotics since bipolar disorder usually comorbids with other disorders. However, this augmentation of medication can become toxic. That is why antidepressant-induced mania (AIM) is the most common medication for bipolar disorder, even if it is not as effective as Lithium.

Lecture 5

Anxiety Disorders

If one sees a threatening stimulus like a snake, the common reaction is a flight, fight or freeze reaction. Even though this reaction is functional, people who have anxiety disorder have it in an abnormal form. Common anxiety disorders are simple phobia, agoraphobia, panic disorder, social phobia and Generalised Anxiety Disorder. Obsessive-compulsive disorder and post-traumatic were included in the anxiety disorders in the DSM-4, but noes have their own category in the DSM-5.

Specific Phobias

In specific phobias, fear results as a response to a specific stimuli or situation. These objects can be various, ranging from animals and natural phenomena (e.g. height) to man-made inventions (e.g. flying). Fear can come in the presence or as an anticipation, such as when somebody thinks about the threatening stimuli. In the DSM-4, irrational fear was labelled as a characteristic of specific phobias. However, the phobic fear is now considered to be overestimated rather than irrational. Another criteria for the diagnosis is that the fear is persistent, meaning it is present for longer than 6 month.

Specific phobias have been tried to be explained by behavioural models which state that the fear results from classical conditioning. For example, when a person got bitting by a snake, it has may be been paired with the snake’s hissing, which consequently becomes a predictor of fear. The fear, in return, results in avoidance. This explanation, however, has been abandoned for several reasons. Firstly, the stimulus-response model is challenged by the black box theory which states that there are internal processes going on in the mind (‘the black box’) which are not accounted for in the regular model. Many people that experienced a negative association with a particular stimulus (e.g. being bidden by a snake) do not become phobic. On the other hand, it has been shown that not everyone who is phobic have had a bad experience. The classical conditioning model does also not account for observations of people who became phobic after hearing that something might be dangerous. Alternatively, the Stimulus-Stimulus (S-S) model takes into account the expectancies of relationship between the conditioned stimulus (CS) and the unconditioned stimulus (UCS) as well as the evaluation of the UCS. Even though the UCS is a predictor of the fear, it is moderated by these expectancies and evaluations.

Panic Disorder

The criterion for the diagnosis of panic disorder is that a person has had at least one unexpected panic attack. The attack itself includes physical symptoms, like short of breath, and psychological symptoms, like the thought of dying. Another diagnostic criteria is that these people worry a lot about it. You can have panic disorder with or without agoraphobia (or agoraphobia without panic disorder). Agoraphobia is a fear and avoidance of places where one might cannot get help (e.g. using the subway). Therapy approaches can involve graded exposure in vivo, where the feared situations are approached stepwise. A hierarchy of situations according to anxiety levels is identified; the patients are then progressively exposed to these different situations. Doing so, it is important that the person stays in the situation until the fear decreases. The idea is that you break the link between fear and avoidance, which may lead to a decoupling of the association between the elevator (CS) and fear. The new insights in exposure lead to a revised behavioural model of fear. It takes into account the individual’s expectancy of what will happen after being exposed to the CS. Concerning panic disorder, sufferers often expect to die in a certain situation. This model focuses more on disconfirmation rather than on the anxiety. It states that one should disconfirm the expectations by providing evidence that these beliefs (e.g. of dying) are not real. The evidence should be given in as many contexts as possible. Safety behaviours may facilitate the exposure.

The difficulty in treating panic disorder refers to the question of how to exposure the patient with their panic symptoms. Nowadays, a so-called “interoceptive exposure” is used, which means that bodily sensations similar to those of a panic disorder are. Actions such as hypoventilation, breathing through a straw or rotating in a chair lead the individuals to have an increased heart beat, shortened breath and / or become dizzy. Patients should be explicitly made aware that these bodily symptoms do not necessarily result in a panic disorder.

Social Anxiety Disorder

A person with social anxiety disorder persistently fears to be judged, laughed at or humiliated by others, resulting in excessive anxiety experienced in social situations. A cognitive model for social anxiety disorder was developed by Clark and Wells. This model states that a social situation (e.g. knocking over a chair) activates assumptions (e.g. “I’m worthless”), which lead to perceived social danger (e.g. “people laugh about me”). A cognitive therapy based on this model focuses on self-attention of the client. That can be done by role-playing with explicit self-focus (e.g. monitoring thoughts and feelings) and roleplaying with attention on the therapist. This method can be generalised to situations in the real world as well.

