Index

6.0 Somatic Symptom and Dissociative Disorder,  Basics. 1

6.1 Somatic Symptom Disorder. 1

6.2 Illness anxiety disorder. 1

6.4 Conversion Disorder ( Functional Neurological Symptom Disorder). 2

7.0 Factitious Disorder – Munchhausen´s syndrome. 2

8.0 Dissociative Disorders. 2

8.1 Dissociative Identity Disorder (Former: Multiple Personality Disorder). 3

8.2 Dissociative Amnesia. 3

8.3 Depersonalization/Derealization Disorder. 3

9.0 Controversies Around Dissociative Disorders. 3

6.0 Somatic Symptom and Dissociative Disorder,  Basics
 

                Somatic symptoms disorder: physiological symptoms that are caused by emotional pain
                                                                          - Shows mind/body fluidity
                                                                          - worry
                                                                          - no diagnosable physical symptoms (eg. Child only has stomach pain in morning)

                                pseydocyesis: Person thinks she is pregnant. (e.g. Anna O)

                                5 disorders in this cathegory:      1. Somatic symptom disorder
                                                                                                2. Illness anxiety disorder
                                                                                                3. Conversion disorder
                                                                                                4. Factirious disorder
                                                                                                5. Psychological factors affecting other medical conditions
                                                                                                     (former psychosomatic disorder)

                Dissociative disorders: develop multiple personality, or forgets important moments of life (loses consciousness)

6.1 Somatic Symptom Disorder

                Identification:    - 1 or more physical symptoms
                                                - excessive thinking or seeking treatment (even surgery) à persist even with contrary evidence
                                                - interfere with daily functioning à avoidance of activity, becomes defining personality trait
               

6.2 Illness anxiety disorder:   - are just afraid of developing a serious illness. Seek excessive treatment
                                                                   à spend their time with many doctors
                                                                - Worry about environmental causes for their illness. (pollution, food,)
                                                                - Experience anxiety and depression, substance abuse, mild physical symptoms
                                                                - physical symptoms mirror their emotional state
                                                                - Duration: Longterm
                                                                - Prognosis: More likely to develop obesity, high blood pressure, death
                                                                - Children: Report emotional distress as symptoms

                6.2.1 Theories of Somatic Symptom and Ilness Anxiety Disorder:

                                - Cognitive factors (catastrophizing, ruminative thinking, self-fullfilling prophecy, wrong interpretation,
                                                                      baseline bias, pay more attention to body)
                                                                     à presents symptoms differently à becomes more affection from family àreinforced
                                - Female more than men (female anxiety + depression; men substance abuse + asocial personality)
                                - Children: May model parents (only way to get attention)
                                - Common in PTSD patients

                6.2.2 Treatment

                                - They are treatment resistan
                                - Psychodynamic therapy: Uncover the traumatic event that triggered the symptoms
                                - Behavioral therapy: Focus on reinforcers + eliminating them
                                - Cognitive therapy: Focus on beliefs, reinterpret bodily symptoms (like in panic-disorder)
                                                                       stop catastrophizing
                                - CBT: Identify + challenge beliefs
                                - Drugs: Antidepressants
                                - Alternative therapy: Spiritual, cultural context healing

6.4 Conversion Disorder ( Functional Neurological Symptom Disorder)

- dramatic version of Somatic symptom disorder
- lose neurological functioning in parts of body
- symptoms: Paralysis, blindness, mutism, seizures, loss of hearing, coordination, anesthesia in a limb.
                         à Glove anesthesia
- very rare

                6.4.1 Theories of Conversion disorder

                                - Emotional symptoms converted into physical symptoms
                                - Freud: primary gain – relief from anxiety
                                                 secondary gain – relief from duties, cause family reinforces passivity
                                - la belle indifference: being unconcerned with heavy somatic symptoms like blindness
                                - highly suggestible/hypnotizable à conversion caused by spontaneous self-hypnosis
                                - Children: Can develop it as consequence of relative being sick (symptom mimics relatives´ symptoms)
                                - Neurological model: Sensory motor areas in brain are impaired by malfunctioning connections to
                                                                           anxiety areas. à anterior cingulate

                6.4.1 Treatment of Conversion Disorder

- Difficult to treat because they do not believe something is wrong
- Psychoanalytic: Gain access to unexpressed pain, emotions
- Behavioural: reduce secondary benefits from conversion
                           - Systematic desensitization and exposure therapy

7.0 Factitious Disorder – Munchhausen´s syndrome

• Person pretends to be sick in order to gain medical attention
• Differs from Somatic symptom disorder because evidence that person is faking is given
• Differs from malingering because they want to gain attention, whereas malingering tries to avoid a negative stimulus (military service) and or gain a positive one (insurances money)

Factitious disorder imposed on another:

Parents fake illness of child to gain attention or something else.

