Summaries for Clinical Psychology Interim 1 - UvA

What is the historical overview of psychopathology? - Chapter 1

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

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

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

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

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

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

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

How is psychological disorder defined?

The best definition of psychological disorder has the following aspects:

• The individual has the disorder within himself.

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

• It often involves a kind of personal distress.

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

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

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

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

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

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

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

The DSM considers developmental, psychological and biological dysfunctions as interrelated.

What is the history of psychopathology?

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

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

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

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

Around 1817, the hospitals provided humane treatment, known as moral treatment. The people in the hospitals had close contact with their supervisors and talked a lot with them. They lived their life as close to normal as possible and took care of themselves most of the time. You can compare the moral treatment to mental hospitals nowadays.

What is the evolution of contemporary thought?

At first the biological approaches. Biological approaches gained credibility when a link was made between infection, damage to the brain and a form of psychopathology. This happened for the first time in 1905, when the microorganisms causing syphilis were discovered. Francis Galton was one of the first to ascribe many behavioral characteristics to heredity as a result of his studies with twins in the late 19th century. He talked about differences in nature (genetics) and nurture (environment). Some researchers became interested in the idea of heritability in psychological disorders and started studying it.

Cerletti and Bini introduced electroconvulsive therapy (ECT), which uses electric shocks in the head to induce seizures. Nowadays, it is used as treatment for schizophrenia and severe depression.

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

Freud was a younger colleague of Breuer. Freud theorized that psychopathology is caused by unconscious conflicts in the individual. This is often referred to as psychoanalytic theory. He divided the psyche into three main parts: id, ego and superego. The id wants immediate gratification of its basic urges. Also known as the pleasure principle. Tension is produced when the urges of the id are not satisfied.

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

The superego can be seen as a person’s conscience. The superego develops throughout childhood. It incorporates the values of the parents to receive the pleasure of the parents’ approval and avoid the pain of disapproval. Freud and his daughter Anna see defence mechanisms as a strategy of the ego to protect itself from anxiety. There are several forms of defence mechanisms.

Psychoanalysis

Psychoanalysis is the psychotherapy based on Freud’s theory. The therapist’s goal is to understand the early-childhood experiences of the patient, the nature of important relationships, and the patterns in current relationships. The therapist pays attention to emotional and relational themes that surface again and again. A key aspect of psychoanalytic therapy is the analysis of transference. The responses of a patient to his analyst sometimes seem to reflect ways of behaving toward important people in the patient’s past. This is what transference is.

Jung was a Swiss psychiatrist who proposed that a part of the unconscious is common to all people. That part is called collective unconscious. Alfred Adler is known as the founder of individual psychology. An important part of his work was on helping people change their dysfunctional ideas and expectations.

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

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

2. Behavior is also influenced by unconscious processes.

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

Behaviorism

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

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

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

3. Modelling. Modelling is learning via watching and imitating others.

Behavior theory is based on the principles of classical and operant conditioning. In this kind of therapy, the clinicians try to change behavior, feelings and thoughts by the use of methods and discoveries made by experimental psychologists. A disadvantage of the behavioral approach is that there was no room for emotion and cognition.

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

What do mental health professionals do?

There are different kinds of mental health professionals: clinical psychologists (study of human behaviour), psychiatrists (medical degree), psychiatric nurses and social workers (focus on psychotherapy).

What are the current paradigms in psychopathology? - Chapter 2

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

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

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

What is the genetic paradigm?

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

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

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

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

1. Heritability estimates range from 0.0 to 1.0. The higher the number, the greater the heritability.

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

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

What are behavior genetics?

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

What are molecular genetics?

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

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

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

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

What are gene-environment interactions?

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

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

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

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

What is the neuroscience paradigm?

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

What are neurons and neurotransmitters?

Neurons are the cells in the nervous system. The nervous system consists of billions or neurons. A neuron has four parts:

1. A cell body.
2. Multiple dendrites.
3. One or more axons of different lengths.
4. Terminal buttons on the many end branches of the axon.

The synapse is a small gap between the cell membrane of the receiving neuron and the terminal endings of the sending axon. What is sent and received is a nerve impulse or signal. Neurotransmitters are chemicals that make the sending possible.

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

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

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

What is the structure and function of the human brain?

