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218 Cards in this Set

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what is the leading cause of disability worldwide?
major depression (depression accounts for 10% of all disability)
the state of arousal defined by the subjective states of feeling (ex: sadness, anger, disgust)
pattern of observable behaviors (ex: facial expression, pitch of voice, body movements)
a pervasive and sustained emotional response that can color perception
can refer to a mood or to a clinical syndrome, a combo of emotion, cognitive & behavioral symptoms
clinical depression
depressed mood accompanied by other symptoms such as loss of energy, loss of pleasure, fatigue, changes in sleep & appetite
flip side of depression; disturbance of mood accompanied by euphoria, grandiosity, decreased need for sleep, pressured speech
2 broad types of mood disorders
1. involves only depressive symptoms
2. involves manic symptoms (bipolar disorders)
5 types of depressive disorders
1. major depressive disorder - single episode
2. major depressive disorder - recurrent episode
3. persistent depressive disorder - dysthymia
4. premenstrual dysphoric disorder
5. disruptive mood dysregulation disorder
**4 & 5 are new to dsm-5
3 types of bipolar disorders
1. bipolar 1 disorder
2. bipolar 2 disorder
3. cyclothymia
general emotional symptoms of mood disorders
-depressed or dysphoric mood
general cognitive symptoms of mood disorders
-slowed thinking
-guilt and worthlessness
-sped up thoughts
-suicidal thoughts
general somatic symptoms of mood disorders
-aches and pains
-changes in sleep & appetite
-loss of sexual desire
general behavior symptoms of mood disorders
-psychomotor retardation
-gregarious and energetic
criteria for MDD
-must have sad mood or loss of interest/pleasure (anhedonia)
-plus 4 of the following symptoms: sleeping too much/too little, psychomotor retardation/agitation, poor appetite & weight loss or increased appetite & weight gain, loss of energy, feelings of worthlessness or excess guilt, difficulty concentrating, thinking or making decisions, recurrent thoughts of death or suicide
-symptoms present nearly everyday most of the day for at least 2 weeks
-symptoms are distinct & more severe than a normative response to a significant loss
psychomotor retardation
slow thoughts & movements
psychomotor agitation
can't sit still; pace, fidget, & wring hands
single episode vs. recurrent episodic MDD
-single: symptoms tend to be present for a distinct period & then dissipate over time
-recurrent: once depression occurs, future episodes likely (avg # of episodes is 4)
subclinical depression
-sadness plus 3 other symptoms for 10 days
-significant impairments in functioning even though full diagnostic criteria aren't met
criteria for chronic/persistent depressive disorder (dysthymia)
-depressed mood for most of the day more than half the time for at least 3 yrs (1 yr for children/adolescents)
-plus 2 other symptoms during that time: poor appetite/overeating, sleeping too much or too little, poor self esteem, trouble concentrating or making decisions, feelings of hopelessness
-symptoms don't clear for more than 2 months at a time
premenstrual dysphoric disorder
-in most menstrual cycles during the past yr, at least 5 of the following symptoms from sec B & C were present in the final week before menses onset & became minimal in the week after menses
-at least one of the following: affective lability, irritability, depression mood, hopelessness or self-deprecating thoughts, anxiety
-at least one of the following: diminished interest in usual activities, difficulty concentrating, lack of energy, changes in appetite, overeating or food craving, sleeping too much/too little, subjective sense of being overwhelmed or out of control, physical symptoms such as breast tenderness or swelling, joint/muscle pain or bloating
what effects do the symptoms of premenstrual dysphoric disorder have on the individual?
-symptoms lead to significant distress or functional impairment
-symptoms aren't an exacerbation of another mood/anxiety disorder or personality disorder
-symptoms present w/prospective daily ratings over 2 cycles
-symptoms present when oral contraceptives aren't being taken
disruptive mood dysregulation disorder
-severe recurrent temper outbursts (verbal/behavioral expressions of temper that are out of proportion in intensity/duration to the provocation)
-temper outbursts inconsistent w/developmental level
-temper outburst occur at least 3x/week
-negative mood between temper outbursts most days
-symptoms have been present at least 12 months & don't clear for more than 3 months at a time
-temper outburst & negative mood are present in at least 2 settings (at home, school, w/peers) & are severe in at least 1 setting
-age 6 or older (or equivalent developmental level)
-onset before age 10
-there's never been a distinct period lasting more than 1 day during which elevated mood & at least 3 other manic symptoms were present
-behaviors don't occur exclusively during the course of MDD & aren't better accounted for by another mental disorder
-diagnosis can't coexist w/oppositional defiant disorder, ADD/hyperactivity disorder, intermittent explosive disorder, or bipolar disorder
depressive disorders course & outcome
-avg age of onset is 32
-length of episodes vary widely
-min duration=2 weeks
-remission: pd of recovery
-relapse: return of active symptoms
-approx. half of depressive patients recover in 6 months
frequency of depression
-depression is common
-lifetime prevalence: 16.2% MDD; 2.5% dysthymia
-3x as common among people in poverty
gender differences in depression
-women=2-3x more vulnerable to depression than men
-women more likely than men to present for mental health services
-more difficult for men to admit to subjective feelings of distress
-gender diff aren't typically observed for bipolar mood disorders
prevalence of MDD by culture
-prevalence varies across cultures
-1.5% in Taiwan
-19% in Beirut, Lebanon
-people who move to the U.S. from Mexico have lower rates than people of Mexican descent who were born in the U.S.