Generalised Anxiety Disorder (GAD)

Generalised Anxiety Disorder (GAD) is more “free-floating”, meaning that people have excessive worry about all kind of things. Affected people feel restless, are very tense, and may also have sleeping problems. This anxiety disorder is presented in a metacognitive model. Individuals with GAD often view worrying in a positive light since it may help them to be prepared for bad situations. However, the worrying often becomes more and more dramatic and unrealistic. Sufferers then even worry about that they are worrying, which is called meta-cognitively worry. As a consequent, they try to suppress thoughts and physical responses. However, suppression of thoughts usually has a rebound effect, leading the person to think even more about the topic he or she did not want to think about. Meta-cognitive therapy focuses on the meta-cognitive worry, trying to change the negative views about the worrying act itself. Therapy usually tries to make the patients able to control their worrying, for example by setting a specific time each day that is reserved only for worrying.

Obsessive Compulsive Disorder (OCD)

Obsessions are recurrent or persistent thoughts. Compulsions are repetitive behaviours, for example washing one’s hand way too often in order to get clean. A central concepts of this disorder is inflated responsibility, which is the belief that one needs to prevent negative consequences by the compulsive actions (e.g. repeatedly checking if one has locked the door to prevent criminality). Another component is the Thought-Action Fusion, which refers to the belief that thinking about something can be as influential as the action itself. Exposure in OCD is aimed at showing the clients that these beliefs are not true. They are exposed to not do the rituals. Patients, for example, who have the compulsion to wash their hands as often as possible are prevented from hand-washing.

Post-Traumatic Stress Disorder (PTSD)

In order to be diagnosed with PTSD, an exposure to a traumatic event in the past is a necessary criterion. Furthermore, re-experiences of the events - such as in nightmares, - avoidance of related stimulus, a negative alterations in cognition and mood as well as hyperarousal are common symptoms of patients with PTSD. A complex model of PTSD by Ehlers and Clark states that the nature of trauma memory is very emotional and seen as a threat. In therapy, patients are exposed to their own memories, for example by asking them to state their traumatic events in detail. In that way, misinterpretations of these experiences may be identified. Additional techniques include cognitive restructuring, where the individual is taught to alternate the thoughts about the past events, and imaginary rescripting, where the memory of the event is changed so that it takes a better ending.

Lecture 6

Schizophrenia

A diagnosis of schizophrenia according to the DSM-5 occurs when a person has two (or more) of 5 major criteria, which include delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour or negative symptoms. Delusions are beliefs that are not consistent with reality, such as delusions of grandiosity like thinking that a person is the future lord of the world. Arotomania is the belief that a celebrity is in love with the concerned person. Hallucinations are most commonly auditory, but can also involve visual ones, where the person may see persons that are not there in reality. Disorganised speech in people with schizophrenia makes it difficult for them to communicate with others. One example is word salad, where all the words and phrases of the speech do not make sense to other people. Catatonic behaviour appears when people stay in a robust posture for a period of time without movement. Negative symptoms include attentive flattening, alogia (the inability to experience pleasure) and avolition (where people hardly give spontaneous speech). If only one criteria is present, but very strongly, schizophrenia may nevertheless be diagnosed.

Hallucinations

People who experience hallucinations are convinced that they really exist. These hallucinations can be positive or negative; the negative experiences can be quite distressing, such as when the person hears voices that talk about death. People may experience it as very realistic, but outstanding individuals may evaluate it as very bizzare, such as when people run away from something that do not actually exist.

Hallucinations, however, are not specific for schizophrenia, but also appear at several other disorders. Twenty-five percent of people with affect disorder experience hallucinations. Alcoholics may experience very severe deliriums.

It is actually quite common to experience hallucinations and delusions at some point. It is not about having hallucinations or not having hallucinations, but rather a dimension. Mild hallucinations may include thinking that people talk about oneself or that somebody is following oneself. However, mentally healthy people do not feel stressed about these hallucinatory symptoms. However, it becomes a mental disease when the hallucinations become very distressing, such as when you think your boss is persecuting you. Half of the voices have negative content, but some have adaptive functions, such as when people have voices in their head who calm them down when they are afraid or lonely.

Possible Underlying Mechanisms

Hallucinations are explained by spontaneous neurons firing in the related brain areas. Furthermore, internal thoughts may be misattributed by being external. It seems to be correlated with dysfunctions in episodic verbal memory. The temporal lobe seem to be a very important part of speech. Studies have found that when there is less grey and white matter in the Superior Temporal Gyrus (STG), the hallucinations are more severe. However, another study found exactly the reverse results, namely that hallucinations are associated with increased matter in this area.

The frontal lobe is implicated in source monitoring, and therefore may be involved in the misinterpretations of thoughts.

The language centres - Broca’s and Wernicke’s area - are active when people hear auditory hallucinations.

The hippocampus and the thalamus seem to play a role as fell. Reduced volume in these areas is associated with more severe symptoms.

There is also an aberrant activation of emotional attention centers such as the amygdala and the ventral anterior cingulate. Deviations within these systems are associated with hallucinations.

Who Becomes Psychotic?