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

1. The frontal lobe.
2. The parietal lobe.
3. The temporal lobe.
4. The occipital lobe.

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

A few brain structures will be discussed briefly:

• The thalamus is a relay station for all sensory pathways except the olfactory.

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

• The cerebellum receives sensory nerves from the vestibular apparatus of the ear and from muscles, tendons and joints.

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

• The HPA axis is related to stress and cortisol (stress hormone). This is a slow process for regulating stress in our bodies. Stress has effect on the immune system. The immune system releases cytokines, which helps the HPA axis.

At some point, the synaptic connections become more specialized and therefore begin to eliminate. This is called pruning and causes stronger brain networks.

Most of the neuroscience related treatments contain medication. It does reduce the symptoms but does not treat the cause of the disorder.

What is the evaluation of the neuroscience paradigm?

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

What is the cognitive behavioral paradigm?

The idea that problem behavior is likely to continue if it is reinforced is one of the important influences from behaviorism. Generally, four possible consequences are seen as reinforcements of problematic behavior:

1. Getting attention.
2. Escaping from tasks.
3. Generating sensory feedback.
4. Gaining access to desirable things or situations.

Treatment can be tailored to change the consequence of the problem behavior when the source of reinforcement is known.

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

The term used to describe the different kinds of mental processes is cognition. The focus with cognitive science lies on how people structure their experiences, how they make sense of their experiences and how people relate their past experiences to current ones.

A schema is an organized network of already accumulated knowledge. Cognitive scientists see people as active interpreters of a situation and trying to fit new information into their existing schemas. Attention is a much studied mental process within cognitive science. These studies are important to psychopathology, because people with certain disorders often have problems with attention.

What is cognitive behavior therapy?

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

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

Which factors cut across the paradigms?

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

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

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

Secondly, the link between sociocultural factors and psychopathology. Various researchers have considered the role of gender in different disorders and concluded that some disorders affect the genders differently.

Other researchers conducted studies that show that poverty is a major influence on psychological disorders. Sociocultural factors are getting more and more attention in genetics and neuroscience.

What is interpersonal therapy?

The importance of different relationships in a person’s life and how problems in these relationships can cause psychological symptoms is emphasized in interpersonal therapy. In this therapy, four interpersonal problems are assessed to determine whether one or more might be causing symptoms: unresolved grief, role transitions, role disputes and interpersonal deficits.

Another important theory is the attachment theory by Bowlby. The attachment of the infant is important for the psychological health in their future. These relationships in a person's life are important in interpersonal therapy. This works for depression for example.

What is the diathesis-stress paradigm?

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

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

What do diagnosis and assessment include? - Chapter 3

Diagnosis and assessment are the first steps in psychopathology. A good diagnose is necessary for good clinical care and helps therapists and researchers to talk accurately with each other. For research on causes and treatments it is necessary to have diagnosis. Receiving a diagnose can evoke feelings of relief in the patient, mostly because it helps with understanding their own symptoms. Assessments are necessary to make a good diagnosis, and can give additional information about a patient beyond the diagnosis.

What are the cornerstones of diagnosis and assessment?

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

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

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

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

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

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

What is the DSM-5 and what are the changes in DSM-5?

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

The DSM-5 is based on symptoms instead of causes. There is not enough knowledge about the etiology to base the diagnoses on the causes of the disorders.

Culture affects the risk factors of psychological disorders. Some disorders are specific for a specific culture. The DSM-5 cautions to keep the culture of your client in mind. It also includes nine cultural specific disorders. Culture has become increasingly important over the past few years.

Some people criticized the number of possible diagnoses in the DSM. The latest edition contains more than 300 diagnoses. Some critics argue that some relatively common reactions to trauma should not be called a psychological disorder. There are too many small differences between diagnoses, which increases the likelihood of comorbidity. A lot of risk factors seem to trigger multiple disorders. The diagnoses therefore do not seem to differ in their etiology or treatment.

The risk factors that seem to trigger multiple disorders are combined in the Research Domain Criteria (RDoC).

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

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

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

A general discussion point is that a diagnosis can have a negative effect. You will always have to carry that diagnosis with you.

What is psychological assessment?

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

What are clinical interviews?

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

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

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

What are assessments of stress?

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

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

What are personality tests?