cross cultural differences
-each culture has its own ways of interpreting reality including expressing or communicating symptoms of physical & emotional disorder
-clinical depression is a universal phenomenon that's not limited to western/urban societies
symptom variation across cultures
-latino cultures: complaints of nerves & headaches
-Asian cultures: complaints of weakness, fatigue, & poor concentration
-small distance from equator (longer day length) & higher fish consumption assoc w/lower rates of MDD
epidemiology & consequences of MDD
-symptom variation across life span
-children: headaches & stomach aches
-older adults: distractability & forgetfulness
-co-morbidity: 2/3 of those w/MDD will also meet criteria for anxiety disorder at some point
what does depression mean for family members?
children of depressed mothers have higher rates of:
-depression & anxiety thruout lifespan
-aggression & externalizing behavior probs
-poor academic achievement & lower iq
-negative affect, lower self-concept & self esteem
-insecure attachment w/mothers
-abnormal prefrontal & cortisol activities
Marriages also have higher rates of conflict & divorce
infants & children of depressed mothers (research has been done studying both clinical depression & depressive symptomatology)
what is the defining feature of each of the 3 bipolar disorders?
manic symptoms
-differentiated by how severe & long lasting manic symptoms are
-mania & depression
mania vs. hypomania
mania: state of intense elation or irritability accompanied by other symptoms (flight of ideas)
hypomania: less extreme than mania (change in functioning that doesn't cause serious probs)
mania & hypomania episodes
-distinctly elevated/irritable mood
-abnormally increased activity/energy
-at least 3 of the following are noticeably changed from baseline (4 if mood is irritable): inc in goal-directed activity/psychomotor agitation, unusual talkativeness; rapid speech, flight of ideas or subj impression that thoughts are racing, dec need for sleep, inc self esteem; grandiosity, distractibility; attn. easily diverted, excessive involvement in activities that are likely to have painful consequences (reckless spending, sexual indiscretions, or unwise bus investment), symptoms present for most of the day, nearly everyday
criteria for manic episode
-symptoms last for 1 wk, or require hospitalization or include psychosis
-symptoms cause significant distress/functional impairment
criteria for hypomanic episode
-symptoms last at least 4 days
-clear changes in functioning that are observable to others, but impairment isn't marked
-no psychotic symptoms are present
criteria for bipolar I
-at least one episode or mania
criteria for bipolar II disorder
-at least 1 major depressive episode w/at least 1 episode of hypomania
criteria for cyclothymic disorder (cyclothymia)
-milder, chronic form of bipolar disorder
-lasts at least 2 yrs in adults (1 yr in children/adolescents)
-numerous periods w/hypomanic & depressive symptoms
-doesn't meet criteria for mania or major depressive episode
-symptoms don't clear for more than 2 months at a time
2 chronic mood disorders
1. persistent depressive disorder
2. cyclothymic disorder
onset for bipolar disorder
-onset usually occurs btwn ages 18-22 yrs
-first onset can be depression or mania
-avg duration of a manic episode runs between 2 & 3 months
prevalence for bipolar disorder
-prevalence lower than MDD
-long term course is often intermittent
-long-term prognosis is mix
are there gender differences in bipolar disorder?
-no gender differences
-women experience more depressive episodes
outcome for bipolar disorder
-severe mental illness
-1/3 were unemployed a yr after hospitalization
-suicide rates high
-50% of people with bipolar I will experience 4 or more episodes
-2/3 people w/bipolar disorder meet criteria for a comorbid anxiety disorder
-unable to work 25% of the time
course specifiers (subtype of mood disorder)
-melancholic features (primarily a specifier of depression)
-psychotic features (primarily a specifier for bipolar disorders)
-post partum
pattern specifiers (subtype of mood disorder)
-rapid cycling: at least 4 episodes w/in the past yr (only for bipolar disorder)
-seasonal affective disorder
*refer to overall patter of episodes over time
how are mood disorders heterogeneous?
same disorder but diff symptoms
dopamine sensitivity in depression vs. mania
depression: diminished dopamine receptor sensitivity
mania: enhanced dopamine receptor sensitivity
which disorder is among the most heritable of disorders?
bipolar (twin studies)
genetic factors of mood disorders
-heritability estimates: 37% MDD, 93% bipolar disorder
-much research in progress to identify 1 specific gene involved but the results of most studies have not been replicated (prob polygenetic)
-DRD4.2 gene (influences dopamine function) appears to be related to MDD
-genetic risk and sensitivity to stress
3 imp neurotransmitters (NTs)
norepinephrine, dopamine & serotonin
NTs in MDD vs. Mania
-original models focused on absolute levels of NTs
-MDD: low levels of norepinephrine, dopamine & serotonin
-Mania: high levels of norepinephrine and dopamine, low levels of serotonin
what do new models of NTs focus on?
-sensitivity of postsynaptic receptors
-dopamine receptors may be overly sensitive in BD but lack sensitivity in MDD
-depleting tryptophan, a precursor of serotonin, causes depressive symptoms in individuals w/personal or fam history of depression
-individuals who are vulnerable to depression may have less sensitive serotonin receptors
brain imaging (structural vs. functional)
structural studies: focus on number of or connections among cells
function activation studies: focus on activity levels
levels on activity among ppl w/mood disorders shown in functional activation studies
amygdala: elevated
subgenual anterior cingulate: elevated
dorsolateral prefrontal cortex: diminished during emotion regulation
hippocampus: diminished
what is the hormonal system known as?
the hypothalamic-pituitary-adrenal (HPA) axis
overactivity of HPA axis
-triggers release of cortisol (stress hormone)
-amygdala overreaction
findings that link depression to high cortisol levels
cushings syndrome: causes oversecretion of cortisol; symptoms include those of depression
injecting cortisol in animals produces depressive symptoms
dexamethasone suppression test: lack of cortisol suppression in people w/history of depression
life events of psychosocial factors
-prospective research: 42-67% report a stressful life event in yr prior to depression onset (ex: romantic breakup, loss of job, death of loved one); replicated in 12 studies across 6 countries
-lack of social support may be 1 reason a stressor triggers depression
-stressful life event linked to manic episodes as well
interpersonal difficulties related to psychosocial factors
-high levels of expressed emotion by fam members predicts relapse
-marital conflict also predicts depression
how does behavior of depressed ppl often lead to rejection by others?