One factor that contributes to whether a person becomes schizophrenic is genetic. Psychosis seems to run in families. The environment also plays a role, such as socio-economic status. Hallucinations or psychosis can result from using drugs, such as amphetamines or cannabis. There are some more triggers such as stress and anxiety that may contribute to the development of psychosis. However, it can happen to anyone.

Families Coping with Schizophrenia

The onset of schizophrenia is usually during adolescence or early adulthood, where many individuals are still living with their families. It can be very difficult for parents if their children experience voices or see things that are not real. They do not know what happened to their child, what they should do and if they are safe. Parents often feel helpless, confused, guilty, sad, embarrassed or angry because they do not have a lot of knowledge about the disorder. Some parents do not see the accomplishments of the children because they do not know how hard it is to go through the psychosis. So the psychosis of the child has a huge impact of the life of the parents. Some parents may neglect their own needs and hobbies and spend their whole time with the child. As a result, friends and partner can be neglected. The relationship of the child with other children decrease with the symptoms as well. The relationship between the child and the parents may be influenced by the kind of delusions and hallucinations, such as whether the parents are involved in the delusion or not. Some parents may neglect or ignore the child, may be due misunderstanding. The two parents may have different opinions about how to deal with the child, which can give restraints to the parental relationship as well.

Expressen Emotions (EE)

An important factor concerning family relationships is the concept of Expressed Emotions (EE), which was developed by George Brown. He was a psychiatrist in London, who treated schizophrenic people with chlorpromazine. People who seemed to recover were sent home, but then they often relapsed when returning to their parental home. Most of these parental homes were characterised by a focus on negative emotions. Research identified five factors of expressed emotions. One factor is criticism, which is usually followed by hostility, which represents a form of anger to deal with the criticism, such as blaming the child for the disease. Emotional over-involvement is kind of the opposite coping strategy and occurs when caregivers become so overprotective that the patient becomes completely dependent on the caregiver. Positive remarks, such as appreciating patients’ effort and warmth are also an important factor. Several measurements have been made to measure EE. The most prominent are Camberwell Family (CFI), a very extensive interview with the family. Another one is the Perceived Criticism (PC), where patients are asked how much criticism they experience in their family. Alternatively, self-reports can be used.

Some factors of caregivers are associated with EE, such as their personality traits. Cargivers in families with high EE often show less empathy, less optimism and motivation about their own life and future. Some caregivers make wrong attributions of the situation, such as thinking that the disease is the patient’s own fault. In that case, criticism of the child is common. On the other hand, other caregivers may think they are responsible for the development of their child’s psychosis. This attribution often lead to overprotection due to the guilt they are feeling. The behaviour of the child is often tried to be changed through control.

This can have various negative consequences, leading to distress for both the parents and the child. It can be seen that pressure in family relations is common and give raise of the child’s relapse.

Family Intervention

The quality of the relationship with the family is more important than the type of family. Inventions to improve this relationship include family psychoeducation, where the knowledge level about the mental illness is increased in the family. It is aimed at changing the caregivers' attitudes positively towards the patients.

A problematic, but common case is when the patient has no insight into the illness, and do not understand that what they see and hear is not real. An invention for that is the LEAP system, which aims at increasing family being. It is really focused on the interaction within the family and determines various important factors that help in the treatment progress. One important factor is to listen to the patient. It is a very active process where the parents need to let go of their own gender and consider the patient’s need. Therefore, a safe place need to be created where the sufferer is free to tell what they feel. The parent should know the fears which may exist due to the related delusions. They should not try to bring order into the patient’s story, but should respect it and identify the underlying feelings (e.g. anger). A lot of people down-play their children’s experiences, such as by saying “these people bother you” when the children think people are trying to kill them in their delusion.

The caregiver should also show empathy and understanding. This might be important if the child rejects medication regime. Caregivers should understand that medication may not be comfortable to take since they have side-effects. They should not state their own opinion about the medication, however, until the patient ask for it. If they ask, they are much more open to the response and therefore are more willing to listen. Medications should be explicitly explained to the children and focus should be set on the advantages. The caregiver should be a partner to the patient. The goal of the patient itself should be on perspective.

Lecture 7

DSM-5 Substance Use Disorder

In order to be diagnosed with substance use disorder, the use of the substance should result in clinically significant impairment or distress according to the DSM-5. The substance is usually abused in larger amounts than intended and it is used despite knowing its negative consequences (such as social, physical and personal problems) due to an inability to give it up. Other activities, such as work or family responsibilities, may be neglected in favour of the drug. Furthermore, withdrawal symptoms occur when the addict does not take the drug. Than, the individual experiences cravings, a strong desire for taking the drug again. With continued use, a tolerance towards the drug builds up, meaning that the drug’s effect diminishes over time. In that way, the individual needs larger doses to get the same effect.