Personality tests are a commonly used psychological test. Self-report personality inventory is an example of such a test. In such an inventory, the individual is asked to fill out a self-report questionnaire indicating whether statements apply to him. The statements are about habitual tendencies. A well-known personality test is the Big Five Inventory-2. This measures vife domains and is more specific than the former Big Five.

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

What are intelligence tests?

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

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

• To help assess whether an individual has intellectual disability.

• To find out if a child is intellectual gifted.

• As part of neuropsychological testing.

Reliability of intelligence tests are high, and they have good criterion validity. Other factors besides IQ play an important role in how well a person will do in school. Examples of those factors are family and circumstances, motivation, expectations, performance anxiety and difficulty of the curriculum.

What is behavioral and cognitive assessment?

Assessments can also focus on behavioral and cognitive characteristics, like characteristics of the individual, the frequency and type of problematic behaviors, the consequences of the problem behaviors and elements of the environment that might contribute to symptoms.

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

What is neurobiological assessment?

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

The CT or CAT scan (computerized axial tomography) helps to see if there are structural brain abnormalities. The MRI (magnetic resonance imaging) can also be used to see the living brain. It produces images of much better quality than the CT scan. The fMRI (functional MRI) is a technique that can measure both brain structures and brain function, by taking MRI pictures extremely fast. Metabolic changes can be seen because of this fastness.

The PET scan (Positron emission tomography) is less precise as MRI or fMRI but useful for research to neurotransmitters. SPECT is less expensive than PET but works the same. You inject a radioisotope into the bloodstream. Nowadays, researchers want to investigate the connections between brain areas.

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

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

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

• Tactile Performance Test – Time.

• Tactile Performance Test – Memory.

• Speech Sounds Perception Test.

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

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

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

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

A measure that is created for one culture or ethnic group may not be as reliable and valid with a different cultural or ethnic group. This notion is referred to as cultural bias. Multiple factors can affect assessment, namely differences in language, differences in religious and spiritual beliefs, and presumed timidity of members of ethnic groups.

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

1. They should learn about basic issues in assessment.

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

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

What are mood disorders? - Chapter 5

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

What are the clinical descriptions and epidemiology of mood disorders?

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

What are depressive disorders?

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

What is major depressive disorder?

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

DSM-5 Criteria for Major Depressive Disorder are sad mood or loss of pleasure in usual activities. At least five symptoms (counting sad mood and loss of pleasure):

• Sleeping too much or too little.

• Psychomotor retardation or agitation.

• Weight loss or change in appetite.

• Loss of energy.

• Feelings of worthlessness or excessive guilt.

• Difficulty concentrating, thinking, or making decisions.

• Recurrent thoughts of death or suicide.

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

What is persistent depressive disorder?

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

DSM-5 Criteria for Persistent Depressive Disorder (dysthymia) are a depressed mood for most of the day more than half of the time for two years (or one year for children and adolescents). At least two of the following during that time:

• Poor appetite or overeating.

• Sleeping too much or too little.

• Low energy.

• Poor self-esteem.

• Trouble concentrating or making decisions.

• Feelings of hopelessness.

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

What are other DSM-5 depressive disorders?

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

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

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

Some people suffer from seasonal affective disorder, also called winter depression. Cultural factors like family cohesion and mental health stigma are also important for rates of depression. The age of onset for depression has decreased. Depression has consequences like suicide and is related to a high risk of other health problem and affects twice as many women as men.

What are bipolar disorders?

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

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

DSM-5 Criteria for Manic and Hypomanic Episodes: distinctly elevated or irritable mood. Abnormally increased activity or energy. At least three of the following are noticeably changed from baseline (four if mood is irritable):

• Increase in goal-directed activity or psychomotor agitation.

• Unusual talkativeness; rapid speech.

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

• Decreased need for sleep.

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

• Distractibility; attention easily diverted.

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

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

For a manic episode:

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

• Symptoms cause significant distress or functional impairment.

For a hypomanic episode:

• Symptoms last at least four days.

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

• No psychotic symptoms are present.

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

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

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

DSM-5 Criteria for Cyclothymic Disorder are for at least two years (or one year in children or adolescents) one should have:

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

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

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

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

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

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

What is the etiology of mood disorders?

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

What are the genetic factors?

