Abnormal Psychology: Concepts and Theoretical Perspectives, Exams of Nursing

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Psych 2490: Abnormal psychology final exam notes Unit One: Concepts of Abnormality Through History & Classification and Diagnosis (p.50- 52) - Psychological abnormality: ● Behavior, speech, or thought that impairs the ability of a person to function in a way that is expected from him/her, in the context where the unusual functioning occurs. - Mental Illness: ● Often used to convey the same meaning but → Implies a medical rather than a psychological cause - Psychological disorder: ● A specific manifestation of this impairment of functioning, as described by a set of criteria that have been established by a panel of experts - Psychopathology: ● Both the scientific study of psychological abnormality and the problems faced by people who suffer from such disorders Attempts at defining abnormality: - Statistical concept ● Behavior judged abnormal if it occurs infrequently in the population ● Not all infrequent behaviors or thoughts should be judged abnormal -- e.g., innovative ideas or athletic prowess ● Not clear how unusual a given behavior has to be in order to be considered abnormal - Personal Distress ● Many people who are considered to have a psychological disorder report being DISTRESSED ● Distress is not present for all people identified as abnormal → e.g., manic patient, exuberant, very happy -- not distressed but suffers from mental disorder ● Others may be distressed but not considered abnormal, as all of us are distressed or even depressed at times which is normal, depends on how long it may persist ● Stone age remains provided evidence of supernatural beliefs ● Skulls have been found with circular sections cut out of them ➔ Trephination: prehistoric practice of chipping a hole into a person’s skull, possibly intended to let out evil spirits ➔ Trephination may have been intended to remove bone splinters or blood clots ● We know from early written records that demonic possession was popularly accepted in early human society as the cause of madness ● Egyption papyri 4000 yrs ago → describe supernatural explanations for various disorders and the use of magic and incantations as treatment • Greek and Roman philosophers and physicians held surprisingly modern views and emphasized biological and psychological causes and treatments of disorders. ● Hippocrates (father of medicine) , Plato, Aristotle, Soranus of Ephesus, Galen -Vomiting or bleeding arose primiarily as result from Hippocrates idea psychological functioning resulted from disturbances of bodily fluids or humours as they were called. First to describe hysteria, conversion disorder: blindness, deafness. In the Arab world , treatment was humane and environmental and psychological factors were emphasized. ● Mohammedan period → supportive and kindly approaches to the mentally ill, reflects compassion ● Avicenna → The canon of medicine. Analyses of mental disorder reflect a practical approach characterized by an emphasis on natural causes, particularly environmental and psychological. • During the Middle Ages in Europe , attributing supernatural causes to psychological disorders became more common again, although some individuals continued to explore other potential causes. - Hypnotism and psychoanalytic ● Mesmer prompted an interest in the powers of suggestion → Charcot (1825-1893) believed that hypnotism might have value in treating hysterics ● Charcot’s student claimed that hysteria resulted from a break in the organized system of thought and emotion ● Joseph Breuer and Sigmund freud → elaborated complex psychological conceptualization of mental disorders and developed specific treatment methods ➔ Breuer → cathartic method (hypnosis in order to have the patient talk freely and relive events) ➔ Freud → Psychoanalysis - Behaviorism ● Watson & Pavlov ● Problematic functions was the result of unfortunate conditioning experiences - Abnormal behaviour may be caused by medical problems such as syphilis. These problems are normally treated pharmacologically and potential medical causes are often ruled out before diagnosing a mental disorder. - Surgical procedures such as lobotomies were used to remove areas of the brain that were implicated in mental disorders. • Electroconvulsive therapy employs electricity in order to induce a seizure in patients. This treatment has become safer over the years and is still used to treat severe depression. • Pharmacological treatments for psychological disorders usually target neurotransmitters and are currently a popular treatment method. • Dr. Ruth Kajander was one of the first psychiatrists to use major tranquilizers to treat schizophrenia. • Albert Bandura developed a theory of learning of aggressive behaviour in childhood and generated a number of treatment approaches emphasizing learning theory. In considering abnormality, we must consider the combination or several determinants of abnormality • Donald Meichenbaum played a key role in the development of cognitive-behavioural therapy, which is now used as a treatment for a variety of psychological disorders. • The Mental Health Commission of Canada was established to improve access to mental health care and to reduce the stigma of mental illness. An emphasis on the potential for recovery is characteristic of the MHCC’s approach to reducing stigma. • Practitioners are now being encouraged to engage in evidence- based practice, i.e., to consider and integrate research evidence into their decisions regarding the best treatment for their clients. 1. Is the behavior common? 2. Does the behavior violate social norms? 3. Do the individuals themselves experience the behaviour as a problem and are they distressed about it? 4. Does the behaviour represent a disability in the sense of impairing some aspect of the individual’s life, such as relationships, school, or work? 5. Is the behaviour, the distress or disability an expected reaction to environmental stressor, or what appears to be a more extreme or unexpected response? Recent Developments The Mental Health commission Canada (MHCC) was established in 2007. The goal of the MHCCC is to developed an integrated mental health system that encourages better co- operation among governments, mental health provides, employers, the scientific community, and Canadians who live with or care for those with mental disorders. Goals: ●● be a catalyst for the reform of mental health policies and improvements in service delivery; ●● act as a facilitator, enabler, and supporter of a national approach to mental health issues; work to diminish the stigma and discrimination faced by Canadians living with mental disorders; and ●● disseminate evidence-based information on all aspects of mental health and mental illness to governments, stakeholders, and the public. (MHCC, 2011) Evidence based practice (EBP) refers to the integration of scientific evidence with individual expertise in order to inform optimum client care (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006). The purpose of EBP is to bolster the efficacious treatment of mental disorders, to maintain the competitiveness of psychologists in the mental health CHAPTER 2: Theoretical Perspectives on Abnormal Psychology TEXTBOOK ONLY Learning Objectives 1. View behaviour and thinking (disordered or not) as arising from the interaction between biological and environmental experiences. 