Addiction as Dyscontrol

Addiction is often seen as a form of dyscontrol. As Widiger and Smith put it: “drug usage becomes a substance use disorder when persons are significantly impaired in their control of this usage”. This idea especially refers to the fact that substance users usually abuse the drug more than they intend to do, their inability to reduce this consumption, and their cravings towards the substance. These three criteria give raise of an apparent inability to control the drug use.

Is Addiction a ‘Thing’?

There has been an influential letter saying that addiction is a disease. This implies that addicts do not really have control over it since it is the result of a dysfunction in the brain. Other people, however, say that it is not a brain disease, but a choice. The debate about whether there is free will in addiction is still ongoing.

Dyscontrol as Use despite Negative Consequences

In an animal study about addiction, rats were given access to cocaine. The results were clear: the drugs become so involved in using the drug that they neglected other needs, such as the need for food or grooming. Finally, they misused the drug to the point of their death.

These results may explain some addictive human behaviour as well. Despite the abstract knowledge that the substance use has negative consequences, addicts continue taking the drug. One person describes it as a “blind spot” in mind, where behaviour becomes automatic, and the drug is just used without thinking. This automatic habit may explain the high relapse rates after treatment.

Different Classes of Commonly Abused Substances

Substances are usually divided into three broader categories, namely stimulants, sedatives and psychogenics. Stimulants include drugs such as amphetamine, cocaine, ecstasy, nicotine, caffeine and ritalin. They stimulate psychological and sensory-motor functioning. People who take stimulants report feelings of alertness, energy and confidence. Amphetamines are used in medical purposes for the treatment of ADHD and narcolepsy. In the past, it has also been used to fight asthma and sinus decongestion. However, this drug has negative side-effect, such as leaving the person irritable, paranoid, as well as not able to sleep or think properly.

Common sedatives are opium, morphine, codeine, heroine and methadone. They lead to feelings of euphoria, well-being and the disappearance of negative feelings and worries. Sedatives might be used therapeutically as analgesics, cough suppresser or antidiarrheal. Methadone, a milder form of sedatives, is given to heroine addicts so that they can overcome their withdrawal symptoms. Sedatives may lead to immediate or long-term adverse effects such anxiety, pain sensitivity or insomnia.

Psychogenics - such as LSD, mescaline and psilocybin - can lead to hallucinations by altering states of consciousness, but this alteration may lead to anxiety and paranoia. People who were given psychogenics in research were rated higher in openness, humour and optimism in a one-year follow-up. Another psychogenic drug, namely cannibinoids (marijuana and hashish) can increase well-being. However, the induced perceptual changes can also lead to agitation, anxiety and paranoia. Cannibinoids are medically widely used in the treatment of nausea, pain, and lack of appetite. Another drug that alters perceptions is MDMA (ecstasy). The users may report feelings of euphoria and sociability, but states of anxiety, depression and fatigue are also likely.

There are also non-substance addictions, like gambling disorders. It is similar to other substance addictive disorders in that gamblers are unable to control their behaviour and become tolerant over time. In the DSM-5, there is currently a debate about whether one can also become addicted to the Internet. Proponents argue that people may neglect other important activities in favour of Internet surfing. The question that remains, however, is if this can really be seen as a form of dyscontrol.

Theories of Addiction

Dual Process Models: Functional Perspective

It is an old idea that drives are controlled by the mind. The “go”-system is thought to be controlled by the “stop”-system, which results in self-control. Therefore, goals are important in these organisms. If we do have incentives (goals), they give us meaning in life. Otherwise, there is apathy. In regard to substance abuse, the addict’s main goal seems to be related to drug use.

The GO! System

The GO! system in the brain includes the dopamine system with the nucleus accumbens. This system is involved in reward, which is demonstrated in animal studies. It is activated at approach as well as escape behaviours. Many drugs influence this area. The evidence shows that rats go great deals to get the drug. They even take electric shocks into account if that means they can get access to the drug. In contrast, they do not take these strains into account for obtaining foods or drinks. This might be parallel to drug addicts who take the drug no matter whether it destroys themselves.

It was traditionally thought that drug abuse involves pleasure, but then addiction was thought of as the result of conditioning. The idea is that cues of drugs can develop appetitive salience, so it activates the GO! system when the addict for example sees the drug. The concepts of liking and wanting have therefore been distinguished in that liking means pleasure and wanting involves the effect of cravings. By becoming tolerant to the liking effect, the wanting effect becomes synthesised.

In one field study, subjects were exposed to four glasses, two of which were green and filled with some alcohol, and the other two were red and were filled with non-alcoholic beverages. Skin conductance and eye gaze were measured. It was found that there was more arousal (skin conductance) when addicts later were confronted with green coloured glasses (where previously have been alcohol in it) rather than red coloured glasses. Subjects also gazed more often at these classes. This study shows that cues such as the colour of the glass can lead to motivational salience, which gives raise of cravings. After the motivational salience, it becomes a constrained choice (previous important things become less important).