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

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

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

A few neurotransmitters that have been studied a lot for their role in mood disorders are dopamine, serotinin and norepinephrine. Dopamine is important for the sensitivity of the reward system in the brain. Researchers belief that dopamine levels might be lowered in depression. For bipolar disorders, researchers belief that the dopamine receptors might be overly sensitive. Researchers belief that people vulnerable to depression may have less sensitive serotonin receptors. The same is believed for people with bipolar disorder.

How does the brain function?

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

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

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

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

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

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

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

What is the involvement of cortisol dysregulation?

The main stress hormone is cortisol. In times of stress, cortisol is released. This increases the activity of the immune system, so that the body can prepare for threats. The HPA axis may be overly active during MDD. Stress reactivity is important for depression. The levels of cortisol are often poorly regulated in people with depression, meaning the body is not functioning well in decreasing the levels of cortisol. If high levels of cortisol are present in the body for too long, it will harm the body.

Cortisol levels increase during waking, this is called the cortisol awakening response (CAR). A larger CAR is associated with a higher risk of MDD. It predicts the first episode.

The same is true for people with a bipolar disorder.

What are the social factors in depression?

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

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

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

What are the psychological factors in depression?

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

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

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

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

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

What are the social and psychological factors in bipolar disorder?

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

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

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

What is the treatment for mood disorders?

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

• Interpersonal psychotherapy (IPT).

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

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

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

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

What is the psychological treatment of bipolar disorder?

Medication, psychoeducational approaches, cognitive therapy and family-focused therapy are necessary and/or very helpful in the treatment of bipolar disorder.

What is the biological treatment of mood disorders?

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

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

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

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

What is suicide?

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

What is the epidemiology of suicide and suicide attempts?

Studies suggest the following:

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

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

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

• Suicide attempts that do not result in death are more likely among women than among men. This probably due to the use of less lethal methods among women. Men are most likely to use a gun or hang themselves, women are more likely to use pills.

• Rates of suicide are higher in old age.

• More and more children and adolescents commit suicide.

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

What are the risk factors for suicide?

Suicide is a very complex and multifaceted behavior. About 50 percent of the people attempting suicide is depressed and about 90 percent of the people attempting suicide has some form of psychological disorder. If a disorder comorbids with depression within an individual, suicide is most likely. The heritability for suicide attempts is about 48 percent.

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

People can have many different reasons to choose suicide as to induce guilt in others, to get love from others, making amends for wrongs, to get rid of unacceptable feelings, to escape emotional pain, or to rejoice a deceased loved one.

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

How can we try to prevent suicide?

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

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

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

What are anxiety disorders? - Chapter 6

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

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

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

What are the clinical descriptions of the anxiety disorders?

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

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

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

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

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

What are specific phobias?

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

DSM-5 Criteria for Specific Phobia are:

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

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

What is social anxiety disorder?

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

DSM-5 Criteria for Social Anxiety Disorder are:

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

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

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

What is panic disorder?

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

DSM-5 Criteria for Panic Disorder are:

• Recurrent unexpected panic attacks.

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

What is agoraphobia?

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

DSM-5 Criteria for Agoraphobia are:

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

• These situations consistently provoke fear or anxiety.

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

What is generalized anxiety disorder?

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

DSM-5 Criteria for Generalized Anxiety Disorder are:

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

• The person finds it hard to control the worry.

• The anxiety and worry are associated with at least three (or one in children) of the following: restlessness or feeling keyed up or on edge, easily fatigues, difficulty concentrating or mind going blank, irritability, muscle tension and/or sleep disturbance.

What comorbids with anxiety disorders?

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

What are gender and cultural factors in the anxiety disorders?

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

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

• Social factors, such as gender roles.

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

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

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

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

What are common risk factors across the anxiety disorders?

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

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

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

Classical conditioning can occur in different ways, namely: direct experience, modeling, and/or verbal instruction. Research shows that people with an anxiety disorder acquire fears more easily than people without the disorder and those fears go slower extinct. A heritability of 50-60 percent is suggested for anxiety disorders.

What are the neurobiological factors?

The fear circuit is a set of brain structures that is activated when people feel anxious of fearful. Some structures in the fear circuit are linked to anxiety disorders: Structures in the fear circuit that are linked to anxiety disorders are the amygdala, media prefrontal cortex and hippocampus. The amygdala is involved in assigning emotional significance to stimuli. The medial prefrontal cortex helps regulating the activity of the amygdala.

What are the personality factors?