2. Define neurotransmitters and describe the four ways in which they can influence abnormal behaviour, using examples. 3. Describe the role of the id, ego, and superego as personality structures and explain how they influence an individual’s defence mechanisms. 4. Explain how classical and operant conditioning can influence an individual’s behaviour and provide examples. 5. Define schemas and describe how they come to influence an individual’s thoughts, beliefs, information processing, and behaviours. 6. Understand how close others (e.g., partners, friends, family) can influence the development and maintenance of mental health disorders through stigma or social support. 7. Identify how gender, race, and poverty influence mental health disorders. THE GENERAL NATURE OF THEORIES - About abnormal behaviours Levels of Theories Single-factor explanation: attempts to trace the origins of a particular disorder to one example. An example: is the disorder runs in the family. Reflect the lack of current comprehensive knowledge of the disorders. Integrationist Explanations: view behaviour as the product of the interaction of a variety of factors; generally make more satisfactory theories in describing mental disorder. Takes into account the biology and behavioral of the individual. Testing theories the null Hypothesis Experiments are no set up to prove the worth of a theory but rather to reject (or fail to reject) what is called the null hypothesis. Null Hypothesis: essentially proposes that the prediction made from the theory is false. The Search for Cause 1) Explain the etiology 2) Identify the factors that maintain the behaviour 3) Predict the course of the disorder 4) Design effective treatments. Etiology: the causes or origins of the problem behaviour. Aaron T.Beck: cognitive formulation of depression and anxiety has proposed to describe CT can not only alter an individual’s cognitive process to reduce symptoms, but also affects her neurobiology. The role of the central nervous system -average individual has 86 billion neurons, equal of non-neuronal gligal cells. Neurotransmitters: are the chemical substances that carry the messages from one neuron to the next Brain Plasticity: -Dr.Bryan Kolb: influenced by hormones, diet aging, stress, disease, and maturation. Two main streams of thought concerning mental disorders: 1. A focus on the biological aspects of disorders 2. A focus on environmental/psychological influences o This follows the nature/nurture distinction that is made in many areas of human functioning. *While biological approaches tend to dismiss or downplay the influence of experience, psychological or environmental approaches tend to emphasize external factors (e.g., poverty, parenting style) in the development of disorders. o Some behavioural theories attribute no effects at all to biology, assuming humans are born a blank slate and that experience shapes all thought and behaviour. (ex: Skinner 1953 and Locke 1632-1704) ● Biological and psychodynamic paradigms view dysfunctional behaviour as the product of forces beyond the individual’s control. o Biological: the role of genetics and neurotransmitters (Emil Kraepelin - who assumed that all mental “syndromes” were biological; Text p.15- 16) o Psychoanalytic: the role of early life experience and unconscious mental processes and conflict (Sigmund Freud) ● Humanistic and existential paradigms lay the responsibility for action and choices on the individual. ● The role of self-concepts and self-identity (Carl Rogers; Abraham Maslow) ● Behavioural and cognitive paradigms imply that a mixture of external and internal factors produce dysfunctions. o Behavioural: the role of environmental learning through classical conditioning (Ivan Pavlov), operant conditioning (B F Skinner) and observation (Albert Bandura) o Cognitive: the role of mental processes, how we think and how we mentally organize our experiences. The mental structures that we use to organize our thoughts, emotions and experiences are called “schemas”. - attitudes, beliefs, and expectations (Aaron Beck). The perspective taken when examining the cause of psychopathology determines: 1. How research is directed 2. How diagnostic decisions are guided 3. Treatment responses o Example: The acceptance of the biological model causes the researchers to seek a physical basis for disorders, formulate a diagnostic system that classifies people as disordered, and the treatment of choice are physical interventions (medication). o In contrast, the behavioural model leads researchers to seek environmental events that shape specific dysfunctional responses, emphasize the classification of behaviours rather than of people and the treatment consists of either manipulating the environment or, from a cognitive- behavioural perspective, modifying the perceptions people have regarding their experiences and themselves. - Perspectives through Hailey’s story of MDD (p. 25) ▪ From a biological view, a genetic basis for MDD would be supported as Hailey’s mother also suffered from depression. ▪ A psychodynamic (resulting from the Freudian psychoanalytic) view would examine Hailey’s childhood relationship with her mother. o In contrast ▪ A behaviourist would examine Hailey’s reassurance seeking and her withdrawal behaviours resulting from her depression ▪ A cognitive theorist would examine how Hailey’s schemas or beliefs (her fear of abandonment), automatic thoughts, and the way she processes information influence her disorder. ▪ Both humanistic and existential approaches would focus on Hailey’s personal decisions, level of acceptance, and perceptions of her experience with depression. ▪ A socio-cultural formulation would examine factors such as whether or not Hailey has good social supports to help her handle her disorder, how being female influences her depression, or how being labelled as being depressed affects her life. o Note: An integrative perspective would look at the dynamic and reciprocal relationships among all these factors. - THEME OF THIS TEXTBOOK: The origins of psychological disorders are complex, with no one factor providing a complete explanation Adoption of a perspective: ● The adoption of a perspective is far more influenced by the prevailing social belief system and by an individual’s disposition to see human behaviour as determined by factors beyond or within the control of the individual, than by the weight of evidence. ▪ Theorists often hold onto a view in spite of evidence to the contrary. ● Beck’s cognitive formulation of depression and anxiety describes how cognitive therapy can not only alter an individual’s cognitive processes in order to reduce symptoms, but also affect his or her neurobiology. o Activation of negative schemas and emotions are associated with increased activation in the amygdalohippocampal subcortical region of the brain. ▪ The anterior cingulate cortex, medial and lateral prefrontal cortex , and orbitofrontal cortex are all associated with reflective processes and cognitive control of negative emotion. - Those with depression or anxiety have limited access to these areas. o Cognitive Therapy has recently shown an increase in activation of the normally limited regions and a decrease in the AHS region. In Summary: Reductionist thinking: The actions of the whole are reduced to the