-excessive reassurance seeking
-few positive facial expressions
-negative self disclosures
-slow speech & long silences
why do some ppl become depressed after stressful life events & others do not?
-response styles & gender: ruminative style (women) & distracting style (men)
-interpersonal factors & soc behaviors : some depressed ppl create difficult circumstances that inc levels of stress
-integration of cognitive & interpersonal factors : vulnerability to depression is influenced by childhood experiences
do negative life events cause depression or does depression lead to negative events?
a special class of circumstances (those involving major losses of imp ppl or roles) seem to play a crucial role in precipitating unipolar depression
-depression more likely to occur when life events are assoc w/ feelings of humiliation, entrapment & defeat
cognitive theories: cognitive vulnerability
-humans are not only social but thinking organisms
-hopelessness theory: ways in which ppl perceive, think about & remember event influence feelings
-attributional style: negative thoughts about self & pessimistic view of the environment maintain depression
-tendency to react w/higher levels of negative affect
-predicts onset of depression
negative triad
negative view of self, world, future
negative schema
underlying tendency to see the world negatively
-negative schema cause cognitive biases
cognitive biases
tendency to process info in negative ways
beck's theory of depression
negative schema, cognitive biases & negative triad lead to depression
example of attributions for why someone failed their GRE math exam
-stable: I lack intelligence/I lack math ability
-unstable: I am exhausted/I am fed up with math
social & psych factors in bipolar disorder
-triggers of depressive episodes in bipolar disorder appear similar to the triggers of major depressive episodes
-negative life events, neuroticism, negative cognitions, expressed emotion, & lack of soc support
predictors of mania
reward sensitivity & sleep disruption
psych treatment for depressive disorders
-cognitive therapy
-interpersonal psychotherapy
-mindfulness-based cognitive therapy (MBCT): strategies, including meditation, to prevent relapse
-behavioral activation (BA) therapy: inc participation in positively reinforcing activities to disrupt spiral of depression, withdrawal, & avoidance
-behavioral couples therapy: enhance communication & satisfaction
cognitive vs. interpersonal therapy
cognitive: focuses on helping patients replace self-defeating thoughts w/more rational statements; current experiences; effective for unipolar depression
interpersonal: focuses on current relationships, esp familial; attempts to improve relationships by building communication & prob solving skill
electroconvulsive therapy (ECT)
-biological treatment for mood disorders
-reserved for treatment non-responders
-induce brain seizure & momentary unconsciousness (unilateral ECT)
-side effects (mem loss)
-ECT more effective than meds, but unclear how ECT works
-biological treatment for depressive disorder
-most frequently used antidepressant
-easier to use than other antidepressants
-fewer side effects (sexual dysfunction, weight gain)
-less dangerous in event of overdose
tricyclics (TCAs)
-biological treatment for depressive disorders
-imipramine & amitriptyline
-more side effects (constipation, drowsiness, drop in BP, blurred vision)
-equal in efficacy to SSRIs
MAO-Is: Phenelzine (Nardil)
-biological treatment of depressive disorders
-not as effective as tricyclics
-side effects: consuming foods w/tyramine (cheese & chocolate) often inc BP
-can be used safely when foods such as beer, cheese & red wine are avoided
-also used in treatment of anxiety disorders, particularly agoraphobia & panic
meds for bipolar disorder
-lithium: up to 80% receive at least some relief w/this mood stabilizer
-potentially serious side effects (lithium toxicity)
-newer mood stabilizers: anticonvulsants (Depakote), antipsychotics (zyprexa); both also have serious side effects
psych treatment of bipolar
-psychoeducational approaches: provide info about symptoms, course, triggers & treatments
-fam-focused treatment (FFT): educate fam about disorder, enhance fam communication, improve problem solving
-psychotherapy: prelim data suggests that meds & psychotherapy together are more effective than meds alone
treatment effectiveness
-published studies may overestimate the effectiveness of meds
-combining psychotherapy & antidepressant meds inc odds of recovery over either alone by 10-20%
-meds quicker, therapy longer lasting effects
-later studies: CT as effective as meds for severe depression; CT more effective than meds at preventing relapse
suicide ideation
thoughts of killing oneself
suicide attempt
behavior intended to kill oneself
death from deliberate self injury
non-suicidal self injury
behaviors intended to injure oneself w/o intent to kill oneself
epidemiology of suicide/suicide attempts
-suicide rate in US is 1/10,000 in a given yr; worldwide 9% report suicidal ideation at least once in their lives, & 2.5% have made at least one suicide attempt
-guns are most common means of suicide in us (60%)
-men are 4x more likely than women to kill themselves; women more likely than men to make suicide attempts that don't result in death
-men usually shoot or hang themselves
-women more likely to use pills
models of suicide
-psych disorders: 1/2 of suicide attempts are depressed
-neurobiological models: heritability of 48% for suicide attempts; low levels of serotonin; overly reactive HPA system
-soc factors: economic recessions; media reports of suicide; soc isolation & a lack of soc belonging
-psych models: prob-solving deficit; hopelessness; life satisfaction
preventing suicide
-talk about suicide openly & matter of factly
-most people are ambivalent about their suicidal intentions