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

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

What are the cognitive factors?

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

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

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

People who find it hard to accept uncertainty are more likely to develop an anxiety disorder. They think the future is too ambiguous.

What is the etiology of specific anxiety disorders?

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

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

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

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

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

• People with this disorder pay more attention then others to how they are doing in social situations and pay more attention to their internal sensations. This focus on the self might interfere with the ability to perform well in social contacts.

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

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

What is the etiology of panic disorder?

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

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

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

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

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

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

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

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

• People with GAD might be avoiding emotions.

• They have a kind of intolerance to uncertainty.

What are the treatments of the anxiety disorders?

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

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

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

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

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

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

What are psychological treatments of specific anxiety disorders?

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

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

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

Exposure therapy in agoraphobia is often done with a graded hierarchy. Exposure therapy in generalized anxiety disorder is often combined with CBT and relaxation training. This seems to be more effective than other therapies.

What medications reduce anxiety?

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

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

In this chapter, obsessive-compulsive-related disorders and trauma-related disorders will be examined. It seems that those patients often report anxiety.

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

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

Obsessive-compulsive disorder is defined by repetitive thoughts and obsessions (urges), and repetitive behaviors or mental acts (compulsions). They cannot control them. The symptoms of repetitive thoughts and behaviors are shared with the other two disorders. These symptoms are for people with any of these three disorders distressing, they feel uncontrollable and take a lot of time. The disorders often co-occur.

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

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

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

DSM-5 Criteria for Obsessive-Compulsive Disorder are:

• Obsessions or compulsions.

• Obsessions are defined by recurrent, intrusive, persistent, unwanted thoughts, urges, or images. The person tries to ignore, suppress, or neutralize the thoughts, urges or images.

• Compulsions are defined by repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a dreaded event. The person feels driven to perform the repetitive behaviors or thoughts in response to obsessions or according to rigid rules. The acts are excessive or unlikely to prevent the dreaded situation.

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

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

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

DSM-5 Criteria for Body Dysmorphic Disorder are:

• Preoccupation with one or more perceived defects in appearance.

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

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

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

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

DSM-5 Criteria for Hoarding Disorder are:

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

• Perceived need to save items.

• Distress associated with discarding.

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

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

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

Genes play a moderate role in these three disorders. Some of the same brain regions seem to be involved in the three disorders:

1. The orbitofrontal cortex.
2. The caudate nucleus.
3. The anterior cingulate.

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

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

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

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

• Poor organizational skills: they have problems with attention and they have difficulty with categorizing their objects and making decisions about them.

• Unusual beliefs about possessions: they often have an extreme emotional attachment to their objects.

• Avoidance behaviors.

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

The most often used medication for these disorders is antidepressants.

Exposure and response prevention (ERP) are the most often used form of psychological treatment in this kind of disorders. The response prevention component of ERP is often used in treating OCD, because people with this disorder believe that their compulsive behavior will prevent terrible things from happening. In this kind of treatment, patients find themselves in situations that elicit their compulsive behaviors and have to refrain from performing those kinds of behaviors. The thought behind this is that the person will feel the full force of the anxiety, because they are not performing their compulsive behaviors, and the anxiety will become less because of exposure.

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

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

Deep brain stimulation is a treatment in development for OCD. In this treatment, electrodes are implanted into the basal ganglia. A lot of people show positive effects after deep brain stimulation.

What is the clinical description and epidemiology posttraumatic stress disorder and what is acute stress disorder?

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

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

• Reexperiencing the traumatic event in an intrusively version.

• Stimuli linked to the event are avoided.

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

• Symptoms of arousal and reactivity are increased.

Sometimes the symptoms develop years after the traumatic event.

DSM-5 Criteria for Posttraumatic Stress Disorder are:

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

• At least 1 of the following intrusion symptoms: (1) Recurrent, involuntary, and intrusive distressing memories of the trauma, or, in children, repetitive play regarding the trauma themes; (2) Recurrent distressing dreams related to the event(s); (3) Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the trauma(s) were recurring, or in children, re-enactment of trauma during play.

• At least 1 of the following avoidance symptoms: (1) Avoids internal reminders of the trauma(s); (2) Avoids external reminders of the trauma(s).

