Student Name: ___________________ Student ID: __________________ Case Study Assignment 1 Instructions: Read the following case description and then answer the four questions that follow. Type your answers directly into the document. Be as detailed and specific as possible and use as many examples as possible from the case description to support your answers. You must write in a clear and grammatical manner. You will lose points for unclear writing. Upload your complete case study assignment using the case studies submission link on Canvas by October 15. You will receive a late deduction of 10% for each day your submission is late. Submissions more than 3 days late will not be accepted. Case Description: Susan is a 29-year-old Caucasian woman who is divorced with two children (a son, age 12, and a daughter, age 7). Since obtaining her bachelor’s degree in business administration 8 years ago, Susan has worked as a bank manager. For the past 9 months she had become increasingly worried about her ability to concentrate and remember things at work, and she went to her family doctor for an evaluation. Finding nothing physically wrong with her, the doctor referred her to a neuropsychologist who suspected her problems might be related to anxiety and referred her to a clinical psychologist. Susan does not use drugs and does not take any medications. During her initial visit to the clinic, Susan again expressed her concerns about her lapses in concentration and memory. She stated that because of these lapses, she had made some “financially disastrous” errors at work. Consequently, she was advised by her supervisor to take some vacation time to relax and “get her head together.” Feeling devastated by her supervisor’s remark, Susan became convinced that her concentration and memory problems were serious and perhaps a result of her experimentation with marijuana in college. In addition to her problems with concentration and memory and worries that her job was in jeopardy, Susan claimed that she was unable to relax outside the office. Susan’s concentration and memory problems usually occurred when she was anxious and worried about some life matter. However, she said that since high school she has been in a state of anxiety and worry about 75% of her waking hours and she almost never experienced worry-free days. She worried a great deal about her job performance, her children’s well-being, and her relationships with men. In addition, she felt stressed about a variety of minor matters such as getting to appointments on time, keeping her house clean, and maintaining regular contact with family and friends. For example, with regard to her children, Susan often became very anxious that her kids might have been hurt or killed if they were out in the neighborhood playing and she had not heard from them in a couple of hours. In addition to being excessive her worries were uncontrollable. When a worry came into her mind, she was unable to dismiss it and get her mind refocused on the task at hand. During these periods of increased worry, Susan would be more forgetful because her mind had not been focused on her work (e.g., she would often forget what her supervisor at work had asked Student Name: ___________________ Student ID: __________________ Case Study Assignment 1 her to do because she was more focused on her worries about failing the task, than on what he was saying to her). In addition to concentration and memory difficulties, Susan’s anxiety and worry were accompanied by irritability. She found that her temper was short, and she would often have the urge to snap at her kids over minor matters. She was experiencing difficulties falling asleep and staying asleep and would find that her worrisome thoughts would keep her awake. While the lack of sleep was troublesome to Susan, she indicated that she believed that this time spent worrying was productive and effective and helped her to avoid negative outcomes. She had frequent muscle tension and as a result would experience frequent headaches. Additionally, she reported feeling keyed up or on edge a lot of the time. Susan was very concerned about her excessive worry and anxiety and by her lack of ability to control negative events: “I hate feeling this way all day. I just want to feel normal and in control of what’s going on in my life!” In addition to the distress her symptoms caused, they interfered a great deal with her life. For example, she spent many extra hours at the office, arriving 30 minutes early every day to “make sure that I have my day all planned out as much as possible.” It took her much longer than necessary to accomplish tasks or to make decisions because she would question the accuracy of every step in the process. In addition, she reported that her symptoms had a negative impact on her social and family life. She claimed that her children often complained that she was always in a bad mood and snapping at them. She knew that she was spending little time with her friends and had notices that the few men she dated never seemed to call her back after the first or second date: “They can sense that I’m not a fun person.” Moreover, her worry and anxiety had affected her physically. She reported having high blood pressure and tension headaches, which her family doctor had attributed to stress. Susan reported a fairly typical middle-class upbringing. She got along quite well with her two younger brothers and her parents. She regarded her parents as “uptight and serious” but they treated her fairly and kindly. She indicated that her mother had a brief period of depression shortly after giving birth to Susan’s youngest brother but to her knowledge that was the only history of mental illness in her family. Susan recalls experiencing similar bouts of worry in high school. The worries in high school began shortly after she started at a new school where she did not know anyone. At first, she was receiving straight A’s but when she started receiving a few B’s she began to worry excessively that she would fail all of her classes. This made it difficult for her to sleep and concentrate and soon she began to worry about her lack of sleep and other trivial day-to-day events. Her symptoms waxed and waned throughout high school and college. She got married shortly after college and enjoyed a few years with few worries or difficulties concentrating but after her divorce her worries began to resurface. Student Name: ___________________ Student ID: __________________ Case Study Assignment 1 Questions: 1. What is the best diagnosis for the case described above? Include appropriate specifiers (if applicable). [20 points] 2. Provide the DSM 5 criteria for the disorder you have diagnosed the case with and provide a specific and detailed justification/description of how the case meets EACH of the DSM 5 criteria for the disorder. You may paraphrase or quote from the case description as necessary. [60 points] 3. What factors appear to have contributed to the etiology of the disorder? [15 points] 4. What treatment approach would you recommend for this individual? [15 points] ****************************************************************************** For Grader: *Total Deductions (10% each day late) ____________ Total Points Earned (out of 110) _____________ Graded by ________________ ****************************************************************************** 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Part I: Key Concepts and Definitions Lecture 1: Definitions and History 1 What is Psychopathology? 2 What is a Psychological Disorder? • “No definition can capture all aspects of all disorders.” (DSM 5-TR) • Psychopathology – The scientific study of psychological disorders • Psychological Disorder – A psychological dysfunction associated with distress or impairment in functioning and a response that is not typical or culturally expected 3 4 1 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 1. Google Poll What is Psychological Dysfunction? • Psychological Dysfunction – A breakdown in cognitive, emotional or behavioral functioning A person who thinks he will never be able to succeed in this course even though he has done well in all his other courses has a breakdown in __________________. – Examples • Believing you are God (breakdown in cognition) • Being unable to experience pleasure (breakdown in emotion) • Being unable to leave home and get to work (breakdown in behavior) a. b. c. • Note: A psychological dysfunction alone is not sufficient to warrant a diagnosis of a psychological disorder d. e. Cognition Emotion Behavior A and C None of the above 5 2. Google Poll Distress and Impairment • Distress – the individual is extremely upset or disturbed by their symptoms (i.e., they are suffering) A person who thinks the water in his house is being contaminated by the CIA and has refused to shower in over a month has a breakdown in ______________. a. b. c. d. e. 6 • Impairment – the individual is not able to function properly in one or more aspects of life (personal, social, occupational) Cognition Emotion Behavior A and C None of the above § Examples – Taking amphetamines and refusing to sleep (impairment) due to fear of being abducted by aliens (distress) – Being unable to get work done (impairment) because you are so anxious (distress) that you will not be able to meet a perfectionistic standard 7 8 2 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Atypical or Not Culturally Expected Distress or Impairment • Atypical – deviating from average • Distress is not a necessary or sufficient condition for a diagnosis of a psychological disorder • Not Culturally Expected – violation of cultural norms – Examples – In most cases if the person is not distressed then they must have impairment in functioning to be given a diagnosis • Cursing and yelling at nothing in particular on the bus • Picking up “junk” from the street and refusing to throw anything away • Impairment in functioning is also not a necessary or sufficient condition for a diagnosis of a psychological disorder • Typically, if the person is not impaired then they must be distressed to be given a diagnosis • If a person has symptoms that are mild, do not cause distress and do not interfere with functioning then typically they are not diagnosed with a psychological disorder 9 Example 10 3. Google Poll • Monique is a 24 yr old law school student. She is neatly dressed and very bright. She has been drinking alcohol since age 14. She drinks 5-6 glasses of wine when she goes out and a 2-3 glasses each night alone. She frequently misses morning classes because of hangovers, she has blackouts occasionally when she’s drunk, and she has withdrawal symptoms when she doesn’t drink. She denies having problems, but others have commented that she needs help. She also tried quitting using alcohol but found it impossible to resist the strong cravings. Does Monique have a psychological disorder? a. Yes b. No 11 12 3 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Attendance Check 1 Important Terms Use the QR Code or URL below to access a Google Forms Survey to input your name and student ID to get