8.0 Dissociative Disorders

Dissociation: Process in which mental experiences are split of from consciousness but remain accessible through dreams and hypnosis

Hidden observer: Consciousness has active and passive mode. Passive seems to be active all the time, no matter if the person is conscious or not.  (mushroom experience)

• People with this disorder have problems to integrate both aspects of consciousness simultaneously

8.1 Dissociative Identity Disorder (Former: Multiple Personality Disorder)

                                - People with this Disorder develop personalities that differ in their expression, age, speech, attitudes

                                - Different personalities = alters,  perform different functions that host personality is unable to perform.

                                                à Persecutor personality: Tries to punish host

• Helper personality: Helpers try to help the person by doing the tasks the person cant.

- Amnesia if other personality is active

- Hear voices inside head

- Women more prone

- High suicide attempt rate

- Children: Emotion-regulation problems, antisocial behaviour, flashbacks to traumas

- Comorbidity high: PTSD, MDD, Substance Abuse, Anxiety Disorder.
- Cultural difficulty to diagnose (evil spirits)

                                Treatment:
                                - Goal is integration of all personalities into one coherent personality and to rebuilt trust in relationships

• Helping each personality to cope with the trauma that led to its formation.

- Hypnosis

- Indigenous healers for possession form DID

            8.2 Dissociative Amnesia

                                - Amnesia without separate personalities.

                                Organic amnesia: By brain injury, drugs, surgery (detectable through neuroimaging)

                                                Often Anterograde amnesia: inability to form new memories     

                                Psychogenic amnesia: Psychological causes, trauma. Rarerly involves anterograde amnesia

More likely Retrograde amnesia: inability to remember past information
à when cause is organic, forget personal- (identity) and general information (semantic)

à when cause is psychogenic, forget only personal information

Problem: Could be faked (to avoid crime and other problems)

Korsakoff´s syndrome: Retrograde amnesia for several years due to substance abuse.

                                Dissociative fugue:  Individual travels to a new place and takes on a new identity without memory of his

                                                                        Previous one.

            8.3 Depersonalization/Derealization Disorder

                                - Frequent episodes of feeling detached from the current moment or mental processes, as if being an

                                   Observer.

                                - Common in everyone when: Sleep deprived, on drugs,

                                - Only diagnosed if symptoms are distressing and dysfunctional

                                à age of onset 23

                                - Comrbid: Depression

                                - History of abuse

9.0 Controversies Around Dissociative Disorders

                - Some claim that abuse-memories are artificially created (memory formation through suggestion)

                - Methods of studies have been criticised by nonbelievers in amnesia.

                - People high in measurements of dissociation are really less likely to remember emotional information

                à Mind-Body Problem
                                à Somatic disorder shows that mind and body are complexly interwoven.

Mood Disorders and Suicide

Characteristics of Depressive Disorders. 1

·       Symptoms: 1

·       Diagnosis: 2

·       Prevalence and course: 3

Theory of Depression. 3

·       Biological Theories: 3

·       Neurotransmitter Theories: 3

·       Structural and Functional Brain Abnormalities: 4

·       Neuroendocrine Factors: 4

Psychological Theories of Depression. 4

·       Behavioural Theory: 4

·       Cognitive Theory: 5

·       Interpersonal Theory: 5

·       Sociocultural theories: 5

Characteristics of Bipolar Disorder. 5

·       Symptoms Mania. 6

·       Diagnosis: 6

5.0 Theories of Bipolar Disorder. 7

5.1 Biological theories. 7

5.2 Psychosocial Theories: 7

6.0 Treatment of Mood Disorders. 7

6.0.1 General Infos about Treatment. 7

6.1 Biological Treatments: 7

6.2 Psychological Treatments for Mood Disorder. 9

7.0 Suicide. 10

7.1 Defining and measuring suicide. 10

7.2 Understanding Suicide. 10

7.3 Treatment and Prevention. 11

Characteristics of Depressive Disorders

• Symptoms:
  - Depressed mood out of proportion to a cause
  - Anhedonia: Loss of interest in life
  - Appetite changes (bidirectional)
  - Sleep disruption (bidirectional)
  - Psychomotor disruption. Agitation or Retardation
  - Negative thoughts, selfbeliefs / mind all over the place
  - (Delusions / Hallucinations)

• Diagnosis:

  Major depressive disorder:
  - Depressed mood or loss of interest in own life
  + 4+ severe symptoms chronically for 2 weeks or more
  + symptoms must interfere with the ability to function in everyday life

                  - single episode: one depressive episode
                  - recurrent episode: 2+ episodes separated by 2 months straight without same symptoms

                  - complicated grief: cannot let go of deceased. Poor functioning for 2-3 years.