influence of one or the other of the component parts. ● This ignores the rather obvious possibility that human behaviour in all its forms is a product of an array of features interacting (biological, developmental, environmental, personal choice, cultural, etc). ● Behaviour and thinking (whether normal or disordered) is viewed as arising from the integrated dynamic and essentially inseparable interactions between multiple biological and environmental experiences. BIOLOGICAL MODELS - Use the model of medicine/language of medicine Based off the Model of Medicine: ● Medical language is used such as calling clients “patients” and their problems “symptoms” or “syndromes,” and describing the response to these problems as “treatment”. Biological theories have primarily implicated: ● Dysfunctions in or damage to the brain (the central nervous system- CNS) ● Problems of control of one or another aspect of the peripheral nervous system (that is, the autonomic nervous system or the somatic nervous system) ● Malfunctioning of the endocrine system. Regions of the brain responsible for distinctive functions: ● The hindbrain primarily directs the functioning of the autonomic nervous system o Controls primarily internal activities- digestion, cardiovascular functioning, and breathing. ● The midbrain is the centre of the reticular activating system o Controls arousal levels (sleep–wake centre) and attentional processes. ● The forebrain controls thought, speech, perception, memory, learning, and planning ● Somatogenesis: the development of behavioral or personality traits or disorders as a result of anatomical, physiological, or biochemical changes in the body. ● Sophisticated methods are now available for detecting even quite small areas of damage or dysfunction in the brain. o CAT, MRI, and PET Scans are some examples. Neurotransmitters and Abnormal Behaviour: ● Neurotransmitters are chemical substances that carry the messages from one neuron to the next in the complex pathways of nervous activity within the brain. ● Abnormal behaviour can result from disturbances in neurotransmitter systems in four ways: 1.There may be too much or too little of the neurotransmitter produced or released into the synapse. 2. There may be too few or too many receptors on the dendrites. 3.There may be an excess or a deficit in the amount of the transmitter- deactivating substance in the synapse. 4. The reuptake process may be too rapid or too slow. ● Any of these problems can cause either too much excitation or too much inhibition in the particular brain circuits, and this excessive or reduced activity may result in abnormal functioning. o NOTE: The level of neurotransmitter activity affects behaviour, but behaviour also affects neurotransmitter activity. ● Brain Plasticity: The incredible capacity of the brain to reorganize its circuitry. The Involvement of the Autonomic Nervous System (ANS) in psychological disorders: ● The ANS has two parts: the sympathetic nervous system and the parasympathetic nervous system o These two systems function together to produce homeostatic activity in bodily functions such as heart rate, digestive and eliminatory processes, sexual arousal, breathing, and perspiration. ● Under Stress, the SNS and PNS function antagonistically. o The sympathetic nervous system readies the body for action (fight or flight response) - increasing heart rate, pupil size (making vision more acute), and breathing (faster and deeper to get more oxygen. o While the parasympathetic nervous system shuts down digestive processes, in order to have that energy directed to body functions necessary for survival. ● Stress physiology: Individuals differ in both the strength and the duration of their response to threat. The ANS response to stress can be either exaggeratedly strong or remarkably weak. There are also individual differences in the regulation of the ANS system. ● This variability has been related to the person’s propensity to develop psychophysiological disorders. ● This explains why one person could develop a severe and enduring conditioned emotional response, while another person exposed to exactly the same experience does not. The Role of the Endocrine System: ● The CNS interacts with the endocrine system in a feedback loop that maintains appropriate levels of hormones circulating in the bloodstream. o The adrenocorticotropic hormone helps the body handle stress. o Thyroid dysregulation has been associated with a variety of psychiatric symptoms including anxiety and depression . The hypothalamic pituitary-adrenal (HPA) axis has also been studied in regards to anxiety and depression. ● The HPA axis is activated in response to stressors and involves an intricate system of communication among the hypothalamus, the pituitary gland, and the adrenal cortex. ● Involves the release of the stress hormone cortiso l into the bloodstream by the adrenal cortex ● Cortisol facilitates an individual’s response to short- term threat by producing a number of changes in the body; such as causing an increase in intracellular glucocorticoid receptors (survival mechanism). ● Altered functioning of the HPA axis is seen in many individuals with depression and anxiety, although the nature of the differences vary Genetics and Behaviour: ● The concept of biological determinism: what a person is happens to be determined largely by inherited characteristics. ● Thomas Hobbes: o Thought that aggression and self-interest were inborn features of all humans, and that it is up to society to restrain and usefully channel these impulses. ▪ For example, Cesare Lombroso (1836–1909) declared that criminals could be identified by the physiological features they had inherited from their degenerate parents. ▪ However, genes do not completely determine behaviour so... ● Modern Behavioural Genetics offer us an insight into the biological bases of abnormal functioning. o There is a reciprocal relationship between genetic predisposition and environmental risk factors ▪ Genes may influence behaviours that contribute to environmental stressors, which, in turn, increase the risk of psychopathology o In one study, Caspi and colleagues (2003) examined the interactive effects of a genotype associated with depression and stressful life events (SLEs). ▪ This gene influences the transmission of serotonin libidinal desires of the id. It does so by unconsciously employing a censoring system found in Defence Mechanisms. Freudian theory is largely speculative and has little empirical support, nor the ability to test the hypotheses. However some of his work has been valuable to modern psychology. ● He legitimized discussion and research on sexual matters, he encouraged a concern with processes beyond our awareness, and he recognized that the motives for human behaviour were not always the obvious ones. BEHAVIOURAL THEORIES John Watson Early behaviourists such as Watson were environmentalists in that they assumed that all (or almost all) human behaviour, including abnormal behaviour, was learned. Conditioning Accounts: ● Eg. Classical Conditioning (Pavlov’s famous dog experiment) o Stimulus-stimulus learning o Most famous application was the acquisition of phobias (Little Albert): ● unrealistic fears of usually harmless things ● Operant conditioning (Skinner): o The importance of the consequences of behaviour. o Reinforcement: When behaviour increases