The STOP! System

The STOP! system is equivalent to our executive functions. Its main purpose is stopping people from responding to environmental stimuli. The related area of the brain is the frontal lobe. The idea is that when we have weak executive control, we respond more to environmental clues such as alcohol bottles. One way to measure this system is the Go/No-go task. A button of go or no-go has been pressed in response to several stimuli. The inability to inhibit the response of pressing “go” gives raise of an inability of response inhibition. Evidence shows that this system is lowered in addicts, so this test is effective in prediction for substance abuse. An impulsive system can predict heavy use.

Treatment

One way to treat addiction is to eliminate the positive association of the drug. A reduction of the positive appreciation of alcohol can be achieved by pharmacological treatment, such as disulfiram and naltrexone. They leave the person having unpleasant effects, such as headaches, whenever using alcohol. However, it is not that easy to make people take the drug.

Another way is evaluate conditioning. Its goal is the development of a negative association by comparing alcohol with negative pictures. Studies found a resulting change in implicit attitudes towards alcohol and drinking behaviour itself.

A further treatment approach includes the strengthening of the STOP! system. This can be done by strengthening control in all kinds of daily activities, such as resisting sweets.

Who Becomes Addicted ? Some Epidemiological Data

The factors that determine which people who try substances really become addicted include both genetic and environmental criteria. The environmental effect has been shown by the Rat Park studies. The idea was that rats in previous experiments became so easily addicted because they were in isolated cages. So the research created rat parks where a lot of experimental activities are created. The isolated rats were compared to the ones in the park. Results show a dramatic difference in the groups: the rats in the rich environment were much less likely than the isolated rats to abuse the drug. In a second experiments, they used rats who were already addicted and found the same results. Rats in the rich environment were more likely to quit using the drug.

Research into genetics found that offsprings of addicts are more sensitive to reinforcing effects of the drug. 

Lecture 8

Power of Positive Thinking

The power of positive thinking involves thinking that everything is possible.

One approach is Neurolinguistic programme (NLP), which is something you are not usually taught in academia. Neurolinguistic programme started as a psychopathologic approach, but moved to business. It assumes that people differ in the modality they prefer, and this is represented by behaviour (e.g. through eye-movement, such as when the person either looks to right or left side of the room). The idea is also that there should be a match between the modalities, so that it facilitates communication (such as in the therapeutic relation). However, there is no evidence for these approach and assumptions. Still, there are a lot of research considering NLP. Five RCTs have been done about these area, of which only one found a significant result stating that NLP is effective. So it was concluded that there is not enough evidence for the efficacy of NLP.

Self-affirmation is another area looked at in research. In one experiment, researchers put subjects in either no-statement or positive-statement condition. What they observed was that in the experimental condition (positive statement condition), people with high self-esteem showed in increase in mood, but for those people with low self-esteem, mood worsened. That is similar to when depressed people are asked about positive memories: they may focus even more on negative things and symptoms increase.

The claim has been made that if you think positively, positive things will happen to you. In contrast, if you think negatively, negative things will happen to you. This has been called the law of attraction which states that “like attracts like”. Even if there might be a correlation, but this theory does not hold true all the time. Even if you think super-positively, not everything will be possible, for example you will never be able to fly.

Positive Psychology

Positive psychology is concerning with flourishing. Therefore, positive psychologists try to understand those factors that make individuals able to grow or develop successfully. A metaphor might be watering a plant so that is grows.

The positive psychology movement started when Martin Seligman was elected to be the president of APA in 1998. He wanted to change the focus of psychology from healing diseases to help people flourishing. So he is seen as the founding father of the positive psychology movement; however, earlier researcher have already focused on positive psychology before. Martin Seligman made in nevertheless firstly to a mission. He thought of it as a theory, claiming that positive psychology is about our choices and motivations in life.

In his theory of authentic happiness, three main elements that make up happiness are identified. The first one is positive emotion, so having a pleasant life. The second element is engagement, which involves the concept of flow - flow occurs when you deploy your highest strength in an activity, such as when playing the piano and losing any sense of time. Meaning in life is considered to be the third element of happiness, stating that a meaningful life occurs when one strives for something bigger than the self (e.g. being a vegetarian). According to the authentic happiness theory, positive psychology has happiness as its topic, which is measured by assessing life-satisfaction and the goal is to increase life satisfaction.

Is Happiness Possible?

Menno de Bree holds the claim that happiness is impossible. There are many life strains. Certainly, you can do things to improve your life and pursuit happiness. However, the pursuit for an ideal life and happiness is often not possible. So Menno de Bree states that people should accept their unhappiness and make the best out of it. When you look at parents, they are on average unhappier than adults without children. So the question is raised why having children is still adaptive. The answer is that people do not only want happiness, but also meaning in life.