-treat the associated mental disorder
-treat suicidality directly
-suicide prevention centers
overview of anxiety disorders
-most common psychiatric disorders
-28% report anxiety symptoms
-most common are phobias
-they share similarities w/mood disorders
symptoms of anxiety vs. fear
anxiety: assoc w/the anticipation of future probs; involves more general/diffuse emotional reactions; emotional experience is out of proportion to the threat
fear: experienced in the face real immediate danger; usually builds quickly in intensity; helps behavioral responses to threats
general symptoms of anxiety disorders
-ppl w/anxiety disorders share a preoccupation w/, or persistent avoidance of, thoughts or situations that provoke fear or anxiety
-diagnosis of anxiety disorders depends on several types of symptoms
excessive worry (symptoms of anxiety disorder)
-cognitive activity assoc w/anxiety
-a relatively uncontrollable sequence of negative, emotional thoughts that are concerned w/possible future threats or danger
-worriers are preoccupied w/"self-talk"
normal vs. pathological worry
distinctions hinges on quantity and quality of worrisome thoughts
-disruptive fear of a particular obj or situation
-fear out of proportion to actual threat
-must be severe enough to cause distress or interfere w/job or social life
general panic attack symptoms
-sudden intense episode of apprehension, terror, feelings of impending doom (intense urge to flee, symptoms reach peak intensity w/in 10 mins)
-physical symptoms include: labored breathing, heart palpitations, nausea, upset stomach, chest pain, feelings of choking & smothering, dizziness, sweating, lightheadedness, chills, heart sensations, & trembling
-other symptoms include: depersonalization, derealization, fears of going crazy, losing control or dying
brief historical perspective of anxiety disorders
-anxiety & abnormal fears didn't play prominent role in psychiatric classification systems during the 2nd half of the 19th century
-freud & his followers were responsible for some of the 1st extensive clinical descriptions of pathological anxiety states
3 main types of anxiety disorders as described in dsm-5
anxiety disorders, obsessive-compulsive & related disorders, & trauma & stressor related disorders
criteria for all anxiety disorders
-symptoms must interfere w/imp areas of functioning or cause marked distress
-symptoms not caused by drug or medical condition
-fears & anxieties are distinct from the symptoms of another anxiety disorder
diagnostic criteria for a specific phobia
1. marked & disproportionate fear consistently triggered by specific objs or situations
2. obj or situation is avoided or else endured w/intense anxiety
3. symptoms persist for at least 6 months
disproportionate fear of a particular obj or situation
-common ex : fear of flying, snakes, heights, etc
-fear out of proportion to actual threat
-most specific phobias cluster around a few feared objs & situations
-high comorbidity of specific phobias
-although there are some common themes, ppl can develop a phobia of anything
plays major role in sensitivity of reward system
-guides pleasure, motivation, & energy in MDD
diagnostic criteria: soc anxiety disorder
1. marked & disproportionate fear consistently triggered by exposure to potential scrutiny
2. exposure to the trigger leads to intense anxiety about being evaluated negatively
3. triggers situations are avoided or else endured w/intense anxiety
4. symptoms persist for at least 6 months
how is soc anxiety disorder more intense & extensive than shyness?
-persistent intense fear & avoidance of soc situations
-fear of negative evaluation or scrutiny
-exposure to trigger leads to anxiety about being humiliated or embarrassed socially
-onset often adolescence
-2 broad headings: performance anxiety & interpersonal interaction
-fear of humiliation or embarrassment
diagnostic criteria for panic disorder
1. recurrent unexpected panic attacks
2. at least 1 month of concern about the possibility of more attacks, worry about the consequences of an attack, or maladaptive behavioral changes because of the attacks
-from greek word "agora" or marketplace
-usually described as fear of public places
-anxiety about inability to flee anxiety-provoking situations (crowds, stores, malls, churches, etc)
-most complex & incapacitating phobic disorder
-at least half of agoraphobics don't suffer panic attacks
diagnostic criteria for agoraphobia
1. disproportionate & marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the event of incapacitation, embarrassing or panic-like symptoms such as : being outside of the home alone, travelling on public transportation, open spaces, being in shops or theaters, standing in line, being in a crowd
2. these situations consistently provoke fear/anxiety
3. these situations are avoided, require the presence of a companion, or are endured w/intense fear or anxiety
4. symptoms last at least 6 months
generalized anxiety disorder (GAD)
-involves chronic, excessive, uncontrollable worry that lasts @ least 6 months & interferes w/daily life (worries lead to significant distress); often can't decide on solution or course of action
-other symptoms: restlessness, poor concentration, tiring easily, irritability, muscle tension
-common worries: relationships, health, finances, daily hassles
-often begins in adolescence or earlier (I've always been this way)
diagnostic criteria for GAD
1. excessive anxiety & worry at least 50% of days a number of events or activities (fam, health, finances, work, school)
2. person finds it hard to control worry
3. worry is sustained for at least 6 months
4. anxiety & worry are assoc w/at least 3(only 1 for kids): restlessness/feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance
most common form of mental disorder
anxiety disorders
what is the expected long-term outcome for ppl w/anxiety disorders?