in frequency as a result of consistent consequences ▪ Positive Reinforcement ● Ex: Opening the fridge door leads to pleasant consequences or rewards (eating ice cream), so the behaviour of going to the fridge increases. ▪ Negative Reinforcement ● Ex: Taking an aspirin results in the reduction of stress (headache goes away) o Punishment: When a behaviour decreases in frequency as a result of its consequences ▪ Positive Punishment: Behaviour is reduced by the consequent occurence of an unpleasant experience. ▪ Negative Punishment: Behaviour is reduced following the removal of something desirable. Social Learning Theory: Bandura and Walters ● Social learning theory suggested that, although classical and operant conditioning experiences are important, the majority of these experiences occur within a social context and are primarily acquired by observation of others rather than by direct personal experience ● Bandura’s Theory emphasized the importance of cognitive processes, such as perceiving the behaviour of others and storing information in the memory o A number of individual characteristics (expectations, abilities, feelings, etc.) appear to influence different responses to stimuli. ● Maslow (Self-actualization): o Believed that people are good and they behave dysfunctionally only as a result of experience (or their interpretation of it). This has diverted them from the path of self-actualization. o Hierarchy (pyramid) of needs that once fully satisfied, result in the actualization of the person’s potential. o Abnormal behaviour results from a failure to attain the self-esteem necessary to achieve self-actualization. Existential Views: Rollo May and Viktor Frankl ● Sees the individual’s awareness of his or her own existence as a critical feature of human functioning. ● Stresses our responsibility for our own free choices and, therefore, our actions. ● The possibility of death or the emptiness of no meaning and the acceptance of responsibility for our actions makes us anxious. o Life becomes a search for meaning (“the courage to be”), the alternative being to give up the struggle and become full of despair. ● Treatment is directed at confronting clients with their responsibility for their actions and assisting in finding meaning in their lives. SOCIO-CULTURAL INFLUENCES A theory that considers the role that society and close others (friends, family, spouses) play in the etiology and maintenance of mental health disorders. Stigma is one of the largest barriers to individuals seeking treatment. ● Public Stigma: Perception held by a group or society- a person who seeks psychological treatment is socially unacceptable/undesirable. ● Self-stigma: Reduction of a person’s self-worth caused by self- labeling as someone who is socially unacceptable. ● Social support is also important. Influence of Gender: ● The influence of societies’ stereotypes and the consequent reaction to specific groups seems to play a role in the development of disorders. o As well as poverty and social class. ● Gender-specific socialization processes render males and females differentially likely to acquire one or another disorder. o Ex: Females overrepresented in the eating disorder category due to the internalization of the body “ideal” of thinness largely attributed to media exposure. o Males are overrepresented in Antisocial personality disorder which involves aggressiveness and self-interest. Influence of Race and Poverty: ● Minority ethnicity and poverty often go together, so it is difficult to disentangle these two influences ● Poverty is a significant risk factor for mental disorders o The socio-economic disadvantage affects education, food insecurity, housing, social class, and financial stress demonstrate the strongest and most consistent associations with a variety of mental illnesses. o Resentment at being poor can generate dysfunctional or antisocial behaviours Integrative Theories It is only through the interaction of all of these various influences that disorders emerge. ● Three models attempt to integrate these influences. Systems Theory: ● Proposes that the whole is greater than the sum of its parts. ● This approach has had profound influences on many areas of science (including biology, engineering, and computer science). ● Sees causation as the combined effect of multiple factors that are likely to be bidirectional. o Example: persistent misbehaviour of a child appears to influence parental behaviour such that the parents’ actions worsen the child’s behaviour. ● The same end result (disorder) can arise from many different causes in different people. Diathesis-stress Perspective: ● A predisposition to developing a disorder (diathesis), interacting with experience of stress, causes mental disorders. ● Cannot be categorized as either solely a biological or solely a psychological model. o Example of biological diathesis- role played by genetics in schizophrenia, mood disorders, and alcoholism. o Psychological diathesis- may arise as a result of temperament, childhood abuse, inappropriate parenting, or social and cultural pressures. ● BUT a predisposition will not produce a disorder without the trigger of some stress, whether biological (physical illness), psychological (breakdown of a relationship), or social (perceived pressure to meet certain standards). The Biopsychosocial Model: ● Like the diathesis model, this model declares that you must take into account each of the factors (biological, psychological, and social) in order to understand and treat a disorder. ● Indicates the importance of the interaction among multiple biological and environmental processes for human functioning. ● Recent movement away from conceptualizing psychopathology as “within the individual” to examining contextual factors that operate “outside the individual” Unit 3: Chapter 5—Anxiety and Related Disorders ▪ Direct stimulation of this circuit at low levels causes subjective anxiety in humans and freezing in rats, whereas stimulation at high levels provokes feelings of terror and flight behavior ▪ Human neuroimaging studies also suggest a role for the insular cortex, which may represent some of the somatic manifestations of anxiety ▪ Higher cortical areas are not directly involved in the fear circuit ▪ The fear system principally involves a subcortical network that can be aroused without the influence of complex cortical input ▪ For example: the amygdala can effectively process external stimuli and determine its survival relevance without the influence of higher brain functioning. ▪ However, cortical and subcortical areas of the brain interact. These higher cortical areas are necessary for extinguishing conditioned fears (i.e., for learning that something that was previously feared no longer need be) ▪ No neurotransmitter system has been found to be solely dedicated to the expression of fear, anxiety, or panic each neurotransmitters involved in fear, anxiety, and panic is also involved in an assortment of general cognitive, affective, and behavioral functions. ▪ For example, GABA is the most pervasive inhibitory neurotransmitter in the brain, and receptors for this transmitter are well distributed along the neural fear. ● Psychological Factors: o Behavioral Factors: ▪ The idea that anxiety and fear are required through learning originated from Pavlov’s discovery of classical conditioning, and idea expanded by