In 2011, Seligman renewed his authentic happiness theory into a new theory, namely the well-being theory, which changed its focus from happiness to well-being. Further components that are involved in well-being were identified, namely positive relationship and accomplishment in addition to the already previously identified elements of positive emotions, engagement and meaning. Well-being is no longer assessed by life satisfaction as happiness has been measured in the authentic happiness theory, but by looking at the extent of the five elements (e.g. accomplishment). The goal is to increase flourishing by increasing these well-being components.

Critique of the Positive Psychology Movement

The positive psychology movement has been criticised in various ways. Firstly, it has been said that this is no new approach, since for example the humanistic psychology involved positive psychology as well. Furthermore, it overs implies that the experience of human emotions, such as that a smiling face does not directly mean happiness. It has also been criticised for its marketing, since people may become more interested in buying the book when they hear the word ‘happiness’. A further critique point is that less effects have been seen than has been claimed, for example in relation to comprehensive soldier fitness. Yet, it lead to a massive increase in studies focusing on positivity.

As a result, positive psychology as a movement has become a popular thing. More people are focusing on research in these field, and journals write about it. In 2010, there was a paper where the claim was for positive clinical psychology. One of these areas might be to identify factors of resilience in people. Well-being is predictive of illness. So you might take actions to lower the risk of disease. Moderators in the relationship of well-being and the onset of disease have also been identified, such as social support and optimism.

Broaden-and-Build Theory

The broaden-and-build theory of positive emotions has been developed by Barbara Fredrickson and it gives an answer to the question of what elements of positive psychology are useful. The theory assumes that emotions are action tendencies. Emotions are thought of as response tendencies that consist of multiple components, namely subjective/ cognitive, physiological and behavioural ones. They are specific and have an object, such as when you are angry about a particular thing. There is also a cognitive level in emotions, such as when you start feeling afraid when you now you are surrounded by a criminal. Negative emotions are adaptive since they show you how to survive in the long-run. Yet negative emotions may result in a downward spiral, where they may lead to attentional narrowing, more negative feelings and may be even psychopathology.

Positive emotions, on the other hand, are related to approach behaviours, which are however not always so clear. They are also adaptive since they can broaden people’s momentary thought-action repertoire. This may lead to further exploration of your environment and thereby enduring personal resources. This upward spiral shows that positive emotions give raise of even more positive experience and decreased stress, which may result in flourishing.

It has been claimed that the ratio of positive and negative emotions predicts who is going to flourish. The ratio suggested is 3:1, so that a person needs to feel three times as many positive emotions rather than negative emotions to be able to flourish.

It has been shown that if people have fun in doing something, they do it more often. One example of this was a study where stairs were build into piano steps in a station in Budapest. As a result, more people used the stairs rather then the elevator. So having more fun in activities can increase adaptive behaviours.

Dispositional Optimism

The idea is that resilience is developed by engaging in positive emotions in the long term. One of these positive emotions is optimism. Dispositional optimism is a trait of having positive expectations for the future. It is measured by the Life Orientation Test (LOT), which involves ten or twelve statements, such as “I don’t get upset too easily”. People who are optimistic have a specific attributional style. Selignman also made a lot of research of the attributional style of depressive people. He made an experiments where dogs were exposed to psychological stage: they were put in a small cage. Even if they had the opportunity to escape later on, they did not. The idea was that they have learned helplessness (the belief that their situation is not escapable). Therefore it is argued that people become depressed because of their attributional styles.

Dispositional are more likely to attribute events to external, changeable and specific resources. For example, when they fail an example, they would think that it was had a bad day where the exam took place. Dispositional optimism is associated with active problem-focused coping, which involves thinking and planning steps to solve problems. This coping style is associated with positive outcomes, such as adjustment to cancer. Pessimism, in contrast, is associated with higher mortality. These studies show a correlation, however, no causality. It does not mean that optimism causes you to live longer. The idea that you are responsible of being happiness might be too generalised as well. Barbara Ehrenreich, who suffered breast cancer herself, argues that positive attitudes cannot change cancer, since cancer depends on your own cells and immune system. The main message is that even if optimism seems to have positive outcomes, it cannot heal everything.

Positive Interventions

It not really clear yet whether positive interventions are effective since adequate control groups are lacking. It is important to distinguish between life-problems, which can be challenged through coaching, and psychopathology, which need to be assessed in psychotherapy. So there is a clear need for randomised clinical trials for positive interventions. For new interventions to be effective, they need to add values to the old ones, or are more cost-effective. It is also important to distinguish between life-problems, which can be challenged through coaching, and psychopathology, which need to be assessed in psychotherapy.