attendance points • Prevalence – the percentage of people in the population who have the disorder – Point Prevalence – the percentage of people in the population with the disorder at any given time – One-Year Prevalence – the percentage of people in the population with the disorder in a given year – Lifetime Prevalence – the percentage of people in the population who have had the disorder at any time in their lives • Incidence – the number of new cases that occur during a given time period (e.g., the one-year incidence) https://forms.gle/XUbaFo5FcHYAmjWf6 13 14 Other Important Terms 4. Google Poll • Approximately 1% of the population have schizophrenia at some point in their lives. This 1% statistic represents a ______. a. Point prevalence statistic b. One-year prevalence statistic c. Lifetime prevalence statistic d. Lifetime incidence statistic e. Point incidence statistic • Clinical Description – the unique combination of behaviors, thoughts, and feelings that make up a specific disorder • Etiology – the causes of a disorder • Sex Ratio – the ratio of females to males who have a disorder • Onset – the beginning of a disorder (how or when the disorder presents itself) – Acute Onset – disorder begins suddenly – Insidious Onset – disorder develops gradually over an extended period – Age of Onset – the age at which a disorder typically present itself 15 16 4 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Important Considerations Other Important Terms • Dimensional vs. Categorical – While a categorical approach is currently used (people are classified as having a disorder or not having a disorder) it is widely recognized that disorders are dimensional (they fall on a continuum of low severity to high severity) – It is normal to have some symptoms of some disorders, but many students misinterpret these low-level symptoms as an indication that they have a disorder. Try not to let this happen to you! • Prognosis – the anticipated course of a disorder • Course – the pattern of development and change of a disorder over time – Chronic Course – disorder tends to last a long time, often a lifetime – Episodic Course – individuals with the disorder tend to recover only to have later reoccurrences – Time-Limited Course – disorder tends to improve without treatment in a relatively short time 17 18 Important Considerations Careers in Psychopathology: The Mental Health Team • People have disorders, they are not the disorders • Clinical Psychologist – typically have a Ph.D. (or Psy.D.) in psychology with both research and clinical specialization and typically work as scientist practitioners (providing therapy and conducting research). Must be licensed and registered. – People have schizophrenia or bipolar disorder, they are not “schizophrenic” or “bipolar.” – Rosenhan study illustrates that these labels are powerful and affect the way we process information about people – Use of these labels increases stigma which can reduce treatment seeking and worsen outcomes • Psychiatrists – have a medical degree (an M.D.). Prescribe medications and some also provide therapy • Counseling Psychologist – typically have a Ph.D. or Ed.D. in psychology. Typically deal with adjustment and vocational problems rather than severe disorders 19 20 5 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Careers in Psychopathology: The Mental Health Team • Psychiatric Social Worker – Typically have a Masters of Social Work (MSW) degree. Focus more on the social issues (e.g., joblessness, homelessness) associated with psychological disorders 5. Google Poll • Do you plan to pursue a career as a mental health professional? a. No b. Yes, I want to become a clinical psychologist c. Yes, I want to become a psychiatrist d. Yes, I want to become a counseling psychologist e. Yes, I want to pursue a different career as a mental health professional • Psychiatric Nurses – Typically have registered nurse (R.N.) certification with specialized training in care and treatment of individuals with psychological disorders. May administer medication, educate families about the disorders and provide other support • Marriage and Family Therapist – Typically have a Masters (M.A.) degree. Often work under the supervision of a clinical psychologist 21 Part II: History 22 Prehistoric (6500 BCE) • Trephining – hole chipped into scull using crude stone instruments, presumably to allow evil spirits to escape – Believed to be the earliest treatment of mental disorders 23 24 6 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Ancient Chinese (2500 BCE) Ancient Greeks (400 – 300 BCE) • Ancient Chinese Medicine – Illness (including mental illness) caused by an imbalance of Yin (negative force/cold, dark vital air) and Yang (positive force/warm life sustaining vital air). – Example – Excited insanity was considered the result of an excess of yang, so treatment involved withholding food (a source of yang). • Humoral Theory – illness (including mental illness) is related to four bodily fluids (humors) • Blood – heart (cheerfulness & delirium) • Black Bile – spleen (melancholia) • Yellow Bile – liver (hot temper or mania) • Phlegm – brain (apathy) • Five elements linked to five climactic factors and various organs which were in turn linked to various emotions called “spirits.” Vital air within a person would concentrate on an organ producing the associated emotion • Hysteria – physical illness without medical cause was thought to be due to a wandering uterus • Heart (joy) • Lungs (sorrow) • Liver (anger) • Spleen (worry) • Kidneys (fear) 25 • Hippocrates – believed psychological disorders had natural causes and were due to brain pathology – First to use an integrative approach (emphasized importance of heredity and head injury as well as psychological and interpersonal dysfunction) – Classified all mental disorders into three categories – 1. mania, 2. melancholia 26 (depression), 3. phrenitis (brain fever) 6. Google Poll Ancient Greeks (400 – 300 BCE) Who attempted to understand psychological disorders by linking together the elements, climates, body, and emotion? a. Ancient Chinese b. Hippocrates c. John Grey d. A and B e. All of the Above • Plato and Aristotle – emphasized role of social environment and early learning in development of psychological disorders – Believed best treatment was rational discussions and humane care 27 28 7 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Middle Ages (500 – 1500 AD) Middle Ages (1500 AD) • Devils, demons and witches were believed to be the cause of mental disorders (and misfortunes) • Paracelsus – Swiss physician rejected ideas that psychological disorders were caused by devils, demons and witches. • Treatments included exorcisms, confessions, and attempts to make the body uninhabitable for evil spirits (confining, beating and torturing people) • Proposed that the movement of moon and stars affect people’s psychological functioning • Advocated treatment by bodily magnetism (passing magnets over people’s bodies), herbs and heavy metals 29 30 7. Google Poll The 18th to 19th Centuries • Moral Therapy (1700s) – originated by Philippe Pinel in Paris. Normal social interaction and behavior were modeled and reinforced. Patients’ emotional and spiritual development was emphasized, and institutions were made more humane • Who is credited for developing moral therapy? a. Dorothea Dix b. Philip Pinel c. Plato d. Aristotle e. C and D • Mental Hygiene Movement (1800s) – Dorothea Dix campaigned tirelessly for reform of asylums and for the humane treatment of people with mental disorders 31 32 8 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y The 19th Century The 18th to 19th Century • Syphilis (1800s) – the discovery that a bacterial infection could produce delusions reinvigorated ideas that psychological disorders had biological causes • Mesmer (1700s) – Austrian physician suggested “animal magnetism” was blocked. Treated patients with hysteria using magnetized water • John Gray (1800s) – prominent psychiatrist and superintendent of a large hospital in NY. Believed psychological disorders always had physical causes and treated patients as physically ill – Promoted rest, good diet and ventilation • Benjamin Franklin put Mesmer’s practices to the test using a double-blind procedure. His findings showed that “mesmerism” was nothing more than the power of suggestion (i.e., the placebo effect) 33 34 The 19th to 20th Century 8. Google Poll • Charcot (1800s) – neurologist who legitimized the practice of hypnosis after observing that the symptoms of hysteria could be induced and removed under hypnosis. Taught Freud • Mesmer’s beliefs were most similar to which of the following? a. Paracelsus b. Ancient Chinese c. Ancient Egyptians d. Hippocrates e. Philip Pinel • Breuer & Freud (1800-1900s) – found evidence of the unconscious using hypnosis (discovered that patients were often unable to recall some of the details they described while hypnotized) • Freud – developed the Psychoanalytic Model – Structure of the mind (id, ego, superego), 35 psychosexual stages of development, and defense mechanisms 36 9 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 9. Google Poll The 20th Century • Psychoanalytic Psychotherapy (Psychoanalysis) • Which of the following did not use hypnosis (or a form of hypnosis)? a. Freud b. Breuer c. Charcot d. Mesmer e. All of the above used some form of hypnosis – Free Association – clients encouraged to say whatever comes to mind without censoring themselves. Used to reveal unconscious conflicts – Dream Analysis – clients encouraged to record and describe their dreams. Attempt to gain insights into underlying emotional issues ²Classic psychoanalysis is rarely practiced today because it is not considered scientific and is not conducive to empirical testing. Nevertheless, some psychoanalytic concepts (unconscious, coping styles) remain valuable and a modern form of psychoanalysis, called psychodynamic psychotherapy, continues to be practiced today (but is less common than most would think) 37 38 Defense Mechanisms Defense Mechanisms • Defense Mechanisms – automatic (unconscious) psychological process that protect an individual against anxiety and awareness of internal or external stressors • Defense Mechanisms continued – Projection – the individual falsely attributes their own unacceptable thoughts or feelings onto to another person – Denial – the individual refuses to acknowledge some painful aspect of external reality or subjective experience that would be apparent to others (e.g., spouse is cheating) – Repression – the individual expels disturbing wishes, thoughts or experiences from conscious awareness – Displacement – the individual deals – Rationalization – the individual comes up with an emotional conflict or stressor by transferring their feelings about one object onto a less threatening object with self-serving but incorrect explanations for their thoughts or behaviors 39 40 10 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 10. Google Poll Defense Mechanisms • Mary didn’t get into the graduate school of her dreams, and it was the only school to which she applies. She decides that