-anxiety disorders are often chronic conditions, some ppl don't recover
-frequency & intensity of panic attacks tend to dec during middle age
-agoraphobic avoidance typically remains stable
-most anxiety disorders are very treatable if ppl seek treatment
frequency of anxiety disorders
-rates for anxiety disorder have been found to be lower when people over the age of 60 are compared to younger adults
-anxiety may inc as people move into their 70s & 80s
-only type of anxiety disorder that begins in late life is agoraphobia
-80% of those w/anxiety disorders meet criteria for another anxiety disorder
-subthreshold symptoms (don't meet full DSM) very common
-causes of comorbidity: symptoms used to diagnose the various anxiety disorders overlap- soc anxiety & agoraphobia might both involve a fear of crowds
-etiological factors may inc risk for more than 1 anxiety disorder
-75% of those w/anxiety disorder meet criteria for another psych disorder
-disorders commonly comorbid w/anxiety: 60% w/anxiety also have depression, substance abuse, personality disordrs, med disorders (coronary heart disease)
gender factors for anxiety disorder
-women=2x as likely as men to have anxiety disorder
-possible explanations: women more likely to report symptoms, men more likely to be encouraged to face fears, women more likely to experience childhood sexual abuse, women show more biological stress reactivity
-relapse rates also higher for women than men
cultural factors for anxiety disorders
-cross cultural comparisons: ppl in western societies often experience anxiety in relation to their work performance, whereas other societies may be more concerned about fam issues or religious experiences; few epidemiological studies have attempted to collect cross-cultural data using standardized criteria
-culturally specific symptoms: taijin kyofusho (Japanese fear of offending/embarrassing others); kayak-angst (inuit disorder in seal hunters at sea similar to panic)
-ratio of somatic to psychological symptoms appears similar across cultures
evolutionary perspective of anxiety disorders
-adaptive & maladaptive fears
-often focused on evolutionary significance of anxiety & fear
-emotional responses are adaptive
-mobilize responses that help the person survive in the face of both immediate danger & long-range threats
why do some negative life events lead to depression while others lead to anxiety?
-nature of the event may be an imp factor in determining the type of mental disorder that appears
-stressful life events, particularly involving danger & interpersonal conflict, can trigger the onset of certain kinds of anxiety disorders and depression
-for depression, an event(s) involving severe loss (lack of hope) is more likely to have occurred
childhood adversity
-concept includes experiences such as maternal prenatal stress, multiple maternal partner changes, parental indifference (neglect) & physical abuse
-children who are exposed to higher levels of anxiety are more likely to develop anxiety disorders later in life
attachment relationships & separation anxiety
-according to attachment theory, anxiety is an innate response to separation, or the threat of separation, from the caretaker
-several studies have found that people w/anxiety disorders are more likely to have had attachment probs as children
behavioral inhibition
-tendency to be agitated, distressed, and cry in unfamiliar or novel settings
-observed in infants as young as 4 months
-may be inherited
-predicts anxiety in childhood & social anxiety in adolescence
personality risk factors (anxiety disorders)- neuroticism
-react w/negative affect
-linked to anxiety & depression
-higher levels linked to double the likelihood of developing anxiety disorders
learning processes
-specific fears might be learned thru classical conditioning
-process by which fears are learned suggests that the process is guided by a module, or specialized circuit
preparedness model
-research results appear to suggest that conditioned responses to fear-relevant stimuli (spiders, snakes) are more resistant to extinction than those to fear-irrelevant stimuli (flowers)
-human beings seem to be prepared to develop intense, persistent fears only to a select set of objs or situations
cognitive factors
-perceptions, memory, & attention all influence reaction to events
-play a crucial factor in the development & maintenance of various types of anxiety disorders
-4 aspects: perception of controllability, catastrophic misinterpretation, attentional biases, thought suppression
perception of control
-ppl who feel that they are able to control events in their environments are less likely to show symptoms of anxiety than ppl who believe they are helpless
-feelings of lack of control contribute to the onset of panic attacks among patients w/panic disorder
catastrophic misinterpretation
-panic attacks can be precipitated by internal stimuli, such as bodily sensations, thoughts or images
-ppl may misinterpret bodily sensations as a catastrophic event
-a person's automatic, negative thoughts may also lead to behaviors that are expected to inc safety, when they are, in fact, counterproductive
attn. to threat & biased info processing
-ppl prone to excessive worrying & panic are unusually sensitive to cues that signal the existence of future threats
-recognition of danger cues triggers maladaptive, self-perpetuation cycle of cognitive processes that quickly spin out of control
is it useful to struggle actively against unwanted thoughts?