Watson and Rayner ▪ In 1947, Mowrer proposed two-factor theory. This theory suggested that fears develop through the process of classical conditioning and are maintained through operant conditioning. ● In the first phase, a neutral stimulus (the conditioned stimulus, or CS) becomes paired with an inherently negative stimulus (e.g., a frightening event, the unconditioned stimulus, or UCS). The individual later learns to lessen this anxiety by avoiding the CS, a behaviour that is negatively reinforced through operant conditioning ● For example: In the case of Little Albert, for example, Watson and Rayner (1920) showed how the fear of a rat (the CS) became conditioned through pairings with a sudden loud noise (the UCS) ▪ Avoidance can be effective in reducing a person’s anxiety in the short term, but can serve to increase anxiety over the long haul. ▪ Subsequent research have demonstrated not all fears develop through classical conditioning. ● For example: it is possible to develop fears by observing the reactions of other people (vicarious learning or modelling). Some people also develop fears by hearing fear-relevant information. ● Example: a mother calling her son. This little boy was standing in some tall grass paying little attention to his mother’s increasing demands to “come when he is called.” Exasperated, the mother resorted to scaring her son, stating, “Come over here quickly. There are snakes in there and you will be bitten.” ● Cognitive Factors: o Beck proposed that people are afraid because of the bias perceptions that they have about the world, the future, and themselves. o Anxious individuals often see the world as dangerous, the future as uncertain, and themselves as ill-equipped to cope with life’s threats. Individuals who are susceptible to anxiety often have core beliefs that they are helpless and vulnerable. o Anxious individuals tend to focus on information that is relevant to their fears (Clark & Beck). ▪ Example: individuals who are phobic of spiders tend to orient toward words like crawl or hairy relative to positive neutral works o Individuals with social anxiety show this effect for words such as boring or foolish o Individuals who are highly conscious may also filter out or ignore information that contradicts the presence of an objective danger ▪ For example: individuals with recurrent panic attacks often have fears that focus on bodily (e.g., “I am going to have a heart attack”), mental (“I am going to go crazy”), or interpersonal (“I am going to be embarrassed”) danger when less threatening interpretations of their symptoms are far more likely. ● Interpersonal Factors: o The early attachment relationship may be important in the development of anxiety. o Attachment theorists have postulated that early parent-child interactions can lead to the development of general belief systems (or “internal working models”) for how relationships operate in general o Children who develop an “anxious ambivalent” attachment style learn to fear being abandoned by loved ones. This attachment style may develop from interactions with parents who are inconsistent in their emotional caregiving toward the infant. ▪ Later in life, these individuals may be wary of the availability of significant others and become chronically worried about negative interpersonal events. o Warren, Huston, Egeland, and Sroufe (1997) found that an anxious- ambivalent attachment style in infancy predicted anxiety problems when the children were 17.5 years old. ● Comment on Etiology o There is complex and dynamic interplay among biological, psychological, and interpersonal factors. o Barlow (2002) advanced a triple vulnerability etiological model of anxiety in which generalized biological (e.g., a genetic predisposition to being high- strung, behaviorally inhibited, nervous), nonspecific psychological (E.g., diminished sense of early adulthood. ● Women are twice as likely as men to be affected by panic disorder. ● panic disorder is often comorbid with other mental disorders, most notably depression, substance abuse problems, and other anxiety conditions, including agoraphobia Panic Attack Specifier Agoraphobia o “fear of the marketplace” o An anxiety about being in places or situations where an individual might find it difficult to escape (e.g. being in crowds, standing in lines, going to a theatre, being on a bridge, travelling in a car) or in which he or she would not have help readily available should a panic attack occur (e.g., being outside of home alone, travelling). o Panic disorder and agoraphobia are highly comorbid, and the occurrence of panic attack often instigates agoraphobia. o When avoidance is persistent and pervasive, the diagnosis of agoraphobia is made. o This diagnosis is made only when feared situations are actively avoided, require the presence of a companion, or are endured only with extreme anxiety; and is made irrespective of whether panic disorder is present o If individual meets the criteria for both panic disorder and agoraphobia, then both diagnoses are assigned. o Diagnosis and Assessment: o Differential diagnosis can be tricky because panic attacks are not unique to panic disorder and occur in other anxiety disorders o The cardinal feature of panic disorder is that individuals initially experience unexpected panic attacks and have marked apprehension and worry over the possibility of having additional panic attacks o In contrast, panic attacks associated with other anxiety disorders are usually cued be specific situations or feared objects o Example: People with a phobia of flying may be concerned that their plane will crash, but those with panic disorder may fear getting on a plane because they might have a panic attack and not be able to escape. o for all anxiety disorders: multi-method assessment that includes a clinical interview, behavioural measurement, psychophysiological tests, and self- report indices is the ideal assessment strategy o structured clinical interview for DSM- 5 is a semi-structured interview that covers the main clinical disorders, including panic disorder and agoraphobia ▪ another popular semi-structured interview is the Anxiety and Related Disorders Interview Schedule for DSM-5, which is used to establish differential diagnosis among the anxiety disorders. o Behavioural assessment is also frequently used to assess avoidance and severity. ▪ For example, a clinician may decide to observe individuals in their naturalistic environments to assess their degree of agoraphobic avoidance. ▪ One strategy is the behavioural avoidance test (BAT). In this test, patients are asked to enter situations that they would typically avoid. They provide a rating of their degree of anticipatory anxiety and the actual level of anxiety that they experience ▪ Another behavioural assessment strategy for panic disorder is the symptom induction test ● Example: For example, a patient may be asked to hyperventilate, to shake his or her head from side to side, or to spin in a chair in order to bring on symptoms of panic. Such exercises can be useful both as a way of assessing symptom severity and as a strategy for exposure treatment. o Psychological Assessment strategies ▪ can include the monitoring of heart rate, breathing, blood pressure, and galvanic skin response while a patient is approaching a feared situation or experiencing a panic attack o self-report questionnaires: ▪ at least 30 empirically supported. ▪ assess panic-related thoughts, behaviours, and symptoms ▪ one popular instrument is the Anxiety Sensitivity Index which measures an individual’s fear of anxiety-related symptoms Dr. Steve Taylor and colleagues, developed an expanded version of this instrument. o Etiology o First, both panic disorder and agoraphobia tend to run in families o The biological relatives of individuals with panic disorder, are about five times more likely to develop panic disorder than individuals who do not have panic- prone relatives. ▪ Situational type: the person fears specific situations, such as bridges, public transportation, and enclosed spaces. ▪ Other type: used for all other phobias not covered in the other categories, such as extreme fears of choking, vomiting, and clowns this category also known as illness phobia (involves an intense fear of developing a disease that the person currently does not have). Illness phobia is different from hypochondriasis, where people believe that they currently have a disease or medical condition . o Etiology: ▪ One of the main criticisms of conditioning model by Watson and Rayner is that it assumes that all neutral stimuli have an equal potential for becoming phobias. This is known as the equipotentiality premise the chances of being afraid of a lamp and a snake are presumed to be equal. However, it is not the case that people have phobias for pretty much everything; rather, a select number of stimuli seem to be consistently related to phobias ▪ Contrary to the associative (conditioning) model of phobias is the nonassociative model ▪ Nonassociative model: proposes that the process of evolution has endowed humans to respond fearfully to a select group of stimuli (e.g., water, heights, spiders), and thus no learning is necessary to develop these fears. ▪ the types of stimuli that elicit fear do so because it is too dangerous for humans to have learn to fear the stimuli with personal experience. ▪ Evidence for nonassociative theories also comes from the finding that babies seem to be born with certain kinds of “prewired” anxiety that is elicited at various developmental stages. ▪ Menzies and Clarke (1995) argue that most of us eventually habituate to the feared stimulus over time. For instance, even though most of us may have initially feared heights as an infant, our fear likely dissipated over time after repeated exposure to heights. ● some people may fail to habituate to certain stimuli. This failure to habituate may occur because they did not have appropriate opportunities for exposure during development, or because of individual differences in the rate of habituation ▪ In 1971, when learning was the primary etiological model of phobias, Seligman (1971) argued that there has to be more to their etiology than classical conditioning. ▪ it is believed that the process of natural selection has equipped humans with the predisposition to fear objects and situations that represented threats to our species over the course of our evolutionary heritage ▪ associative learning is still necessary to develop a phobia. This helps to obviate problems with the equipotentiality premise ▪ as associative ▪ learning experiences will produce phobias for those stimuli that represent threats in an evolutionary sense. Hence, this explains why learning to fear snakes is easier than learning to fear lamps. ▪ Disgust sensitivity: refers to the degree to which people are susceptible to being disgusted by a variety of stimuli such as certain bugs, types of food, and small animals. ● The main hypothesis is that people develop some phobias because the phobic object is disgusting and possibly contaminated. ▪ Women tend to have a higher degree of disgust sensitivity than do men, and recent evidence suggests that this gender difference might partly explain the higher prevalence of specific phobias for women. ▪ Kirmayer (2001), a scientist at the Culture and Mental Health Research Unit in Montreal, reports that in many areas of the world people do not view symptoms of anxiety as problematic and may even reject psychological explanations and treatments. He argues that a clinician’s objective should be to understand, from the patient’s point of view, how his or her symptoms are experienced and to derive a treatment strategy that will be acceptable to that patient. Social Anxiety Disorder: o a marked and persistent fear of social or performance-related situations. o People with social anxiety have an underlying fear of being evaluated negatively and frequently worry about what others might be thinking about them. This may include fears that they will expose their inner-felt anxiety to others by not making eye contact, by blushing, or by being awkward in their speech or posture during social interactions. o One of the most prototypical fears is being the “centre of attention.” o social anxiety is one of the most prevalent psychiatric disorders, with a prevalence rate comparable to unipolar depression Table 5.2: DSM-5 Diagnostic Criteria for Social Anxiety Disorder o Individuals with social anxiety disorder fear interacting with others in most social settings. In contrast, those individuals with performance only social phobia fear - For individuals with GAD it is often not the amount of stress in their lives that is the clinical problem, but rather the amount of anxiety and worry they experience as a result of a relatively normal level of life stress. - Diagnosis and Assessment: o primary criterion for GAD, in DSM-5, is the presence of excessive worry, which must be present for more days than not for a period of at least six months (see table 5.3) o Three or more other symptoms of anxiety must also be present, such as restlessness, muscle tension, and sleep problems. One of the challenges in making the diagnosis of GAD involves determining that the source of a person’s anxiety and worry is not confined to another clinical disorder. o Individuals with panic disorder often worry about future panic attacks, and those with social anxiety disorder tend to worry about upcoming social interactions. Worry can also be a prominent symptom in other “non-anxiety” disorders. - Etiology: o Tom Borkovec proposed that individuals with GAD use worry primarily as an avoidance strategy. One thing that individuals with GAD appear to “avoid” by worrying is physiological arousal. o The physical feeling of anxiety can be quite discomforting and bothersome, and therefore avoidance of arousal is reinforcing to the individual. The process of worry tends to decrease somatic arousal o Individuals with less tolerance for uncertainty display reductions in heart rate variability during a worry-inducing task compared to those with greater tolerance of uncertainty. o How does worry decrease physiological arousal? ▪ It that anxious images elicit arousal, whereas verbal thoughts decrease arousal. ▪ worrying is negatively reinforced because it can lead to a reduction in anxiety symptoms. ▪ Another purpose of worry is to avoid future threat. For many people with and without GAD, worry is considered to be a very useful way of preparing for the future ▪ Many people believe that worry is an effective way of preventing or preparing for future threat o Drs. Michel Dugas and Robert Ladouceur: proposed their own theory of GAD, which primarily focuses on a cognitive vulnerability factor