school really wasn’t for her anyway. Which defense mechanism is she most likely using? a. Denial b. Displacement c. Rationalization d. Sublimation e. Projection • Defense Mechanisms continued – Reaction Formation – the individual substitutes thoughts or feelings that are diametrically opposed to their own unacceptable thoughts or feelings – Sublimation – the individual deals with emotional conflict or stressors by channeling maladaptive feelings or impulses into socially acceptable behavior 41 Attendance Check 2 42 The 20th Century Use the QR Code or URL below to access a Google Forms Survey to input your name and student ID to get attendance points • Insulin Shock (1920s) – insulin was used to produce convulsions that seemed to alleviate symptoms. Very dangerous and some patients went into comas and died • Electric Shock (1930s) – Italian psychiatrists successfully treated patients by inducing convulsions. A more refined version of ECT is still used today to treat mood disorders – Sherwin Nuland Ted Talk http://www.ted.com/talks/sherwin_nuland_on_electroshock_therapy.html https://forms.gle/x4mFVbiACcnSLmUp6 43 44 11 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Sherwin Nuland Ted Talk The 20th Century • Lobotomy (1930s) – surgical procedure that involved severing the connections to the prefrontal cortex – Believed it would calm emotions and stabilize patient without harming their intelligence or motor functions – Initially used in extreme cases but then marketed for less extreme disorders – Over 50,000 people in the US were lobotomized until one died 45 46 The 20th Century The 20th Century • Drugs (1950s) – drug called Reserpine and a class of drugs called neuroleptics (major tranquillizers) were found to be effective in reducing hallucinations and delusions and reducing agitation and aggressiveness • Humanistic Theory – the basic quality of human nature is positive, and we can all reach our highest potential (self-actualize) if given the freedom to grow – Carl Jung – emphasized the positive nature of humans and the importance of setting goals and realizing our fullest potential • Benzodiazepines – (minor tranquilizers) were also found to be effective in reducing anxiety – Alfred Adler – believed human nature reaches its fullest potential when we contribute to others and society 47 48 12 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y The 20th Century The 20th Century • Humanistic Theory – the basic quality of human nature is positive, and we • The Behavioral Model – emphasizes the role of learning in human behavior and the importance of studying directly observable behavior can all reach our highest potential (self-actualize) if given the freedom to grow – Pavlov (1920s) – physiologist who discovered – Maslow (1940s) – postulated a hierarchy of needs and suggested that we need to fulfill our more basic needs (food and shelter) before we can progress to self-actualization classical conditioning • Neutral stimulus (tone) paired repeatedly with unconditioned stimulus (shock). Neutral stimulus will begin to produce the unconditioned response (startle) – Watson (1920s) – first to apply classical – Carl Rogers (1960s) – developed Person-Centered Therapy in which the therapist uses unconditional positive regard and makes as few interpretations as possible conditioning to humans. Conditioned a fear of rats in a baby named Albert by startling him each time he reached for the rat 49 50 The 20th Century The 20th Century • The Behavioral Model – emphasizes the role of learning in human behavior and the importance of studying directly observable behavior – Jones (1920s) – student of Watson who used principles of extinction to extinguished a fear of furry objects in a boy named Peter • The Behavioral Model – emphasizes the role of learning in human behavior and the importance of studying directly observable behavior – Skinner (1930s) – discovered operant conditioning in which the behavior that is reinforced will be repeated • Based on Thordike’s Law of Effect – Wolpe (1950s) – created systematic – Bandura (1960s) – emphasized learning desensitization • A highly effective treatment in which individuals are very gradually introduced to the object or situation they fear. Over time they learn that nothing bad happens and their fear begins to diminish through modeling which is the idea that behavior can be shaped simply by watching other people’s behavior be reinforced • Famous Bobo doll study 51 52 13 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Attendance Check 2 A Multidimensional Integrative Approach Use the QR Code or URL below to access a Google Forms Survey to input your name and student ID to get attendance points • Multidimensional Integrative Approach (1990s) – Behavior is a product of the interaction between biological, psychological AND social influences 53 https://forms.gle/x4mFVbiACcnSLmUp6 54 12. Google Poll 11. Google Poll • How do you find my lecture style? a. Very monotone and boring b. A bit monotone and boring c. Fine d. Somewhat engaging and interesting e. Very engaging and interesting • How do you find my lecture speed? a. Way too slow b. A bit slow c. Good d. A bit fast e. Way too fast 55 56 14 8/20/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 13. Google Poll • How much do you like my class? a. I strongly dislike it b. I don’t really like it c. It’s fine d. I like it e. I really like it a lot 57 15 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y What Causes Psychological Disorders? Lecture 2: Contemporary Theories of Psychopathology • Multidimensional Integrative Approach (Biopsychosocial Model) – Contemporary theories of psychopathology focus on the many different factors that can contribute to psychological disorders and how they may interact with each other to increase a person’s susceptibility for developing a psychological disorder 1 What Causes Psychological Disorders? 2 Part I: Biological Contributions • Biological Factors – genetic factors, neurotransmitters, brain structure and function • Psychological Factors – cognitive, behavioral, emotional, and developmental factors • Social Factors – cultural factors, gender, social relationships, stigma, and abuse 3 4 1 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Genetics Gene Environment Interactions • Genetic factors contribute to all psychological disorders but typically account for less than half of the risk (the amount varies across disorders) – Polygenetic – influenced by many genes rather than by one “defective” gene (dominant or recessive) • Diathesis-Stress Model – individuals inherit (through multiple genes) tendencies or vulnerabilities to express certain traits or behaviors which may then be activated under certain environmental conditions like stress – Protective Factors (like a consistent, loving, nurturing environment) may modify the response to stress • Genetic effects are indirect – “Faulty” genes may lead to structural abnormalities in CNS, hormonal imbalances, neurotransmitter imbalances, etc. • Epigenetics – environmental factors (e.g., diet, smoking, drug use) can turn genes on or off + é Risk 5 Gene Environment Interactions 6 1. Google Poll • Which statement bests describes the influence of genetics on psychological disorders? • No matter how strong a specific genetic predisposition is, it may never be expressed • Similarly, maladaptive environments may have little effect on the development of a psychological disorder unless the individual has a genetic predisposition a. b. c. • Further, not everyone who has a genetic predisposition to a disorder and who experiences a major stressor will go on to develop a psychological disorder (protective factors can guard against these effects) d. 7 Genes cause psychological disorders in a direct manner Genes cause psychological disorders indirectly by causing us to be stressed Genetic predispositions interact with environmental conditions to produce psychological disorders Genes play a minimal role; it is our environment that is most important 8 2 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Neurons 2.Google Poll • Which part of the neuron secretes the chemical messages (i.e., neurotransmitters) out of the neuron and into the synapse? a. Dendrites b. Axon c. Axon terminals d. Terminal buttons • Neurons – cells in the nervous system that transmit information via electrochemical impulses • Dendrites – branches on cell body of neurons. Contain receptors which receive chemical messages in synapses • Cell Body – the metabolic center of the neuron (contain mechanisms to keep cell alive) • Axon – branch on neuron that transmits messages from cell body to terminal buttons • Terminal Buttons (Axon Terminals) – release neurotransmitters into the synapse • Neurotransmitters – chemical messengers secreted by terminal buttons into synapses • Synapses – spaces between neurons e. C and D 9 Neurotransmitters 10 Neurotransmitters • Serotonin – regulates behavior, mood and thought processes • GABA – an inhibitory neurotransmitter that inhibits a variety of behaviors and emotions. Reduces anxiety, overall arousal, and emotional responses – Low levels associated with instability, impulsivity, obsessive compulsiveness, tendency to overreact, aggression, depression – Drugs – Tricyclic Antidepressants , SSRIs (e.g., Prozac) Treat anxiety, mood, OCD, and eating disorders – Drugs – benzodiazepines (e.g., Valium) • Dopamine – associated with exploratory and pleasure-seeking behaviors – Used to treat anxiety • Glutamate – an excitatory neurotransmitter that facilitates expression of behaviors and emotions – Overactive in individuals with schizophrenia and underactive in people with depression – Drugs – Antipsychotics (e.g., Reserpine) – Drugs – PCP and Ketamine (NMDA antagonists) • Norepinephrine (aka Noradrenaline) – involved in the “flight or fight” response, alertness, arousal – Can produce symptoms of schizophrenia – Drugs – Tricyclic Antidepressants, SNRIs – Treat depression 11 12 3 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y The Endocrine System – Hormones The HPA Axis • Pituitary Gland – master gland which • HPA Axis – hypothalamic pituitary-adrenal cortical produces regulating hormones. Connected to the hypothalamus • Pineal Gland – produces melatonin which affects sleep patterns and circadian rhythms • Thyroid Glands – produce thyroxin which facilitates energy, metabolism and growth – Exposure to chronic, unpredictable stress during early development can sensitize this system – Implicated in several psychological disorders including depression, anxiety, and posttraumatic stress disorder – Hypothyroidism produces symptoms of depression – Hyperthyroidism produces symptoms of mania • Adrenal Glands – produce epinephrine (aka adrenaline) and cortisol in response to stress 13 14 Neuroimaging 3. Google Poll • Neuroimaging Techniques – used to better understand structural and functional abnormalities associated with various disorders – CAT Scan and MRI – detect structural abnormalities • Which of the following is NOT implicated in depression? a. Serotonin b. Dopamine c. Norepinephrine d. HPA Axis e. All of the above are implicated