One intervention that has been researched a lot is increasing gratitude. Gratitude happens if you receive something that you think is valuable to you. It is a kind of thankfulness if somebody is giving something to you. It does not need to be interpersonal, however. You can also feel gratitude for abilities you have, such as good physical ability. Interventions to increase gratitude is to keep a gratitude diary. People write down three things that they are grateful for every day. Another intervention is a gratitude letter, so writing a letter to somebody you are thankful for. Furthermore, meditation can increase gratitude. The idea is that you direct compassion to yourself (such as not punishing yourself, but treat yourself softly). In meditation, loved ones can be added, and gratitude can also be directed towards them. Meditation programmes yield effective outcomes. Note however, that it might be influenced by selection bias. People who enter these interventions are favourable towards meditation already.

A further example of positive intervention, which is promising but does not have a lot of empirical support yet, is self compassion exercises, which can be added to Cognitive Behaviour Therapy (CBT). It was found that people who are high in self-criticism do not really recover in CBT. These patients tend to punish themselves when start thinking in irrational terms again. These self-punishing fashion should be addressed by imagination. Patient should image their own critical voice (e.g. an attacking teacher) and should identify that this self-critical image is not helpful. They may notice that a helpful teacher is more effective than a criticising one. This technique can be used as an encouragement in various difficult situations.

Lecture 9

Chronic Fatigue Syndrome (CFS)

Chronic Fatigue Syndrome (CFS) is defined as a disabling fatigue apparent for at least six months whiteout an organic cause. Concerned people experience many disabilities because of their tiredness. Eight diagnosis criteria are defined, of which four criteria are pain symptoms, namely sore throat, muscle pain, joint pain and headache. The four other symptoms include cognitive deficits such as problems with memory and concentration as well as tender lymph nodes, unrefreshing sleep and increase in symptoms after effort. A person is diagnosed as suffering from CFS if he or she has four out of the eight symptoms.

A lot of people think that these people are not really sick, but it is in fact a real illness. People with CFS suffer as much as people with medically explained illnesses such as cancer. However, it is hard to recognise CFS from an outside-perspective, since these people can seem quite energetic and sometimes also manic. Chronic Fatigue Syndrome is very controversial: some people think it is because of some nerve abnormalities; they are looking for a somatic cause for the CFS. Currently their research focuses on the role of the immune system, since people with CFS may be more vulnerable to immune diseases.

It is very important to recognise chronic fatigue since CFS sufferers would not recovery without treatment (only 5% would recover when being left untreated). The prevalence rate of CFS sufferer include 30.000 - 40.000 patients alone in the Netherlands.

Fatigue in Other Illnesses

Some people also stay fatigue after other illness, such as cancer. It has also be found in soldiers after a peace mission. So symptoms do not always give raise of CFS, but might also be the consequence of other illnesses.

When people are depressed, they can also become very tired. However, a clear distinction between depression and CFS can be drawn since symptoms of depression, like feelings of guilt, are not present in CFS. In contrast, CFS individuals enjoy their activities and are happy when able to do them, but are often just too tired to do them. Depression, however, can become secondary to CFS. So it is really important to check in therapy if CFS may preceded the depression.

There is no difference between people suffering from psychosis like schizophrenia and non-psychotic people in terms of diagnosis or treatment outcomes.

Is CFS a hype?

Fatigue is one of the most common reasons why people go to see the doctor. CFS has already been diagnosed 30 years ago, so it is not a hype.

CFS in the Brain

People with CFS have decreased grey matter. However, we do not know what comes first: the brain abnormality or the CFS symptoms. Research indicates, however, that if people go to treatment and change behaviour, an increase in grey matter is seen. So the decrease of grey matter may develop due to the reduced behavioural activity.

Checklist Individual Strength (CIS)

The Checklist Individual Strength (CIS) is a questionnaire which measures extreme fatigue. It considers tiredness and concentration problems. Furthermore, it assesses whether there is decreased motivation. It is really important to check whether there is a decreased motivation in order to treat the underlying cause of it, so that the patients are able to achieve their goals. In order for treatment to work, patients need to be motivated.

CFS is not just fatigue, but also impairment. People who are fatigue for a long time become impaired in many life areas, such as household, work or social activities. CFS patients report much more of such limitations compared to the average GP visitors.

What causes CFS?

There are predisposing factors, representing risk factors for the disease, precipitating factors, which lead to the onset of the disease, and perpetuating factors, which maintain the symptoms.

Predisposing factors are being female, premorbid mood or psychopathology (e.g. an anxiety disorder in the past), trauma in childhood, viral infections (e.g. a flue), low or average level of education and limiting disease in childhood (e.g. asthma) as well as neuro-endocrine dysfunctions.

Precipitating factors which trigger the onset of the disease are often bacterial viruses or psychosocial stressors. However, this is based on what people believe when they started becoming tired. Note that whereas viral diseases are considered risk factors, bacterial ones trigger the onset of CFS.