Persistent depressive disorder: (dysthymic disorder, chronic MDD)
- Depressed the whole day most of days for min. 2 years (1 year for children)
- 2+ of symptoms: a. poor appetite
                                     b. insomnia/hypersomnia
                                     c. low energy or fatigue
                                     d. low self-esteem    
                                     e. poor concentration
                                     f. hopelessness
- must not be without these symptoms for more than 2 months straight.

à high risk for comorbid disorder, 70%,  eg (anxiety, panic, substance abuse)
                                               
Subtypes of depression:

Seasonal affective disorder SAD:
- 2 years on off MDD. Full recovery in between MDD periods
- Depressed when daylight hours become shorter, winter.
- Mood changes cannot be result of psychosocial event

Premenstrual dysphoric disorder:
- Mixture of depression, anxiety, tension, irritability, anger + physical symptoms (swelling, bloating,
   muscle, joint pain, tenderness of breasts)
- Start from 1 week before to 1 week after
- only 2% of women

• Prevalence and course:

  - 16% Americans once in a life MDD
  - 3% in Japan
  - 18-29 year olds most likely to have had MDD in the past year
  - Lowest rate from 65-85, than rise at 85.
  à Reasons: Less willing to report, nonsupportive society
                          Occur in contect of medical condition
                          Confused between cognitive disfunction
  à Alternative Explanation: People with story of MDD are more likely to die
                                                        Develop more adaptive coping skills
                                                        Historical change to vulnerability to depression
  - Children: 2.5% mdd, 1,7% persistent dd,
  - 24% will experience episode of mdd before 20years.
  - Women are .5 times more likely to develop depression.
  - Children show different symptoms: irritation instead of sadness, failure to gain expected weight.
  - MDD Patients suffer avg. of 4 months per year with severe symptoms / 1 month lost work capacity
  - 75% relapse rate after one episode of mdd
  à reasons to not seek treatment: lack of insurance
                                                                      expect the symptoms to go away by their own

Theory of Depression
 

• Biological Theories:
  Genetics:
  - First degree relatives 2-3x more likely to develop mdd
  - Early life = stronger genetic basis
  - Serotonin transporter gene damage + negative life events
   
• Neurotransmitter Theories:
  - Monoamines: Norepinephrine, serotonin, dopamine
  à in limbic system (regulation sleep, appetite, emotions)

  

•  
  

  Structural and Functional Brain Abnormalities:
  - Prefrontal cortex:
  - Attention, working memory, planning, problem solving
  - Reduced gray matter + lower brain-wave activity (left side)
  à left side: goal orientation, motivation

  - Anterior cingulate:
  - Response to stress, emotional expression, social behaviour
  à alterarion in depression cause for anhedonia
       + planning of appropriate responses and attention

  - Hippocampus:
  - Memory, fear related learning
  - Reduced volume and metabolic activity
  - Damage can be result of chronic arousal of stress response (cortisol) (treatment: Antidepressants, ECT)

  - Amygdala:
  - Attention to emotionally salient stimuli
  - Depression enlarges, increased activity
  à focus on aversive, arousing information à lead rumination of negative memories and environment

•  Neuroendocrine Factors:
  - Regulates hormones à thus regulates: sleep, appetite, sex drive, ability to experience pleasure
  - Hypothalamic-pituitary-adrenal axis HPA:
                  - fight or flight reaction
                 
                 

Psychological Theories of Depression

• Behavioural Theory:
  - Life stress reduces positive reinforcers à self-perpetuating chain à anhedonia
  à affect interrelated biological pathways (neuroendocrine system) and reward processing (dopamine sys.)