in depression • Patients with schizophrenia have been shown to have enlarged ventricles 15 16 4 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Neuroimaging Implications for Psychopathology • Neuroimaging Techniques – used to better understand structural and functional abnormalities associated with various disorders – PET, SPECT and fMRI– detect functional abnormalities • Presently, brain imaging is not used to diagnose psychological disorders – But people (e.g., neuroscientists) are working toward this so perhaps one day brain imaging will be helpful for diagnosis and treatment… • Limbic structures do not function normally in people with psychopathy • Brain imaging studies give us insight into areas implicated in various psychological disorders, but the direction of causality is unclear • Many psychological disorders are associated with “chemical imbalances” and drugs that balance these systems can be beneficial in treating disorders • However, therapy can also produce changes in the brain (even placebos can produce these changes) 17 18 Part II: Psychological and Social Contributions 4. Google Poll • Results from brain imaging studies: a. Provide insights into structural and functional abnormalities associated with psychological disorders b. Have provided proof that psychological disorders are directly caused by brain pathology c. Are difficult to interpret because psychological experiences can change the brain d. A and C e. All of the above 19 20 5 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Modern Behaviorism Modern Behaviorism • Learned helplessness (Seligman) – animals (including people) who repeatedly encounter negative conditions over which they have no control will give up • Social Learning Theory (Bandura) – we often learn vicariously, by observing the consequences of others’ behaviors vModern behaviorism has a cognitive element, incorporating our attributions and appraisals of our learning experiences 21 22 Cognitive Contributions Cognitive Contributions • Cognitive science has provided evidence for the unconscious, supporting the notion that our behavior can be guided by processes outside of our awareness • Memory and attention biases are associated with several psychological disorders – Blindsight – neurological condition in which individuals report that they cannot see objects, but they do react to them – Implicit memory – previous experiences can influence our behavior without our conscious awareness of those previous experiences – Individuals with depression tend to have biases towards attending to and remembering negative information – Individuals with OCD tend to have biases towards attending to and remembering stimuli that are perceived as threatening “Until you make the unconscious conscious, it will direct your life and you will call it fate.” ~Carl Jung 23 24 6 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 5. Google Poll Cognitive Contributions • The term “cognitive” is also used to refer to dysfunctional attributions and thought processes common in individuals with some disorders – Individuals with OCD tend to overestimate the likelihood of threat and their responsibility for preventing harm – Individuals with depression tend to think one failure they experience makes them a complete failure as a person – Individuals with anxiety tend to think anxiety is good and productive • The term “cognitive” refers to: a. memory and attention b. thought processes c. beliefs and attributions d. A and B e. All of the above 25 26 Cognitive Behavioral Therapy (CBT) Developmental Contributions • Focuses on identifying and correcting the dysfunctional attributions, attitudes and beliefs associated with some disorders • Several disorders have a typical age of onset in early adulthood • This is a particularly stressful time when people are undergoing many life changes and social stress • The brain is not fully mature until early adulthood. Abusing drugs before this time can therefore have greater detrimental effects (e.g., imbalances in certain neurotransmitter systems) – Exposure and Response Prevention • Prenatal exposure to viruses (mother becoming ill during pregnancy) is linked to some disorders (ERP) – a specific type of CBT used to treat OCD. Clients are exposed to their feared situation and prevented from engaging in the associated ritualistic behavior • Other disorders (e.g., dementias) do not present themselves until older adulthood 27 28 7 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Social Contributions Social Contributions • Neglect, abuse and maladaptive peer relationships can contribute to psychological disorders • Lower socioeconomic status (SES) is associated with higher rates of psychological disorders – Impairment associated with disorders can lead to decreased SES – Lower SES can increase stress and vulnerability to • The size and quality of social networks is inversely correlated with physical illness and some psychological disorders (e.g., depression, alcoholism) psychological disorders • The social stigma associated with many psychological disorders leads many to avoid seeking help or discussing their problems 29 30 Social Contributions Cultural Contributions • Gender differences in many disorders illustrate the important role social factors can play in the expression of psychological disorders • Research suggests that many psychological disorders are universal (e.g., schizophrenia) however others can appear quite different across cultures (e.g., depression) and some are specific to certain cultures (e.g., Koro). 31 32 8 1/17/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Impacts of Racism and Discrimination 6. Google Poll • Race – social (not biological) construct used to divide people into groups based on superficial physical traits (e.g., skin color) • Which of the following social factors are NOT believed to contribute to psychological disorders? a. Socioeconomic status b. Gender roles c. Relationships with friends and family d. Culture e. All of the above are believed to contribute • Racism exists at personal, interpersonal, institutional, and social structural levels • Racism and discrimination based on race can have profound effects on mental health – Racism contributes to a wide variety of adverse health outcomes, including suicidal behavior, post-traumatic stress disorder and can predispose people to substance use, mood disorders, and psychosis – Other adverse consequences of discrimination include unequal access to care and clinician biases in diagnosis and treatment • Misdiagnosis (e.g., schizophrenia in Black people), more coercive pathways to care, less time in outpatient treatment, more frequent use of physical restraints and suboptimal treatments 33 34 Conclusions • The issue of what causes psychological disorders is extremely complex – Numerous factors including biological, psychological (behavioral, cognitive, developmental), and sociocultural factors combine and interact to increase vulnerability to psychological disorders • Equifinality – The same disorder may present itself in different people for different reasons (have different underlying causal factors) 35 9 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Anxiety Disorders Lecture 4: Anxiety Disorders • Affect over18% of the population in the past year (one-year prevalence) and nearly 30% in their lifetime (lifetime prevalence) • Most common category of psychological disorders in the U.S. • Highly treatable but only ⅓ of those with an anxiety disorder seek treatment 1 2 What is Anxiety? What is Fear? • A negative mood state characterized by bodily symptoms of physical tension and apprehension about the future • Anxiety involves anticipation of future threat • In contrast, fear is an emotional response to real or perceived imminent threat § Subjective Component – sense of unease, worry, dread, sense of being unable to predict or control future threat – Subjective Component – thoughts of immediate danger § Behavioral Component – appearing worried, fidgeting, active avoidance – Behavioral Component – escape behaviors § Physiological Component – elevated heart rate and muscle tension – Physiological Component – surge of autonomic arousal (flight or fight) 3 4 1 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Panic Disorder Part I: Panic Disorder and Generalized Anxiety Disorder 6 5 Panic Disorder: Summary of DSM 5 Criteria Panic Disorder: Summary of DSM 5 Criteria A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state or an anxious state. • Recurrent – more than one panic attack is necessary • Unexpected – indicates panic attack occurs out of the blue; with no obvious trigger Note: The abrupt surge can occur from a calm state or an anxious state. • Intense fear response that occurs in the absence of any real danger and is accompanied by a sense of imminent danger or impending doom and an urge to escape Expected – indicates panic attack has an obvious cue or trigger • • Can also occur but cannot be used toward diagnosis of panic disorder 7 8 2 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 1. Google Poll Panic Disorder: Summary of DSM 5 Criteria A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: 1. palpitations 2. sweating 3. trembling or shaking 4. sensation of shortness of breath or smothering 5. choking feeling 6. chest pain or discomfort 7. nausea or abdominal distress 8. feeling dizzy or faint 9. chills or heat sensations 10. paresthesia (numbness or tingling sensations) • Have you ever experienced a panic attack? a. No b. Yes c. I don’t think so (possibly) 11. derealization (feeling detached from outside world) or depersonalization (feeling detached from oneself) 12. fear of losing control or “going crazy” 13 fear of dying 9 10 Panic Disorder: Summary of DSM 5 Criteria Panic Disorder: Summary of DSM 5 Criteria B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences C. The disturbance is not attributable to the physiological effects of a substance or another medical condition • Individuals often worry that the panic attacks signify life-threatening illness (like cardiac disease), about embarrassing self, losing control, “going crazy” 2. A significant maladaptive change in behavior related to the attacks • Individuals often engage in behaviors designed to avoid panic attacks (e.g., avoid situation that provoked previous attacks) • Interoceptive Avoidance – avoidance of situations or activities that produce physiological symptoms related to a panic attack (e.g., avoid exercise, sex, horror movies) • • 11 Must not be due to drugs like caffeine, cocaine, amphetamines, steroids Must not be due to medical conditions like hyperthyroidism or heart condition 12 3 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 2. Google Poll Panic Disorder: Summary of DSM 5 Criteria D. The disturbance is not better accounted for by another mental disorder (e.g., social phobia, specific phobia, OCD) • Chantelle has been under a lot of financial stress lately due to her recent divorce and job loss. She experienced a panic attack while in a shopping mall 2 weeks ago. Since that time, she has been worried that she will have additional