recent evidence suggest that trying to rid one's mind of a distressing or unwanted thought can have the unintended effect of making the thought more intrusive
genetic factors for anxiety
-sheds light on the relationship between anxiety and depression
-twin studies suggest heritability
-about 20-40% for phobias, GAD, & PTSD
-about 50% for panic disorder
-relative w/phobia increases risk for other anxiety disorders in addiction to phobia
-anxiety appears to be modestly heritable between 20-30%
neurobiological risk factors for anxiety disorders
-fear circuit overactivity: amygdala, medial prefrontal cortex deficits
-neurotransmitters: poor functioning of serotonin & GABA; higher levels of norepinephrine
etiology of specific phobias
-mowrer's 2 factor model
1. pairing of stimulus w/aversive UCS leads to fear (classical conditioning)
2. avoidance maintained thru negative reinforcement (operant conditioning)
3 extensions of 2 factor model
1. modeling: seeing another person harmed by stimulus
2. verbal instruction: parent warning a child about danger
3. those w/anxiety tend to acquire fear more readily - and be more resistant to extinction
cognitive factors of etiology of soc anxiety disorder
-unrealistic negative beliefs about consequences of behaviors
-excessive attn. to internal cues
-fear of negative evaluation by others (expect others to dislike them)
-negative self evaluation (harsh, punitive self-judgment)
interoceptive conditioning
classical conditioning of panic in response to internal bodily sensations
etiology of panic
-cognitive factors: catastrophic misinterpretations of somatic changes; interpreted as impending doom (I must be having a heart attack); beliefs inc anxiety & arousal (creates vicious cycle)
-anxiety sensitivity index - high scores predict development of panic
etiology of GAD
-gaba system deficits
-borkovec's cognitive model: worry reinforcing b/c it distracts from negative emotions & images; allows avoidance of more disturbing emotions (distress of previous trauma); worrying decreases psychophysiological arousal; avoidance prevents extinction of underlying anxiety
best treatment for anxiety disorders
anxiety disorders are 1 of the areas of psychopathology in which clinical psychologists & psychiatrists are best prepared to improve the level of the client's functioning
psychoanalytic psychotherapy
emphasis in this type of treatment is on fostering insight regarding the unconscious motives that presumably lie at the heart of the patient's symptoms
systematic desensitization
-initially developed for the purpose of treating anxiety disorders, esp phobias
-crucial feature of the treatment involves systematic maintained exposure to the feared stimuli
-progressive relaxation
-a hierarchy of feared stimuli
situational vs. introceptive exposure
(exposure & response prevention treatments)
situational: used to treat agoraphobic avoidance (procedure involves the person repeatedly confronting the situations that have been previously avoided)
interoceptive: aimed at reducing the person's fear of internal, bodily sensations frequently assoc w/panic
relaxation skills training
involves teaching the client to alternately tense & relax specific muscle groups while breathing slowly & deeply
-this procedure is described to clients as an active coping skill
breathing retraining
-involves education about the physiological effects of hyperventilation & practice in slow breathing
-client learns to control breathing thru repeated practice using muscles of the diaphragm, rather than the chest
cognitive therapy intervention
-identify cognitions that are relevant to their probs
-recognize the relation between these thoughts & maladaptive emotional responses
-examine evidence that supports or contradicts these beliefs
-teach clients more useful ways of interpreting events
-helps clients to review how they think about situations in their lives, decatastrophisize (what if the worst case scenario happened?)
-sessions followed by extensive practice & homework assigments
-drugs that reduce anxiety
-benzodiazepenes: valium, Xanax
-antidepressants: tricyclics, SSRIs, SNRIs
-d-cycloserine (DCS) : enhances learning during exposure treatment
antianxiety meds
-most frequently used minor tranquilizers are from the class of drugs known as benzodiazepines (valium & Xanax)
-these drugs reduce many symptoms of anxiety, esp vigilance & subj somatic sensations
-they have less effect on worry & rumination
side effects of benzodiazepines
-sedation accompanied by mild psychomotor & cognitive impairments
-probs in attn. & memory, esp among elderly
-potential for addiction - the most serious effect of benzodiazepines
what is the preferred form of meds for treating all forms of anxiety?
-selective serotonin reuptake inhibitors (SSRIs)
-include: Prozac, luvox, Zoloft, paxil
-fewer unpleasant side effects and are safer to use
-withdrawal reactions are less prominent
do psych treatments have any advantages over meds for treatment of anxiety?
-in actual practice, anxiety disorders are often treated w/a combo of psych & biological procedures
-selection of specific treatment components depends on the specific group of presenting symptoms
-major disturbances in thought, emotion & behavior
-can disrupt interpersonal relationships, diminish capacity to work or live independently
-significantly inc rates of suicide and death
-lifetime prevalence ~1%
-onset typically late adolescence or early adulthood
-diagnosed more frequently in African americans (may reflect diagnostic bias)
proposed DSM-5 criteria for schizo
1. delusions
2. hallucinations
3. disorganized speech
4. abnormal psychomotor behavior (catatonia)
5. negative symptoms (blunted affect, avolition, asociality)
3 major clusters of schizo symptoms
1. positive (delusions, hallucinations)
2. negative (avolition, blunted affect, asociality)
3. disorganized (disorganized behavior & speech)
proposed dsm-5 criteria for schizophrenia
-disruption in work, relationships or self-care
-signs of disorder for at least 6 months; at least 1 month of the symptoms above or, if during a prodromal or residual phase, negative symptoms or 2 or more of symptoms 1-4 in less severe form
types of delusions
persecutory, thought insertion, thought broadcasting, outside control, grandiose delusions, ideas of reference
types of hallucinations
1. auditory: 74% have this symptoms
2. visual
3. hearing voices: inc levels of activity in broca's area during hallucinations
behavioral deficits
avolition, adociality, anhendonia, blunted affect & alogia
2 domains of negative symptoms
1. experience domain: motivation, emotional experience, socialty
2. expression domain: outward expression of emotion; vocalization
disorganized speech
-formal thought disorder
-loose associations (derailment)
disorganized behavior
-odd/peculiar behavior
motor abnormality
catatonic immobility
maintain unusual posture for long periods of time (e.g. stand on one leg)
waxy flexibility
limbs can be manipulated and posed by another person
genetic factors of schizo
-genetically heterogeneous
-fam studies: relatives at inc risk
-adoption studies: inc likelihood of developing psychotic disorders
-familial high-risk studies: differing negative vs. positive symptomatology
association stuides
-2 genes assoc w/schizophrenia (DTNGP1 & NGR1)
-2 genes assoc w/cognitive deficits (COMT & BDNF)
genome wide scans
-identification of gene mutations
-several identified but results need to be replicated
dopamine theory
disorder due to excess levels of dopamine
-drugs that alleviate symptoms reduce dopamine activity
revised dopamine theory
-excess numbers of dopamine receptors or oversensitive dopamine receptors
-excess dopamine localized mainly in the mesolimbic pathway
-mesolimbic dopamine abnormalities mainly related to positive symptoms
-underactive dopamine activity in the mesocortical pathway mainly related to negative symptoms
why doesn't dopamine theory completely explain disorder?