  Learned helplessness theory:
  - Stressful events (frequent) lead to belief of uncontrollability à helpless à lose motivation to act
  à indecisiveness

• Cognitive Theory:
  - bias toward negative thoughts and memories
  - find it hard to disengage attention from negative stimuli
  - overgeneralized memory

  Negative cognitive triad:
  - People have negative view of themselves, the world, future. à leads to bias in thinking à perpetuation

  Reformulated learned helplessness theory:
  - Focus on causal attributions people make: internal, stable, global
  à I was reason, because I am genetically like this, and this will determine every aspect of my life

  Hopelessness depression:
  - Pessimistic attributions for most important events in their lives à good predictor of depression +relapse
  - Perceive no way to cope with life and consequences

  Ruminative response style theory:
  - Focus on PROCESS of thinking, not content.
  - People do not try to think in a direction, rather stagnate on their current depression, they ruminate
  à is linked to genetical, neural and physiological approaches

• Interpersonal Theory:
  - Social and relationship factors as trigger of depression
  - Also conflict in relationships is more likely in people with depression (deficits in social and communication
     skills) + result of negative thinking pattern, history of maltreatment, genetic vulnerability.
  - Are highly insecure in relationships and have rejection sensitivity: perceive rejection easily. Highly
    dependent on affirmation. They never believe it when someone tells them they are a beautiful person.
  - Early childhood treatment affects behavioural and cognitive coping patterns in children

• Sociocultural theories:
  Cohort effects:
  - Historical changes increase or reduce vulnerability of pop. to depression
  - Depression rate rose 50% from 1915 compared to 1955 (disintegration of family, expectations ect)

  Gender differences:
  - Women 2x more likely than men to develop depression. à cultural, biological causes
  - Women ruminate more, report symptoms more, base self-worth on healthy relationships (good)
  - Men more likely to substance abuse

  à differences in coping due to social norms, gender socialization

Ethnicity/Race Differences:
- Subgroups under more stress, poverty, discrimination à higher rate of depression

Characteristics of Bipolar Disorder

• Symptoms Mania

  - Mood elation
  - grandiose self-esteem (inflated), sometimes delusions
  - Racing thoughts and impulses (sex, buying)
  - Rapid / forceful speech
  - Agitated and irritable
  - (seasonal aspect 25%)

  Children: - Temper tantrums and rages
                     - irritability, rapid mood switches
  - Difficult to distinguish ADHD, mania, risky behaviour.
  à age 6+ can be diagnosed with

  Disruptive mood disorder:
  - severe temper outbursts grossly out of proportion (verbal, physical rage)
  - outbursts occur 3x per week over 12 months in at least 2 or more different settings
  - intensity and duration is inconsistent with developmental level.

   

• Diagnosis:

  Bipolar I disorder:
  - Manic episodes + above symptoms
  - Fall into depression afterwards is very likely
                  - mixed episodes: full criteria manic episode + min. 3 symptoms of mdd in the same day for 1 week

- 90% have more than one episode in their life

Bipolar II disorder:
- Mania episodes are milder, but shows mdd symptoms
                hypomania: symptoms do not interfere with daily functioning, no delusions/hallus., min 4 days in a                                       row

Cyclothymic disorder:
- Chronic shift between hypomanic symptoms and depressive symptoms over min. 2 years
à symptoms are not sever enough to be cathegorized for real hypomania or mdd
- not really impaired functioning
- Increased risk of developing Bipolar I

Rapid cycling bipolar disorder:
- 4+ episodes that meet criteria for manic, hypomanic, mdd within 1 year

5.0 Theories of Bipolar Disorder

            5.1 Biological theories

• Genetic Factors:
  - strongly related to genetics
  - first degree relatives 1-10x higher risk
  - identical twins: 45-75%

• Structural and Functional Brain abnormalities:
  - Dysfunction and structure in amygdala (processing of emotions)
  - Prefrontal cortex (control of emotion, planning ect)
  - Striatum (Part of Basal Ganglia) (responsible for reward processing of environmental cues)
    à more activated = more sensitive.
  - Circuit from Prefrontal cortex through striatum to amygdala is dysfunctional. (rigid response to
    rewards) à excessive reward seeking or disinterest
  - Abnormalities in white matter (connector between brain areas) à loss of control of behaviour
  !!!! Not Hippocampus, like in depression !!!!