attacks and has avoided malls and grocery stores. Should Chantelle be given a diagnosis of panic disorder? a. Yes b. No • If the person only experiences panic attacks during feared social situations, then social phobia is likely a better diagnosis • If the person only experiences panic attacks when exposed to a perceived threat (e.g., contamination) then OCD is likely a better diagnosis • However, individuals can have comorbid disorders (additional diagnosed disorders) if they meet full criteria for each disorder 13 14 DSM 5 Statistics Contributing Factors: Biological Contributions • Sex Ratio – 2:1 • Twin and family studies suggest a genetic contribution – First degree biological relatives of individuals with panic disorder are up to 8 times more likely to develop the disorder – Increased risk for panic disorder among offspring of parents with anxiety, depressive and bipolar disorders • Prevalence – One-Year – 2-3% – Lifetime – 4.7% • Age of Onset – median age of onset is 20-24 years • Likely a vulnerability to stress and neurobiological tendency to be over-reactive to stress (more likely to have an emergency alarm reaction when confronted with stressor) • Course – episodic course with years of remission between episodes or continuous severe symptomatology – Anxiety sensitivity – tendency to catastrophize the meaning of anxiety related bodily sensations – Heritable and common in individuals with panic disorder – Neuroticism – proneness to experience negative emotions ²Approximately 20% of individuals with panic disorder have attempted suicide (comparable to rates associated with major depressive disorder) – Heritable risk factor 15 16 4 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Contributing Factors: Biological Contributions Contributing Factors: Social Contributions • Over-activity in the noradrenergic system – Noradrenalin is synthesized in the locus coeruleus and stimulation of this brain region causes monkeys to have a panic attack – Drugs that stimulate activity in this brain region can elicit panic attacks in people with panic disorder • Stress – Most individuals report identifiable stressors in the months before their first panic attack • Modeling – parents may model anxiety sensitivity (tendency to catastrophize the meaning of anxiety related bodily sensations) • Diminished GABA receptor binding sites – GABA neurons typically inhibit noradrenalin activity – PET scans have found fewer GABA receptor binding sites in people with panic disorder 17 18 Contributing Factors Contributing Factors: Psychological Contributions • Conditioning – association of internal (e.g., racing heart) and external cues (e.g., location) with attack – These cues become “learned alarms” so the next time they are experienced they may trigger another panic attack Panic Cycle • Individuals experience anxiety about the prospect of having more attacks, this anxiety produces more physical sensations, they have an increased awareness of these sensations and that creates more anxiety, which results in more symptoms, creating a vicious cycle • Dysfunctional Beliefs – belief that physical sensations mean something terrible is going to happen (e.g., death) • Heightened interoceptive awareness – increased awareness of internal sensations (e.g., racing heart) 19 20 5 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Treatment: Medications Treatment: Therapy • SSRIs (e.g., Prozac) • Exposure-Based Treatment – gradual exposure exercises that are sometimes combined with anxiety reducing coping strategies (relaxation, deep breathing) – Significantly diminish panic attacks in as many as 70% of clients – More commonly prescribed because they are associated with fewer side effects • Tricyclic antidepressants (e.g., Imipramine) • Benzodiazepines (e.g., Xanax) • Panic Control Treatment – focuses on exposing clients to interoceptive sensations associated with an attack (e.g., ask client to shake head, spin in chair, hold breath) to teach them that these sensations are normal and not dangerous and that they are in control of them – Can lead to dependence and addiction (not a long-term solution) • Approximately 60% of individuals with panic disorder are free of panic as long as they stay on an effective drug, but relapse is common once they stop taking the drug ²In the short-term medications and therapy are about equally effective but the effects of therapy tend to outlast the effects of medications so in the long-term therapy is superior § About 50% relapse after stopping a tricyclic antidepressant § About 90% relapse after stopping a benzodiazepine 21 3. Google Poll 22 Generalized Anxiety Disorder (GAD) • What is a comorbid diagnosis? When a person has an unconfirmed diagnosis When a person has a confirmed diagnosis c. When a person has a diagnosis for more than one disorder d. When a person is diagnosed after they have died a. b. 23 24 6 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 4. Google Poll GAD: Summary of DSM 5 Criteria A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (e.g., work, school performance) • Are you worried about the first exam? Very worried A little worried c. Somewhat worried d. Not at all worried a. b. • Excessive – The intensity, duration or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event • More days than not for at least 6 months – more than just normal short period of anxiety • Anxiety and worry about a number of events or activities (cannot be limited to work or school) § Individuals with GAD tend to worry about everything especially routine life circumstances 25 26 GAD: Summary of DSM 5 Criteria GAD: Summary of DSM 5 Criteria B. The individual finds it difficult to control the worry D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning – Difficult to keep worrisome thoughts from interfering with attention to other tasks C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): 1. Restlessness or feeling “keyed up” or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling asleep or staying asleep, or restless, unsatisfying sleep) • • 27 Most individuals with GAD report feeling distressed by their constant worries Many have difficulties with concentration that affect work 28 7 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y DSM 5 Statistics GAD: Summary of DSM 5 Criteria • Sex Ratio – 2:1 E. The disturbance is not attributable to the physiological effects of a substance (e.g., drug of abuse or medication) or another medical condition (e.g., hyperthyroidism) • Prevalence – Lifetime – 5.7% – One-Year – 3% F. The disturbance is not better accounted for by another mental disorder (e.g., panic disorder, social anxiety disorder, OCD) – – – • Onset – mean age of onset is 35 years If only worried about panic attacks, then panic disorder may be a better diagnosis If only worried about social situations, then social phobia may be a better diagnosis If only worried about contamination or other obsessions, then OCD may be a better diagnosis • Course – chronic course with waxing and waning symptoms (waxing especially during times of stress) 29 Contributing Factors: Biological Contributions 30 Contributing Factors: Biological Contributions • Family and twin studies suggest genetic contribution • Possible functional deficiency in GABA • ⅓rd of the risk of developing GAD is genetic – GABA plays a role in inhibiting anxiety in stressful situations so this • It is the tendency to develop anxiety generally, rather than GAD specifically deficiency may result in difficulty inhibiting anxiety that is inherited • GAD and major depressive disorder appear to have a common underlying genetic predisposition • May be result of personality trait neuroticism that is inherited • May be genes related to activation of corticotropin-releasing factor (CRF) system (which in turn activates the HPA axis) Same genes combined with different environmental conditions may produce anxiety or depression 31 32 8 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Contributing Factors: Psychological Contributions Treatment: Medications • History of experiencing unpredictable and uncontrollable stress (e.g., inconsistently angry parent) v Fewer people seek treatment for GAD than other anxiety disorders • Benzodiazepines (e.g., Valium) – Could lead to chronic state of anxiety – Side effects include cognitive impairments and dependence – Could sensitize the HPA axis (which would increase susceptibility to anxiety) • Antidepressants (e.g., Paxil) • Dysfunctional Beliefs – intolerance of uncertainty (even more so than other anxiety disorders), beliefs that worry is beneficial (think it helps avoid negative outcomes) • Perceived lack of control – Contributes to sense of uncertainty • Attentional bias toward perceived threats – Focus more on perceived threats 33 5. Google Poll 34 Treatment: Therapy • Cognitive Behavioral Therapy (CBT) – focuses on helping clients to identify, challenge, and correct erroneous beliefs about worry, to diminish intolerance of uncertainty and to intervene with relaxation techniques (breathing and visualization exercises, progressive muscle relaxation, meditation) when worry begins • Which neurotransmitter system do benzodiazepines most directly affect? a. Serotonin b. Norepinephrine c. Dopamine d. GABA e. All of the above – Therapist may also help the client evaluate the usefulness of worry and consider the likelihood of negative outcomes they are worried about ²As many as 77% of clients no longer meet criteria for GAD following CBT ²Medications and therapy show same benefits in short-term, but therapy shows longer lasting benefits 35 36 9 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Part II: Specific Phobia and Social Anxiety Disorder Specific Phobia 38 37 Specific Phobia: Summary of DSM 5 Criteria 6. Google Poll A. Marked fear or anxiety about a specific object or situation • Do you have a fear of a specific object or situation? a. Yes b. No • Response must differ from normal, transient fears that commonly occur in the population • Marked – fear or anxiety must be intense or severe – May take the form of a panic attack • Focus of fear may be anticipated harm from some aspect of the object or situation (plan crashing, dog biting) or concerns about losing control (panicking, fainting, falling) 39 40 10 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Specific Phobia: Summary of DSM 5 Criteria Specific Phobia: Summary of DSM 5 Criteria B. The phobic object or situation almost always provokes immediate fear or anxiety C. The phobic object or situation is actively avoided or endured with intense fear or anxiety Person responds with fear or anxiety every time they encounter the phobic stimulus – Degree of fear expressed may vary across different occasions or situations • More common for the phobic stimulus to be avoided than endured • Active avoidance – individual intentionally behaves in ways that are designed to prevent or minimize contact with phobic stimulus (e.g., move to an environment where snakes are rare) • Immediate – Fear occurs as soon as the phobic stimulus is encountered • 41 42 Specific Phobia: Summary of DSM 5 Criteria Specific Phobia: Summary of DSM 5 