-antipsychotics block dopamine rapidly but symptom relief takes several weeks
-to be effective, antipsychotics must reduce dopamine activity to below normal levels
other neurotransmitters involved in dopamine theory
-serotonin, GABA, glutamate, medication that targets glutamate shows promise
prefrontal cortex (&schizo)
-ind w/schizophrenia show impairments on neuropsychological tests of prefrontal cortex
-ind w/schizo show low metabolic rates in prefrontal cortex
-disrupted communication among neurons due to loss of dendritic spines
structural & functional abnormalities in temporal cortex (schizo)
-temporal gyrus
-anterior cingulate
-reduced gray matter & volume evident
environmental schizophrenia factors
-damage during gestation or birth
-obstetrical complications rates high in patients w/schizophrenia
-viral damage to fetal brain
-presence of parasite, toxoplasma gondii, assoc w/ 2.5x greater risk of developing schizo
-in finnish study, schizo rates higher when mother had flu in 2nd trimester of pregnancy
psychological stress of schizo
reaction to stress: ind w/schizo & their first degree relatives more reactive to stress
SES: highest rates of schizo among urban poor; sociogenic hypothesis; social selection theory (research supports soc selection)
fam factors of schizo
-schizophrenogenic mother: cold, domineering, conflict inducing; no support for this theory'
-communication deviance (CD): hostility & poor communication; inconclusive at this time
expressed emotion (EE)
-hostility, critical comments, emotional over involvement
bidirectional assoc
-ususual patient thoughts --> inc critical comments
-inc critical comments --> ususual patient thoughts
developmental histories of kids who later developed schizo
-lower iq
-more often delinquent (boys) & withdrawn (girls)
-coding of home movies: poorer motor skills & more expression of negative emotion
high risk studies in schizo
-id a number of factors that predict developing schizo
-having a biological relative w/schizo
-a recent decline in functioning
-high levels of positive symptoms
-high levels of social impairment
-lower iq in childhood is a predictor of later onset of schizo & that the iq deficits are stable across childhood
1st generation antipsychotics (med treatment of schizo)
-reduce agitation, violent behavior
-block dopamine receptors
-little effect on negative symptoms
-extrapyramidal side effects
-tardive dyskinesia
-neuroleptic malignant syndrome
2nd generation antipsychotics (med treatment of schizo)
-clozapine (clozaril)
-impacts serotonin receptors
-fewer motor side effects
-less treatment noncompliance
-reduces relapse
-side effects: can impair immune symptom functioning; seizures, dizziness, fatigue, drooling, weight gain
-new meds may improve cognitive functioning: olanzapine (zyprexa) & risperidone (Risperdal)
psychological treatments for schizo
-recommended treatment: meds plus psychosocial intervention
-social skills training: teach skills for managing interpersonal situations; involves role-playing & other practice exercises both in group & in vivo
-fam therapy to reduce expressed emotion
-cognitive behavioral therapy
-case management
how does fam therapy reduce expressed emotion?
-educate fam about causes, symptoms, & signs of relapse
-stress importance of meds
-help fam to avoid blaming patient
-improve fam communication & problem solving
-encourage expanded support networks
-instill hope
cognitive behavioral therapy
recognize & challenge delusional beliefs
cognitive remediation training or cognitive enhancement therapy (CET)
seek to enhance basic cognitive functions such as verbal learning ability
case management
multidisciplinary team to provide comprehensive services
brief psychotic disorder
-symptom duration of 1 day to 1 month
-often triggered by extreme stress, such as bereavement
schizoaffective disorder
-symptoms of both schizo & mood disorder
-dsm5 likely to require appearance of major depressive or manic episode
delusional disorder
-delusions may include: persecution, jealousy, being followed, erotomania (loved by a famous person), somatic delusions
-no other symptoms of schizo
attenuated psychosis syndrome
possible new category in dsm5
in the dsm 4, obsessive-compulsive & related disorders & trauma disorders were included w/what?
anxiety disorders
(now they are separate)
repetitive thoughts & urges (obsessions)
repetitive behaviors & mental acts (compulsions)
body dysmorphic disorder
repetitive thoughts & urges about personal appearance
-preoccupied w/imagined or exaggerated defect in appearance
-perceive themselves to be ugly or monstrous
-women focus on skin, hips, breasts, legs
-men focus on height, penis size, body hair, muscularity
-engage in compulsive behaviors: check appearance often in mirrors; camouflage appearance (tanning, makeup, plastic surgery)
hoarding disorder
repetitive thoughts about possessions
-can't part w/acquired objs
-extremely attached to objs
-resistant to relinquishing objs
-66% are unaware of severity of problem
-33% engage in animal hoarding (animals often receive inadequate care)
-severe consequences: squalid living conditions, negatively impacts relationships
-intrusive, persistent, & uncontrollable thoughts or urges
-experienced as irrational
-most common: contamination, sexual & aggressive impulses, body probs
-impulse to repeat certain behaviors or mental acts to avoid distress (cleaning, counting, touching, checking)
-extremely difficult to resist the impulse
-may involve elaborate behavioral rituals
-compulsive gambling, eating, drinking NOT considered compulsions (since pleasurable)
DSM 5 for OCD
1. obsessions or compulsions
2. obsessions or compulsions are time consuming (require at least 1 hr/day) or cause clinically significant distress or impairment
when does ocd develop?