• Neurotransmitter:
  - Monoamine neurotransmitters (Norepinephrin, Serotonin, Dopamine)
  à Dysregulation in dopamine à high levels of dopamine = reward seeking

5.2 Psychosocial Theories:

- Great sensitivity in reward seeking heightens relapse in reward-dense areas (casinos)
- Environments of punishment (military), can lead to relapses (although no one get into military with bip.d.)
- Highly stressful events (precipitating) or stressful families can trigger a relapse
- Change in bodily rhythms or routines (sleep, eating, social climate) à rhythm therapy

6.0 Treatment of Mood Disorders

            6.0.1 General Infos about Treatment

                                - Almost equally effective
                                - slight difference from best to worst: behavioural, cognitive, (drugs = 50% success)
                                - Joint therapy is best = 85% success
                                - Relapse is less likely with psychotherapy and not just drugs, and maintenance therapy (1x per month)

6.1 Biological Treatments:
 

• Drug Treatment:
  - SSRI
  - SNRI
  - Tricyclic antidepressants
  - Monoamine oxidase inhibitors              
  à slow emerging effects (weeks) (not directly effective), activate genes (epigenetic) à
       neurotransmitter regulation and stress response
  à effective in 50-60% of people (work better for severe depression)
  à Discontinuation during first 6-9 months = 2x risk of relapse

  Selective Serotonin Reuptake Inhibitors, SSRI´s:
  - few sideeffects (5-10% discontinue)à gastrointestinal effects, tremor, nervousness, insomnia,
    sleepiness, low sex-drive, no orgasm, evtl. Manic symptoms
  - saver in overdose
  - lead to small increase in suicidal thoughts in children and the opposite in elderly persons

  Selective Serotonin-Norepinephrine Reuptake Inhibitors, SNRI´s:
  - slight advantage in preventing relapse to SSRI´s

  Bupropion: Norepinephrine-Dopamine Reuptake inhibitor:
  - very useful for “negative symptoms” (psychomotor retardation, anhedonia, hypersomnia,
                                                                              cognitive slowing, inattention and cravings (cigarettes)

  Tricyclic antidepressants:
  - oldtimer
  - side effects + fatal in overdose (anticholinergic effects: against neurotransmitter acetylcholing)
                                                                    drop in blood pressure, cardiac arrhythmia)
  - not for suicidal people

  Monoamine oxidase Inhibitors:
  - oldtimer
  - Monoamine oxidase = enzyme that prevents breakdown of monoamine neurotr. In the synapse
  - dangerous side-effects: rise of blood pressure with some foods (old cheese, wine, beer) +
                                                     interact with over the counter drugs, liver dmg, weight gain, lowering of
                                                     blood pressure, same like tricyclic antidepressants
   

• 6.1.2 Mood stabilizers:
  Lithium: - improves abnormal intracellular processes à prevent relapse, lower suicide risk

                    - difficult to dose, must be monitored
                    - side- effects: abdominal pain, nausea, vomiting, diarrrhea, tremors, twitches, blurred vision
                                                  concentration problems, diabetes, hypothyroidism, kidney dysfunction,
                                                  birth defects
                    - 55% resistance after 3 years

Anticonvulsants and Atypical Antipsychotic Drugs:

                - Antiepileptic drug carmazepine: - side- effects: blurred vision, fatigue, vertigo, dizziness, rash
                                                                                                                  nausea, liver disease, birth defects

                - Atypical antipsychotics: (see chapter 7)
                                                                   - reduce dopamine levels
                                                                   - used to quell manic symptoms

• 6.1.3 Electroconvulsive Therapy: (see chapter 2)
  - good against depression, but high relapse rate

•  
  

  6.1.4 Brain Stimulation
  - rTMS: repetitive transcranial magnetic stimulation
  - VNS: Vagus nerve stimulation
  - deep brain stimulation
                 

• 6.1.5 Light Therapy:
  - against SAD (60% effective)
  - reset circadian rhythms à normalize hormone and neurotransmitter function
  - decrease hormone melatonin: reduces norepinephrine and serotonin

6.2 Psychological Treatments for Mood Disorder

• 6.2.1 Behavioural Therapy
  - Focus:- Increasing positive reinforcement /reduction of aversive stimuli
                  - Change of interaction with environment
                  - 12 weeks
                                  1. Analysis: Identification of connections between symptoms and circumstances
                                  2. Skills: Control environment, social skills, relaxation techniques

• 6.2.2 Cognitive-Behavioural Therapy
  - Focus: - Change negative belief-patterns
                  - Solve current problems (specific problems)
                  - Clients must set goals and make decisions ≠ behavioural therapy
                  - Develop skills
                  - 6-12 weeks
                                  1. Discover negative + automatic thoughts (homework)
                                  2. Challenge thoughts
                                  3. Recognize deep beliefs that fuel depression
                                  4. Teach skills