Criteria D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more • Fear or anxiety must be excessive or unreasonable • Individuals with specific phobia often recognize their reactions as disproportionate, however, they tend to overestimate the danger of the phobic stimulus and thus the judgment of being out of proportion is made by the clinician • Helps distinguish transient fears from full blown specific phobia F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in functioning 43 • Distress must occur outside the context of being confronted with the phobic stimulus • If the phobia does not significantly interfere with functioning (cause problems at work or home) or cause marked distress, then the diagnosis should not be made 44 11 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Specific Phobia: Summary of DSM 5 Criteria 7. Google Poll G. The disturbance is not better explained by the symptoms of another mental disorder (e.g., OCD, social anxiety disorder) • A panic attack in response to a phobic stimulus would be classified as: a. an unexpected panic attack b. an expected panic attack c. panic disorder d. A and C e. B and C • A fear of contamination may be better classified as OCD • A fear of panic attacks may be better classified as panic disorder ² To be diagnosed with a specific phobia the person must meet ALL of these criteria (A-G) 45 Specifier 46 Specific Phobia Specifiers • Situational – Fears of specific situations (e.g., tunnels, elevators, flying, driving, enclosed places) • Specifier – additional standardized “tags” or add-ons that can be applied to a primary diagnosis in order to better characterize the specific manifestation of the disorder • Natural Environment – Fears of objects in the natural environment (e.g., water, storms, heights) Blood/injection/injury 47 48 12 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y DSM 5 Statistics Specific Phobia Specifiers • Sex Ratio – 2:1 • Blood-Injection-Injury – Fears of blood or injury or receiving an injection or other medical procedure. Associated with strong vasovagal response (and fainting) – Varies across subtypes • Blood-injury-injection shows more balanced sex ratio than other types • Prevalence – Lifetime – 7-11% – One-Year – 8-12% • Animal – Fears of animals or insects • Other – Fears of other things (e.g., choking, vomiting, characters in costumes) • Onset – median age of onset is between 7 and 11 years of age • Course – chronic if left untreated (but very treatable) 49 Contributing Factors: Biological Contributions 50 Contributing Factors: Psychological Contributions • Family studies suggest a genetic contribution • Experience – Direct Experience – traumatic experience – Some evidence indicates that the specific with object or in situation, including panic attack – Vicarious Experience – witnessing traumatic experience – Information Transmission – being repeatedly told of dangers – Prepared Learning – a biological preparedness to fear certain objects that is shaped evolutionarily by natural selection subtype of phobia may run in families – Neuroticism (heritable personality trait) is a risk factor • Blood-Injury-Injection type is especially heritable • Specific phobia is associated with abnormal activity in the amygdala, anterior cingulate cortex, prefrontal cortex, and insula in response to the phobic stimulus • Vulnerability to Anxiety § Person must develop anxiety by focusing on feared outcome or event 51 52 13 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Treatment: Therapy 8. Google Poll • Exposure Therapy – Involves controlled gradual exposure to the feared object or situation • What is the difference between exposure therapy and systematic desensitization? a. • Systematic Desensitization – Involves controlled gradual exposure to the feared object or situation while relaxation techniques are used b. • Participant Modeling – Therapist calmly models interacting with the phobic stimulus or situation c. d. ²Only 12-30% of people with specific phobias seek professional help e. Exposure therapy involves relaxation techniques Systematic desensitization involves relaxation techniques In exposure therapy the feared object is introduced more gradually than in systematic desensitization In systematic desensitization the feared object is introduced more gradually than in exposure therapy B and D 53 Exposure Therapy 54 9. Google Poll • Do you sometimes feel a bit anxious in social situations? a. Yes b. No 55 56 14 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Social Anxiety Disorder: Summary of DSM 5 Criteria Social Anxiety Disorder (Social Phobia) A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others Examples include social interactions (e.g., having a conversation, meeting new people) , being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech) • • – Marked – fear or anxiety must be intense or severe May take the form of a panic attack 57 Social Anxiety Disorder: Summary of DSM 5 Criteria Social Anxiety Disorder: Summary of DSM 5 Criteria B. The individual fears that they will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others) • Individual may be concerned that they will be judged as anxious, weak, crazy, stupid, boring or unlikable • Individual may fear that they will show anxiety symptoms such as blushing, trembling, sweating, stumbling over words or staring that will be negatively evaluated by others 58 C. The social situations almost always provoke fear or anxiety • Degree and type of fear or anxiety may vary across situations, but they almost always experience symptoms of anxiety in feared social situations and may have a panic attack D. The social situations are avoided or endured with intense fear or anxiety • 59 More common for the social situation to be avoided than endured 60 15 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Social Anxiety Disorder: Summary of DSM 5 Criteria Social Anxiety Disorder: Summary of DSM 5 Criteria E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Individuals with social anxiety disorder often overestimate the negative consequences of social situations so the clinician must make this judgment • F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more • An individual afraid to speak in front of an audience would not receive a diagnosis if this activity is not routinely encountered in their job or at school and the individual is not distressed about it H. The fear, anxiety, or avoidance is not attributable to the effects of a substance or another medical condition Helps distinguish from more transient social anxiety 61 Social Anxiety Disorder: Summary of DSM 5 Criteria 62 Social Anxiety Disorder: Summary of DSM 5 Criteria I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder (e.g., panic disorder, body dysmorphic disorder, autism spectrum disorder) J. If another medical condition is present (e.g., Parkinson’s disease, obesity, disfigurement) the fear, anxiety or avoidance is clearly unrelated or is excessive • A person with Parkinson’s Disease who is afraid of trembling in public would not qualify for a diagnosis and a person with an eating disorder afraid of exhibiting abnormal eating in public would not qualify for a diagnosis ² To be diagnosed with social anxiety disorder the person must meet ALL of these criteria (A-J) 63 64 16 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 10. Google Poll Social Anxiety Disorder: Additional Characteristics • Which approach to classification is used for the diagnosis of specific phobia and social anxiety disorder? • Commonly hypersensitive to criticism, negative evaluation or rejection • Often have difficulty being assertive, have low self esteem, and feel inferior to others Categorical Prototypical c. Dimensional d. More than one of the above a. b. • Typically fear evaluation by others • May manifest poor social sills (like failing to make eye contact and talking less). This can make the problem worse because people may react negatively to them and like them less as a result of their poor social skills, confirming their beliefs that they are being judged poorly 65 66 Social Anxiety Disorder: Additional Characteristics DSM 5 Statistics • Often underachieve at school and work because of performance anxiety. • Sex Ratio – 1:1 in clinics but 1.5:1 in community • Tend to have decreased social support networks • Prevalence – One-year – 7% – Lifetime – 12% • In severe cases they may drop out of school, be unemployed and not seek work due to difficulty interviewing for jobs, have no friends, refrain from dating or stay at home with their parents • Onset – median age of onset is 13 years Onset may be acute (following a stressful or humiliating experience) or insidious • Self-medication with substances like alcohol is common • Course – chronic 67 68 17 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Contributing Factors: Biological Contributions Contributing Factors: Psychological Contributions • Family studies suggest a genetic contribution Experience – First degree biological relatives of individuals with social anxiety disorder have a 2-6 times greater chance of developing the disorder • Modeling – socially anxious modeling by parents • Direct Experience – experienced social humiliation – 55% of people with social anxiety recalled and identified a direct traumatic experience as being involved in the origin of their anxiety – 92% of people with social anxiety reported a history of severe teasing in childhood • Vicarious – witnessed another’s social humiliation • A trait of behavioral inhibition (i.e., shyness) is heritable and is evident as early as 4 months of age – Babies with this trait cry more and become more agitated by novel stimuli – Infants who demonstrate this trait have higher rates of social anxiety by adolescence 69 70 Contributing Factors: Psychological Contributions Treatment • Dysfunctional Beliefs – expect to be rejected and negatively evaluated. Overestimate others’ abilities to detect their anxiety • Medications – Tricyclic antidepressants – SSRIs (e.g., Paxil) – These thoughts interfere with their ability to interact skillfully with others creating a vicious cycle • Relapse is common once drugs are stopped • Attention and memory biases towards critical expressions – Increased activation in amygdala when viewing angry faces • Therapy – Cognitive Behavioral Group Therapy – involves rehearsing and role-playing socially phobic situations in front of others with social phobia. Therapist works to uncover and challenge distorted cognitions • Ruminate about previous social experiences especially negative ones • Produces longer lasting results than medication 71 72 18 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Agoraphobia Part III: Brief Consideration of Other Anxiety Disorders A. Marked fear or anxiety about two or more of the following: 1. Using public transportation 2. Being in open spaces 3. Being in enclosed places 4. Standing in line or being in a crowd 5. Being outside of the home alone B. The individual fears/avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms or other incapacitating or embarrassing symptoms C. The agoraphobic situations almost always provoke fear or anxiety D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety 73 Agoraphobia E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more Change to DSM 5 • DSM IV – had separate classifications for Panic Disorder with Agoraphobia and Panic Disorder without Agoraphobia • DSM 5 (and DSM-5-TR) – Panic Disorder and Agoraphobia have been separated into two distinct disorders G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other areas of functioning – Individuals can still be diagnosed with both panic disorder and agoraphobia (comorbid diagnosis) H. If another medical condition (e.g., Parkinson’s disease, inflammatory bowel disease) is present, the fear, anxiety, or avoidance is clearly excessive I. 74 • About 90% of people with agoraphobia have other mental disorders (other anxiety disorders, PTSD depressive disorders, and alcohol use disorder are common) The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder (e.g., social anxiety disorder, separation anxiety disorder) 75 76 19 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Separation Anxiety Disorder Separation Anxiety Disorder A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those whom the individual is attached as evidenced by at least 3 of the following: A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those whom the individual is attached as evidenced by at least 3 of the following 1. 