Perceptuating factors include low self-efficacy in terms of when individuals believe they cannot change their fatigue. It leads them to become less physically active, which increases fatigue again. They also constantly focus on their body to check whether something is wrong. The social environment also plays an important role: if others (e.g. friends, spouse) try to help them by doing tasks for them, the patient becomes in turn still more inactive and tired. Negative consequences can also be seen for the reverse case: if other people do not believe that the patient is really tired, this person may act even more tired to give evidence of their fatigue.

Treatments

Proven effective treatment methods are Graded exercise therapy (GET) and Cognitive Behavioural Therapy (CBT). A lot of other different therapies for CFS offered that are not empirically supported. CBT is the most recommended therapy. There is no evidence for the claim that CBT might be dangerous or may increase symptoms. It is considered to be a safe treatment.

The CBT has a step-wise treatment programme to treat CFS. The treatment usually starts by setting goals: patients are for example asked where they want to be in future. This step increases motivation, since the patients may realise where they are at the moment and how they want to be in future. Another advantage of setting goals is that if the therapist knows the individual's goal for the therapy, he or she also knows when the therapy can be ended, namely when the individual goal is reached.

The next step in therapy is assessing the patient’s circadian rhythms. What can be seen in people with CBT is that they alter their normal circadian rhythm, for example by staying in bed late or sleeping during the day. They engage in this alteration because of their belief that they need to sleep due to being tired. In therapy, people are told to start a fixed circadian rhythm, for 7 days a week. Every patient has a different fixed circadian rhythm, so it depends on their own preferences how their personal fixed rhythms looks like.

A further therapeutic step is to change and challenge dysfunctional beliefs. The hopeful thought of being able to be active despite being tired may help them to increase behaviour.

Another symptom that needs to be overcome is that they focus too much on bodily symptoms since it leads them focusing too much on their fatigue. Invention techniques might involve the big-toe experiment, where patients should distract their attention from the fatigue and focus more on the specific body part. It aims at showing the patient that when attention is giving to specific body parts, their feelings of it grow. Thanks to this specific focus, patients may experience their fatigue less. Changing behaviour, however, is hard and takes time.

Graded activity program is another progress in therapy. The person should re-engage in certain activities in their daily lives, such as physical exercises, work or household duties. Already the perception of being more active makes people experience less fatigue. So it is about the beliefs they have.

The therapy than ends when the goals are achieved.

Chronic Fatigue and Chronic Pain

About 80 to 90 per cent of people with CFS experience pain symptoms, for which there is no medical explanation. These symptoms result in further impairments in daily functioning. Due to the fact that tiredness and pain are the main criteria for CFS, the question has been raised of whether there is an underlying mechanism both. Evidence shows that fatigue and pain seem to decrease simultaneously in therapy. These give raise of an underlying mechanism for both symptoms. The process variables (such as focusing on symptoms) that are responsible for fatigue and chronic pain do overlap, however not completely. We still need further research to address this issue.

Lecture 10

Forensic Psychiatric Center

In a forensic psychiatric center, people are treated who are mentally ill and committed a (violent) crime and who would not have high hopes of recovery without treatment. The first task of the clinic is to see whether there is a relationship between the mental illness and the criminal behaviour. Then, treating the mental illness and reintegrating the patient into society are the further aims.

Psychopathology in TBS

The type of mental illnesses of people who committed a crime most commonly include personality disorders, psychotic disorders, autistic spectrum disorders, and deviant sexual behaviour.

Personality Disorders are usually associated with deviations in early development and behaviour. During the course of life, the person with the personality disorder usually has problems of establishing or maintaining interpersonal relations and of monitoring their own thoughts and behaviours. They typically use maladaptive coping strategies by externalising their problems.

People with psychotic disorder, in contrast, are thought to be “out of touch with reality”. They typically have hallucinations and delusions, resulting in difficulties in daily functioning and interpersonal relations.

Autistic people usually also have difficulty in social and unexpected situations. They are hardly able to take the perspective of other people. Nevertheless, they are more sensitive to other, daily stimuli.

People with mental disorders sometimes show deviant sexual behaviour. This may the result of a sexual disorder such as pedofilia or a way of coping with other problems.

Therapies and Training

Various therapies are offered for mentally ill people who committed crimes. These include nonverbal therapy, psychotherapy, sexuological therapy as well as specific training such as learning how to manage aggression and emotions properly or how to deal with substance abuse. Furthermore, lifestyle choices such as sport and education are being considered. During the treatment, many different clinicians work together, such as therapists, social workers and nurses. Criminals who have a mental illness provide specific difficulties to treatment, since they usually do not have any motivation to be treated and they tend to lie and be aggressive. Therefore, special attention needs to be drawn to security management. Special safety measures - such as cameras, security guards and risk assessment - are required.

Source

These notes are based on the lectures of 2014/2015