they call intolerance of uncertainty o Intolerance of uncertainty (IU) refers to an individual’s discomfort with ambiguity and uncertainty. Everyone has a different threshold for accepting and dealing with life’s uncertainties; individuals with GAD tend to have lower thresholds for these uncertainties, leading to anxiety and distress. ▪ IU is responsible for creating and exacerbating “what if . . . ” questions, which are questions we all ask ourselves at some point in time. ▪ individuals with GAD are constantly grappling with these questions because they have a selective bias for uncertainty. ▪ individuals with high levels of IU tend to pay more attention to threatening and uncertain information and to interpret ambiguous information as more threatening than do those with low IU ▪ not only does IU lead to the identification of more uncertainty in both daily life and the future, but this uncertainty is also considered to be more threatening o This construct consistently correlates with pathological worry and anxiety (Gentes & Ruscio, 2011) and distinguishes between individuals with GAD and those without the disorder o In addition, elevated levels of anger appear to be an associated feature and often characterize individuals with this disorder. o The belief that uncertainty is unfair appears to contribute to feelings of anger in individuals with symptoms of GAD and feelings of anger in turn result further reinforce the belief that uncertainty is unfair Obsessive- Compulsive and Related Disorder: o Include the diagnoses of obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder, trichotillomania (hair- pulling disorder) and excoriation (skin-picking disorder) o Kessler and colleagues (2012) have estimated that the one-year prevalence rate for OCD in the general population is about 1 percent, with approximately 3 percent of the population expected to develop the disorder at some point in their lifetime Obsessive- compulsive disorder (OCD): o primary features are recurrent obsessions and compulsions that cause marked distress for the individual. o Obsessions are defined as recurrent and uncontrollable thoughts, impulses, or ideas that the individual finds disturbing and anxiety- provoking. o Example: thoughts related to uncertainty (e.g. doubting if one has locked the door), sexuality, violence, and contamination (e.g. believing one is dirty and covered with germs) o individuals with OCD often attempt to cope with their feelings of discomfort by engaging in compulsions. o Compulsions: repetitive behaviours (e.g. washing hands) or cognitive acts (e.g. counting numbers, praying) that are intended to reduce anxiety o Compulsions involve observable behaviour or mental acts that are used to reduce anxiety o Neutralizations are behavioural or mental acts that are used by individuals to try to prevent, cancel, or “undo” the feared consequences and distress caused by an obsession o One of the more striking aspects of individuals with OCD is their excessive beliefs about personal responsibility and feelings of guilt individuals are concerned with making sure their behavior will not lead to negative consequences. o Another aspect: there can be an inflated sense of responsibility for their thoughts. Having an unwanted thought such as hitting a child can make people feel immoral— and the more responsible they feel for the content of their thoughts, the worse they feel o Thought-action fusion (TAF) refers to two types of irrational thinking: o (1) the belief that having a particular thought increases the probability that the thought will come true (e.g., “If I think about getting hit by a car, I’m more likely to get hit by a car”); o (2) the belief that having a particular thought is the moral equivalent of a particular action (e.g. having a thought about harming someone is the moral equivalent of actually doing it) o Diagnosis and Assessment: o When assessing for the presence of obsessions, it is important to distinguish obsessions from excessive worries about everyday problems. o characteristics that distinguish obsessions from worries, obsessions tend to be more bizarre and involve more imagery than do worries o Table 5.5: DSM-5 Diagnostic Criteria for Obsessive- Compulsive Disorder o many individuals with OCD have obsessions and compulsions specifically related to themes of contamination and washing or cleaning. These individuals may experience discomfort or distress because they feel contaminated or “dirty”, or they may be concerned about germs harming themselves or others - Etiology: well as avoid places, people, or activities that may remind them of the trauma. These symptoms can be classified as cognitive avoidance and behavioural avoidance, respectively, and they often co-occur as prototypical features of anxiety spectrum behaviour. - Individuals with PTSD may be unable to remember aspects of the traumatic event, or have exaggerated feelings of guilt and self-blame. - Mood alterations may occur and include a markedly diminished interest or participation in pre-trauma daily-living activities, feeling detached or estranged rom others, and being unable to experience certain feelings (especially positive affect). This set of symptoms represents - an inability to experience emotions, and has been referred to as emotional numbing - Individuals with PTSD also experience sleep difficulties, concentration problems, irritability, significant anger problems, and other symptoms of elevated arousal. These individuals are frequently hypervigilant to threatening stimuli and exhibit an exaggerated startle response to unexpected stimuli. - Diagnosis and Assessment: o The diagnosis and assessment of PTSD generally involves the combination of a semi-structured clinical interview and the results of psychometric scales. One of the most well-used and validated interview measures of PTSD is the Clinician Administered PTSD Scale. - Etiology: o exposure of an individual to a traumatic life event plays a role in the development of PTSD o women are two times likely to develop PTSD following exposure to a traumatic event than are men. o Men more often reported witnessing someone badly injured or killed; being exposed to fires, floods, and/or natural disasters; being involved in life- threatening accidents, physical attacks, or war-related combat; being threatened with weapons; or being held captive or kidnapped o women more often reported being raped, sexually molested, neglected by their parents as children, and physically abused as children o Risk factors of PTSD include: pre-event and post-event factors. ▪ Pre-event: Pre-event risk factors for adult PTSD include being low in socio-economic status, education, and tested intelligence; having a previous psychiatric history; and experiencing childhood adversity, including being abused as a child ▪ Post-event: Post-event risk factors are somewhat more powerful predictors of PTSD than are pre-event factors, and include the severity of the traumatic event, lack of social support, and whether or not additional stressful experiences occur after the traumatic event. o In addition, exposure to interpersonal traumas (e.g., related to physical violence or sexual abuse) is generally more likely to provoke PTSD than exposure to non-interpersonal traumas (e.g., natural disaster, car accident). o Research suggests that individuals with this disorder have dysfunctional