• At least 2 of the following negative alterations in cognition and mood began after the event: (1) Inability to remember an important aspect of the trauma(s); (2) Persistent and exaggerated negative beliefs or expectations about one’s self, others or the world; (3) Persistently negative emotional state, or in children younger than 7, more frequent negative emotions; (4) Markedly diminished interest or participation in significant activities; (5) Feeling of detachment or estrangement from others, or in children younger than 7, social withdrawal; (5)Persistent inability to experience positive emotions.

• At least 2 of the following changes in arousal and reactivity: (1) Irritable or aggressive behavior; (2) Reckless or self-destructive behavior; (3) Hypervigilance; (4) Exaggerated startle response; (5) Problems with concentration; (6) Sleep disturbance.

• The symptoms started or worsened after the trauma and continue for at least one month.

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

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

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

What is the etiology of posttraumatic stress disorder?

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

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

The function of the hippocampus seems to be uniquely linked to PTSD. These people experience more activation of the hippocampus during cognitive tasks. This can contribute to psychological vulnerability. People with PTSD avoid thinking about the trauma (dissociation). This is a coping strategy.

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

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

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

• Reminders of the traumatic event.

• Imaginal exposure.

• Exposure via virtual reality technology.

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

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

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

What are dissociative disorders?

What is a depersonalization/derealization (dissociative) disorder?

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

DSM-5 Criteria for Depersonalization/Derealization Disorder are:

• Depersonalization or derealization. Depersonalization include experiences of detachment from one’s mental processes or body, as if one is in a dream. Derealization includes experiences of unreality of surrounding.

• Symptoms are persistent or recurrent.

• Reality testing remains intact.

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

What is dissociative amnesia?

DSM-5 Criteria for Dissociative Amnesia are:

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

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

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

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

What is dissociative identity disorder (DID)?

DSM-5 Criteria for Dissociative Identity Disorder are:

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

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

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

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

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

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

What is the etiology of DID?

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

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

What treatment is used for DID?

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

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

What are somatic symptom and related disorders?

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

There are several reasons to criticize the criteria for diagnosis:

• The conditions are particularly varied.

• The criteria are too subjective.

• Patients often think the diagnosis stigmatizes too much.

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

What is the clinical description of somatic symptom disorder?

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

DSM-5 Criteria for Somatic Symptom Disorder are:

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

• Excessive thought, distress, and behavior related to somatic symptom(s) or health concerns, as indicated by at least one of the following: (1) health-related anxiety; (2) disproportionate and persistent concerns about the seriousness of symptoms; (3) excessive time and energy devoted to health concerns; (4) duration of at least 6 months.

• Specify if predominant pain.

What is the clinical description of illness anxiety disorder?

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

DSM-5 Criteria for Illness Anxiety Disorder are:

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

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

• No more than mild somatic symptoms are present.

• Not explained by other psychological disorders.

• Preoccupation lasts at least 6 months.

What is the clinical description of conversion disorder?

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

DSM-5 Criteria for Conversion Disorder are :

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

• The symptoms are incompatible with recognized medical disorder.

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

DSM-5 Criteria for Factitious Disorder are:

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

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

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

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

What is the etiology of somatic symptom-related disorders?

Heritability seems not to be a factor in these disorders. Finding the reason why some people are more aware of and distressed by somatic symptoms is the key issue in understanding somatic symptom disorders. The focus lies on brain regions that are activated by unpleasant body sensations in neurobiological models of somatic symptom-related disorders. Heightened activity in the anterior insula, anterior cingulate cortex and somatosensory cortex is linked to greater propensity for somatic symptoms. Pain and somatic symptoms can be increased by anxiety, depression and stress hormones.

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

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

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

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

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

There are more possible reinforcers for somatic symptoms.

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

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

What is the treatment of somatic symptom and related disorders?

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

People first go to their general practitioners with their complaints about somatic symptoms. It is therefore important that general practitioners can tailor care for people with somatic symptom-related disorders. To help people with somatic symptom-related disorders, cognitive behavioral clinicians have applied different techniques:

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

• Change their cognition about their symptoms.

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

• Gaining more reinforcement for engaging in different social interactions.

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

When pain is the focus of somatic symptom disorder, multiple techniques can be helpful: cognitive behavioral techniques, meditation, hypnosis, acceptance and commitment therapy and antidepressants.

CBT can be helpful for the conversion disorder (without reinforcing the symptoms).