-either before age 10 or during late adolescence/early adulthood
-1.5x more common in women
ocd often chronic
-only 20% complete recovery
-75% have comorbid anxiety disorder
-66% have major depression
-33% have hoarding symptoms
-substance abuse common
dsm 5 criteria for body dysmorphic disorder
-preoccupation w/1 or more perceived defect in appearance
-person has performed repetitive behaviors or mental acts (mirror checking, seeking assurance, or excessive grooming) in response to appearance concerns
-preoccupation is not restricted to concerns about weight or fat
dsm 5 criteria for hoarding disorder
-persistent difficulty discarding or parting w/possessions
-perceived need to save items
-distress assoc w/discarding
-symptoms result in accumulation of a large number of possessions that clutter active living spaces to the extent that their intended use is compromised unless others intervene
genetic links
BDD & hoarding = higher likelihood of fam member w/OCD
hyperactive regions of the brain
-orbitofrontal cortex
-caudate nucleus
-anterior cingulate
operate reinforcement
compulsions negatively reinforced by the reduction of anxiety
cognitive factors of OCD
-lack of a satiety signal
-yadasentience: subjective feeling of completion; knowing that you have thought enough or cleaned enough; individuals with OCD have a yadasentience deficit
-attempts to suppess intrusive thoughts - trying to suppress thoughts may make matters worse
etiology of Body Dysmorphic Disorder
-focus on details of appearance
-no actual distortion of physical features
-attend to physical attractiveness features (facial symmetry)
-miss the gestalt, or the whole picture
-become engrossed in small flaws
-believe in an exaggerated importance of appearance
etiology of hoarding disorder
-evolutionary perspective: adaptive to stockpile vital resources
-cognitive behavioral factors: poor organizational abilities, unusual beliefs about possessions, avoidance behaviors
-comorbid w/ocd: may share some genetic & neurobiological factors
treatment of obsessive-compulsive & related disorders
-meds : ssris (serotonin reuptake inhibitors); tricyclic antidepressants : anafranil (clomipramine)
-exposure plus response prevention (ERP) : not performing ritual exposes the person to the full force of the anxiety provoked by the stimulus; exposure results in the extinction of the conditioned response (anxiety)
-cognitive therapy: challenge beliefs about anticipated consequences of not engaging in compulsions (usually also involves exposure)
traumatic stress
an event that involves actual or threatened death or serious injury to self or others and creates intense feelings of fear, helplessness, or horror
historical perspective of diagnosis of ASD & PTSD
-maladaptive rxns to trauma have long been an interest to the military
-"shell shock" or "combat neurosis"
-Vietnam war prompted much interest in PTSD due to delayed rxns to combat being very common
PTSD & ATSD: disaster & emergency workers
-not immune to trauma's aftereffects
-emergency works are less than half as likely to develop PTSD as victims
-training, preparation, & sense of purpose appear to be protective
-hardiness: sense of commitment, control, challenge facing stress
does childhood trauma effect later parenting?
pitt mother & child project measures
-mothers depression = 18 mo
-observed rejecting parenting (24 mo.)
-observed child noncompliance (42 mo.)
-mom report of internalizing & externalizing (42 mo.)
-controls: neighborhood risk, single mom, status, SES, minority status
-frequency of trauma: any sort = 93%; interpersonal = 71%; trauma during childhood = 50%
common risk factors w/other anxiety disorders for PTSD
-genetic, overactive amygdala, childhood exposure to trauma, selective attn., neuroticism, & negative affectivity
-2 factor model of conditioning also applicable
unique factors of PTSD
-severity & type of trauma
-neurobiological (smaller hippocampal volume linked to PTSD)
-avoidance coping, dissociation, mem suppression
-intelligence, soc support, & ability to grow from the experience enhance coping
psych treatment of PTSD
-exposure to memories & reminder of the original trauma
-either direct (in vivo) or imaginal
-virtual reality (VR) effective
-more effective than meds or supportive therapy
-treatment can be difficult at first
-possible inc in symptomatology
-cognitive therapy: enhance beliefs about coping abilities, adding CT to expose doesn't improve treatment response
-treatment of ASD may prevent PTSD: shows benefits even 5 yrs after traumatic event
antidepressants for ptsd
-antidepressants & therapeutic reexposure are first-line therapies for ptsd
-effectiveness of ssris is likely at least partially due to the high comorbidity between ptsd & depression
-traditional antianxiety meds aren't effective in treating ptsd
3 main categories of traumatic stress
1. hyperarousal : persistent expectation of danger
2. intrusion: imprint of the traumatic event
3. constriction: numbing response
persistent expectation of danger
-hypervigilance, startle response
-lack of sense of safety
-physiologic changes leading to elevated baseline of arousal - always ready for danger, generalized anxiety, specific fears
-memory intrusions of event
-flashbacks, nightmares, avoidance of similar situations/environments
-affective dysregulation
-poor attn. due to preoccupation & disrupted cognitive functioning
-attempts to master the trauma - reenactments of trauma in role of victim or abusing others
-numbing response; "freezing"
-interpersonal isolation
-emotional restriction, detachment
-amnesia for part/all of traumatic event
-turning to substances to numb
-constriction of present life & future
-lack of agency
3 stage process of trauma treatment
1. safety
2. mourning
3. reconnection
-only stage one treatment activities recommended for brief interventions