2. 3. 4. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures Persistent and excessive worry about losing major attachment figures or about possible harm to them (e.g., illness, injury, death) Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation 5. 6. 7. 8. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings Persistent reluctance or refusal to sleep away from home or go to sleep without being near a major attachment figure Repeated nightmares involving separation Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea) when separation from major attachment figures occurs or is anticipated 77 78 Separation Anxiety Disorder Selective Mutism B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults A. Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations B. The disturbance interferes with educational or occupational achievement or with social communication C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning C. The duration of the disturbance is at least 1 month D. The disturbance is not better explained by another mental disorder (e.g., autism spectrum disorder, psychotic disorder, agoraphobia) E. D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation 79 The disturbance is not better explained by a communication disorder and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder 80 20 2/6/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Other Anxiety Disorders Case Study 1 • Substance/Medication-Induced Anxiety Disorder – symptoms of panic or anxiety judged to be due to the effects of a substance (drug of abuse, medication, toxin) • For the case study you will need to: i. Identify the best diagnosis for the case described [20 pts] ii. Describe in detail how the case meets the criteria for that diagnosis (in as much detail as possible) [60 pts] iii. Identify factors that may have contributed to the etiology of the disorder [15 pts] iv. Recommend an approach for treatment [15 pts] • Anxiety Disorder Due to Another Medical Condition – symptoms of panic or anxiety that are judged to due to the physiological effects of another medical condition • Other Specified Anxiety Disorder – presentations of symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment but do not meet the full criteria for any of the anxiety disorders • Worth 110 points • Due March 2 81 82 21 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Changes to the DSM 5 • In the DSM 5 a new class of disorders was created: the Obsessive-Compulsive and Related Disorders that includes Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, and Excoriation Disorder Lecture 5: Obsessive-Compulsive and Related Disorders • Obsessive-Compulsive Disorder (OCD) was classified as an Anxiety Disorder in previous editions of the DSM • Body Dysmorphic Disorder (BDD) was classified as a Somatoform Disorder in previous DSM editions • Hoarding was previously considered a symptom of OCD but is now its own disorder 1 Part I: Obsessive-Compulsive Disorder (OCD) • Trichotillomania (hair pulling disorder) and excoriation disorder (skin picking) used to be classified as impulse control disorders 2 1. Google Poll • Do you ever have aggressive, blasphemous, sexual or inappropriate thoughts that you find strange and out of character (e.g., thoughts of swinging your car into oncoming traffic, pushing or tripping an elderly person, having sex with someone you are not attracted to, yelling in class)? a. Yes, sometimes b. Yes, frequently c. No, never 3 4 1 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y OCD: Summary of DSM 5 Criteria OCD: Summary of DSM 5 Criteria A. Presence of obsessions, compulsions, or both A. Presence of obsessions, compulsions, or both • Obsessions are defined by (1) and (2): The individual can just have one without the other (e.g., compulsions without obsessions, or obsessions without compulsions). However it is more common for individuals with OCD to experience both obsessions and compulsions 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress • Ego-dystonic (or ego alien) – the content of the obsession is not within the individuals control and is discordant with their actual attitudes or beliefs – Example: Priest having blasphemous thoughts • Common obsessions include thoughts about contamination, doubts that tasks were performed (door was locked), aggressive, sexual or violent thoughts • The individual recognizes the intrusions come from their own mind 5 6 OCD: Summary of DSM 5 Criteria OCD: Summary of DSM 5 Criteria A. Presence of obsessions, compulsions, or both A. Presence of obsessions, compulsions, or both Obsessions are defined by (1) and (2): Compulsions are defined by (1) and (2): 2. The individual attempts to ignore or suppress such thoughts, urges, or images or to neutralize them with some other thought or action (i.e., by performing a compulsion) 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly • Example: an individual who has blasphemous thoughts may say a prayer to try to neutralize the thought • Examples of behaviors: repeated washing, repeated checking, ordering objects ² To qualify as an obsession both 1 AND 2 must be present • Examples of mental acts: praying, counting, repeating words silently 7 8 2 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y OCD: Summary of DSM 5 Criteria OCD: Summary of DSM 5 Criteria A. Presence of obsessions, compulsions, or both B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational or other important areas of functioning Compulsions are defined by (1) and (2): 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or they are clearly excessive • Some individuals show active avoidance of objects or situations that provoke obsessions or compulsions. In some cases, this avoidance can restrict functioning and in severe cases can leave the individual housebound • Performing compulsions may become a major life activity leading to disability in other areas of life • Individuals with obsessions about contamination may reduce mental distress by washing (excessive but connected in a realistic way) ² This criteria helps distinguish OCD from the occasional intrusive thoughts and repetitive behaviors (double checking a door is locked) that are common in the general population • Individuals distressed by blasphemous thoughts may count to 10 backwards and forwards 10 times (excessive and not connected in any realistic way) ² To qualify as a compulsion both 1 AND 2 must be present 9 10 2. Google Poll OCD: Summary of DSM 5 Criteria • What is a specifier? a. A person with OCD who insists everything must be specific b. A person with low tolerance for uncertainty c. A tag on that can be applied to a diagnosis to better characterize the specific manifestation of the disorder d. A drug that acts specifically on one neurotransmitter system C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., drug of abuse or medication) or another medical condition D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., GAD, BDD, eating disorder, illness anxiety) • Obsessive preoccupation with food may be better classified as an eating disorder, compulsive checking of a perceived physical defect would be better classified as body dysmorphic disorder, obsessive preoccupation and concern that one may have a serious illness may be better classified as illness anxiety 11 12 3 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y OCD: Video OCD: DSM 5 Specifiers • With good or fair insight – The individual recognizes that the obsessivecompulsive beliefs are definitely or probably not true or that they may or may not be true – Example: believe the house probably won’t burn down if they don’t check the stove 30 times Clip of “Chuck” • With poor insight – The individual thinks the obsessive-compulsive beliefs are probably true – Example: believe the house probably will burn down if they don’t check the stove 30 times • With absent insight/delusional beliefs – The individual is completely convinced that the obsessive-compulsive beliefs are true – Example: believe the house definitely will burn down if they don’t check the stove 30 times 14 13 DSM 5 Statistics 3. Google Poll • Sex Ratio – 1.5:1 in adults – In children it is more common in boys • What does the term “ego dystonic” refer to? a. The Freudian nature of intrusions (e.g., their tendency to focus on sex and aggression) b. People’s inability to control intrusive thoughts c. The tendency for intrusions to be in accord with people’s beliefs and values d. The tendency for intrusions to be discordant with people’s beliefs and values e. A and D • Prevalence – Lifetime – 2.2% – One-Year – 1.2% • Onset – mean age of onset is 19.5 years Onset is typically insidious but acute onset also possible • Course – chronic but waxing and waning 15 16 4 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Contributing Factors: Biological Contributions Contributing Factors: Biological Contributions • Neuroimaging and neuropsychological studies suggest functional brain abnormalities in the frontal regions and basal ganglia (including caudate nucleus and amygdala) • Family and twin studies suggest a genetic contribution – Monozygotic twins are more likely to both have the disorder than dizygotic twins – Difficult to know if these are a cause or consequence of OCD (or both) – First degree biological relatives of adults with OCD are twice as likely to – Caudate nucleus is important in managing habitual develop OCD – First degree biological relatives of adults who had a childhood onset of OCD are 10 times more likely to develop OCD and repetitive behaviors – Increased activation of frontal lobes may reflect their over concern with their own thoughts • Adverse perinatal events, premature birth, and maternal smoking during pregnancy are associated