• 6.2.3 Interpersonal Therapy:
  - 4 Types of problems:
                  1. Loss of loved one à face it and go on
                  2. Interpersonal role disputes à define roles in a relationship
                  3. Role transmission à Seeing new roles in a positive way
                  4. Deficit in interpersonal skill à teach skills (assertiveness)
  - For Bipolar: Help to organize routine and maintain daily rhythms and social relationships

• 6.2.4 Family Focused Therapy:
  - To reduce interpersonal stress
                  1. Education of family about disorder
                  2. Train family in communication and problem-solving skills

7.0 Suicide

            7.1 Defining and measuring suicide
               
                Suicide: death from injury, poison, suffocation that is self-inflicted
                                 and intentional
                                - falls along continuum. Difficult to detect
                                - stigmatized

                                completed suicide: dead
                                attempts: does not end in death
                                suicidal ideation: thoughts or plans

                Gender difference: - 2x times more women attempt suicide, but men 4x times more likely to succeed.
                                                     - poisson (women) vs firearms (men)

                Ethical difference: - Minorities more affected (cause: discrimination, lack of education, poverty)
                                                      - Religious stigma may help prevent suicide
                                                      - Homosexuals are 2-6x more likely
                                                      - Hispanic girls very high (cause: cultural difference in social situations, family vs school)

                Suicide in Children and Adolescents: - high rate in teenagers (cause: psychopathology increases in this age)
                                                                                         - rate doubled from 1950 to 1990 (cause: substance abuse), then decline

                Suicide in Older People: - high risk above 85 (cause: loss of relative, escape illness, burden to others
                                                                                                                        ,cognitive impairment à impulsiveness)

                Nonsuicidal Self-injury, NSSI: - 13-45% do it one point in their life
                                                                           - Predictor for future suicidality
                                                                           - Prevalent in mood disorders, borderline
                                                                           - Reduce distress /regulate emotions / release tension
                                                                           - Draw sympathy or punish others
                               

            7.2 Understanding Suicide

• • 7.2.1 Historical Perspective:
    - Freud: Expression of anger against themselves. Try to eradicate the person that accepts maltreatment
                     Punish persons that maltreat them
    - Durkheim: Mindset of societal conditions.
                            3 types of suicide:

                                    Egoistic suicide: Feel alienated from others, alone in unsupportive world
                                    Anomic suicide: Disorientation after change in relationship to society. Confusion or role
                                    Altruistic suicide: Suicide with belief that it will benefit society
                    à continuum, hard to define

• • 7.2.2 Psychological Disorder and Suicide:
    - 90% of suicide people meet criteria for disorder
    - depression and bipolar increase it 7x
    - 1 of 5 people attempt suicide with bipolar I / II
    - past suicidal thoughts predict future suicidality

• • 7.2.3 Stressful Life Events
    - Interpersonal violence, sexual abuse (increase 2-4x women, 4-11x men)
    - Loss of loved person (no future perspective)
    - Economic hardships
    - Physical illness early in life (epilepsy)

• • 7.2.3 Suicide contagion

    suicide cluster: People that relate to person in space and time that killed itself commit suicide.
                                   
    suicide contagion: Cause of suicide clusters
                                         à suicide became more acceptable (lower inhibition)
                                         à modelling of behaviour
                                          à media attention as incentive

• • 7.2.3 Biological Factors:
    - genetical (increase likelihood if family-member was suicidal)
    - Neurotransmitter dysregulation (serotonin)

• • 7.2.4 Cognitive Factors:
    - Impulsive personality trait (evtl. Overlaid by disorder)
    - Hopelessness: Negative prediction / belief of future, no way to change it (stable)

7.3 Treatment and Prevention

• 7.3.1 Treatment:
  - Involuntary hospitalization
    à lithium treatment, SSRI´s,
  - community based crisis intervention programms
     à Suicide hotlines, walk-in clinics, suicide prevention centers
  - Dialectical behaviour therapy
    à Focus on managing lower spectrum emotions, controlling impulses, social skills

• 7.3.2 Suicide Prevention:
  - Educate communities about suicide à effect is ambiguous
  - Screening for high-risk individuals
  - Gun regulation laws (50% mean of suicide in US) à not related to disorders
     à no immediate availability = cooldown period for impulses
   

Chapter Integration, Depression