with increased risk of OCD • Occasionally develops after brain insult or injury (e.g., brain tumor, encephalitis, head injury) 17 Contributing Factors: Psychological Contributions • Infectious agents and post-infectious autoimmune syndrome 18 Contributing Factors: Psychological Contributions • Dysfunctional Beliefs • Stressful events (e.g., childhood physical and sexual abuse and other stressful or traumatic events) associated with increased risk of developing OCD • Memory and attention biases • Inflated sense of the importance of thoughts and need to have control over them – Thought action fusion: belief that negative thoughts are the moral equivalent of actions and/or that these thoughts will increase the likelihood that something terrible will happen – Attend more to stimuli that are perceived to be threatening and are therefore better able to remember these threatening stimuli – Individuals with checking compulsions appear to have problems with prospective memory (the ability to remember to do things). Prospective memory failures may contribute to doubt that other tasks were not completed which may increase urges to check – Repeated checking can diminish memory for their performance on the task • Inflated sense of responsibility and inflated sense of threat • More likely to think that bad things will happen and that they are responsible for preventing them from happening – Believe not preventing harm is as bad as causing harm 19 • Heightened levels of perfectionism and increased intolerance of uncertainty 20 5 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 4. Google Poll Contributing Factors: Psychological Contributions • Did you think of a pink elephant? a. Yes, more than once b. Yes, but only once c. No not at all • Individuals with OCD believe their thoughts are unacceptable and/or terrible and so they often try to suppress them. However, attempts at thought suppression backfire and increase intrusions 21 Treatment: Medication 22 Treatment: Brain Surgery Psychosurgery • Surgical lesion to the cingulate bundle – Only used in severe cases that are not responsive to medication or therapy (radical last resort) • SRIs (SSRIs and Clomipramine) – Effective in about 50% to 60% of individuals but only moderately reduce symptoms and relapse is common when drug is discontinued Deep Brain Stimulation – Involves implanting electrodes into the nucleus accumbens that sends electrical impulses to stimulate this brain region (like a pacemaker for the brain) 23 24 6 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Treatment: Therapy Treatment: Therapy • Exposure and Response Prevention (ERP) – individuals are gradually exposed to their feared stimuli (e.g., contamination) while resisting engaging in compulsions (e.g., washing) • Traditional Cognitive Behavioural Therapy (CBT) – focuses on identifying and challenging dysfunctional beliefs • Taught that most people have intrusive thoughts and that they are normal and don’t make them a bad person – Teaches them anxiety subsides on its own even if they don’t engage in compulsion and that nothing terrible happens if they don’t engage in the compulsion – Requires about 15-20 90-minute sessions – About 15-20% refuse or drop out of treatment and another 20% do not show improvement with treatment 25 26 Part II: Body Dysmorphic Disorder (BDD) Treatment: Therapy • ERP and CPT are about equally effective – While ERP does not directly target dysfunctional beliefs it does correct them – Many therapists use a combination of these two types of therapy • ERP alone is more effective than medication alone. • The combination of ERP and medication is equally as effective as ERP alone suggesting ERP alone is an effective treatment approach 27 28 7 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y BDD: Summary of DSM 5 Criteria BDD: Summary of DSM 5 Criteria A. Preoccupation with one or more perceived defects or flaws in appearance that are not observable or appear slight to others B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, etc.) or mental acts (e.g., comparing their appearance to others) in response to their appearance concerns • Individual perceives flaw or defect as ugly, abnormal or deformed, but the flaw is not observable to others or appears slight to others • Individual may spend hours a day checking the imagined defect in reflective surfaces and use special lighting or magnifying mirrors to scrutinize perceived flaw (others avoid mirrors and still others alternate between the two) • Concerns range from looking unattractive or not right to looking hideous or like a monster • Preoccupations can focus on one or many body areas, most commonly the skin, hair and nose – • Intent of checking is to reduce anxiety, but it tends to intensify their preoccupation and anxiety Examples – hair thinning, acne, wrinkles, scars, paleness, redness, asymmetry, facial hair, size or shape of nose, eyes, teeth • May try to camouflage their perceived defect, get plastic surgery or resort to self-surgery • Preoccupations are intrusive, unwanted and time-consuming (occurring on average 3-8 hours a day) and are difficult to control 29 BDD: Summary of DSM 5 Criteria Plastic surgery is not successful and can cause the disorder to worsen or spread to new preoccupations 30 BDD: Summary of DSM 5 Criteria C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder Most individuals experience a great deal of distress and describe it as “intensely painful,” “tormenting,” or “devastating” • Thoughts can start to dominate life • Self-consciousness may lead to avoidance of work, school or public places – About 20% of youths with BDD drop out of school because of symptoms • Can lead to repeated hospitalization, suicidal ideation and suicide attempts • 31 32 8 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y 5. Google Poll BDD: Specifiers • Which of the following is NOT one of the specifiers for OCD? a. With poor insight b. With good or fair insight c. With absent insight/delusional beliefs d. With panic attacks e. All of the above are specifiers for OCD • With good or fair insight – The individual recognizes that the body dysmorphic beliefs are definitely or probably not true or that they may or may not be true • With poor insight – The individual thinks that the body dysmorphic beliefs are probably true • With absent insight/delusional beliefs – The individual is completely convinced that the body dysmorphic beliefs are true – May also have ideas or delusions of reference (false belief that others are thinking/looking/talking about their perceived defect) 33 34 BDD: Video BDD: Video Doug Doug 35 36 9 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y BDD: Video DSM 5 Statistics • Sex Ratio – 1:1 • Prevalence – Point Prevalence – 2.4% of general population – Much higher rates seen in cosmetic surgery and dermatology settings Doug • Onset – mean age of onset is 16-17 years of age. Typically presents before the age of 18 – Onset is typically insidious with subclinical concerns evolving gradually to the full disorder 37 • Course – chronic with few symptom free intervals (but intensity may wax and wane) – Area of concern may stay the same or change over time Contributing Factors Contributing Factors: Psychosocial Contributions • Theory that it is a variant of OCD – It shares many features with OCD • Intrusive thoughts about defect and compulsive checking • Similar age of onset and course • Similar abnormal brain functioning • Both disorders respond to similar treatments • Prevalence of BDD is elevated in first degree relatives of people with OCD (shared genetic vulnerability) • Childhood neglect and abuse • Experience – more likely to have been teased about their appearance • Dysfunctional Beliefs – may believe they are worthless if they are not attractive 38 – Hold attractiveness as their primary value • Attentional bias towards beauty and attractiveness – Found to selectively attend to words related to beauty and attractiveness – Focus on details of faces more than others who see face as whole ² The similarities with OCD are why the DSM 5 moved BDD from the somatoform disorders section to the new Obsessive-Compulsive and Related Disorders section • Our society values and emphasizes beauty 39 40 10 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Treatment 6. Google Poll Medications • Plastic surgery for individuals with body dysmorphic disorder generally results in: a. little, if any, patient satisfaction b. an improved self-image c. complete relief from the current concern, but with new concerns arising over time d. temporary relief followed by a relapse e. c and d • SRIs (e.g., Fluoxetine and Clomipramine) Therapy • Exposure and Response Prevention Therapy – involves getting the client to identify and change distorted appraisals of their body, engage in exposure to anxiety-provoking situations (e.g., wearing something that highlights rather than disguises their perceived “defect”) and prevent checking responses (mirror checking and reassurance seeking) – Produces marked improvement in 50-80% of individuals with BDD ²Therapy is more effective than medication 41 42 Hoarding Disorder Part III: Brief Consideration of Other OC-Related Disorders A. Persistent difficulty discarding or parting with possessions, regardless of their actual value B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). 43 44 11 2/27/23 WA S H I N G T O N S T AT E U N I V E R S I T Y Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others) A. Recurrent pulling out of one’s hair, resulting in hair loss E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome) C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., OCD, major depressive disorder, psychotic disorder) B. Repeated attempts to decrease or stop hair pulling D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition) E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., BDD) 45 46 Excoriation (Skin-Picking) Disorder Other Obsessive-Compulsive and Related Disorders A. Recurrent skin picking resulting in skin lesions • Substance/Medication-Induced Obsessive–Compulsive and Related Disorder – symptoms of OCR disorders predominate but there is evidence that the symptoms developed during or soon after medication/substance intoxication or withdrawal and the substance/medication is capable of producing the symptoms B. Repeated attempts to decrease or stop skin picking C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Obsessive–Compulsive and Related Disorder Due to Another Medical Condition – symptoms of OCR disorders predominate but there is evidence that the disturbance is the direct pathophysiological consequence of another medical condition D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) another medical condition (e.g., scabies) E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., BDD) • Other Specified Obsessive-Compulsive and Related Disorder – presentations of symptoms characteristic of an OCR disorder that cause clinically significant distress or impairment but do not meet the full criteria for any of the obsessive-compulsive and related disorders 47 48 12
Purchase answer to see full attachment