neurocircuitry in areas of the brain implicated in processing and responding quickly to threat. These brain regions include the brainstem, amygdala, and frontotemporal cortex, and have been collectively conceptualized as part of the Innate Alarm System(IAS) ▪ PTSD has been associated with greater activity and connectivity between IAS brain regions ▪ Several studies of male combat veterans and Holocaust survivors have found decreased cortisol and/or enhanced negative feedback of adrenal function o Cognitive theories of PTSD emphasize the multiple levels upon which traumatic experiences can affect the mind. ▪ Dual Representation Theory details differences in the way that traumatic memories and non-traumatic memories may be stored and retrieved ● Traumatic memories may be initially stored and retrieved in a nonverbal sensory-based form, whereas non-traumatic memories are typically encoded and retrieved in a verbal form. Therefore, sensory-based memories may need to be transferred into verbal form in order for the individual to effectively process the traumatic experience. ▪ Additional cognitive theories focus on the individuals’ perceptions of meaning that a traumatic event has for themselves, others, and their environment. Individuals who have experienced trauma are forced to integrate conflicting previous beliefs (e.g., “the world is a safe place”; “people are generally good”) with the discrepant realities of the trauma they have just faced (such as rape). ▪ As a result, individuals may alter pre-existing beliefs to reflect their traumatic experience (e.g., “the world is not safe”; “all men are dangerous”.) These new beliefs may be maladaptive and lead to a sense of current and generalized threat, subsequently contributing to symptoms such as chronic arousal, distress, and hypervigilance Treatment of Anxiety and Anxiety-related Disorders: ● When considering both short- and long-term outcomes, exposure- based behavioural interventions and cognitive-behavioural therapy are the most effective treatments for anxiety disorders. Treatment guidelines recommend that cognitive-behavioral interventions be administered first as first line treatments. I. Pharmacotherapy o Benzodiazepines (minor tranquilizers): ▪ Provide rapid, short-term relief from physiological symptoms of acute anxiety such as heart palpitations, muscle tension, and gastrointestinal distress. ▪ Bind to receptor sites for the neurotransmitter GABA which functions to temporally inhibit activity broadly across neural sites, including brain systems that are involved in generating fear and anxiety. ▪ benzodiazepines have many side effects, which include psychomotor (e.g., dizziness and drowsiness) and cognitive (e.g., attention and memory) impairments, depending on the dosage and type of benzodiazepine used. This drug is used as temporary relief of subjective distress and less suitable as long-term treatment for anxiety disorders o Drs. Henny Westra and Sherry Stuart: argue that exposure therapies seek to increase clients’ self-efficacy by demonstrating to them that physiological symptoms of anxiety are not harmful in themselves, and that anxiety-provoking situations can be managed despite anxious feelings. o Antidepressant drugs are currently the most well-used and effective medications for the treatment of anxiety disorders. As the name implies, these medications were first used in treating depression, and their efficacy in the treatment of both anxiety and depression suggests that there may be some level of overlap. o Monoamine oxidase inhibitors: ▪ this medication type is effective in the treatment of social phobia. ▪ Interfere with monoamine oxidase, an enzyme that degrades certain neurotransmitters after being released by neurons, increasing the number of these transmitters in the bran generally. o Tricyclic Antidepressants (TCA) ▪ are in more widespread use, and function to block the reuptake of the neurotransmitters norepinephrine and serotonin. These drugs (especially clomipramine) have been found to be particularly effective in the treatment of OCD, although they too are associated with significant side effects, which include possible weight gain, blurred vision, dry mouth, and constipation. o Serotonin Reuptake Inhibitors (SSRIs) ▪ the most well-prescribed anxiolytic medications. As their name implies, these drugs have a particular affinity for serotonin receptors. Patients usually tolerate the side effects of SSRIs better o Azapirones: ▪ azapirones, appears to elicit its anxiolytic effects primarily through serotonergic effects, in addition to altering dopamine levels in the brain o Venlafaxine Hydrochloride: ▪ Venlafaxine hydrochloride is a newer antidepressant medication that is particularly effective in the treatment of GAD. This medication acts not only to increase serotonin but also to increase both norepinephrine and dopamine levels in the brain, and is generally associated with fewer side effects than traditional SSRI medications. II. Cognitive Restructuring: o Cognitive restructuring is based on the idea that anxiety and other emotional disorders are, at least in part, due to faulty, maladaptive, or unhelpful thinking patterns o In the case of anxiety, these thoughts are future-oriented and involve themes of imminent or looming threat. Individuals with anxiety problems often overestimate the probability and severity of various threats (risk) and underestimate their ability to cope with them o The goal of cognitive restructuring is to help patients develop healthier and more evidence-based thoughts— to help them adjust the imbalance between perceived risk and resource o Patients learn to become better scientists of their own thoughts by monitoring and identifying automatic thoughts and underlying beliefs, examining the validity of these cognitions, and developing more balanced appraisals o Strategies include: thought record-- With the help of a therapist, patients examine the evidence for or against various beliefs and are taught strategies for developing more balanced thinking styles o therapists use a style of Socratic questioning to elicit and test a patient’s beliefs. The Socratic approach involves asking a number of questions to query and evaluate the beliefs and behaviours that o involves starting at a very high level of intensity rather than working gradually through the fear hierarchy. Graduated and intense exposure are both effective; which approach is taken sometimes simply depends on what the patient is willing to tolerate. - Exposure to internal cues (i.e., bodily sensations) is called interoceptive exposure and is also effective for panic disorder. Interoceptive exposure involves the induction of physical sensations (e.g., dizziness) by means of hyperventilating, spinning in a chair, exercising, and so on - The main treatment for OCD involves exposure and ritual prevention (also called response prevention). Ritual prevention involves promoting abstinence from rituals that, while reducing anxiety in the short term, only serve to reinforce the obsessions in the long run - An important component of exposure also involves helping individuals to reduce their subtle avoidance - Stanley Rachman and Adam Radomsky have argued that whereas the judicious use of safety behaviours may be helpful early in treatment by making exposure less threatening and fostering a sense of control, as treatment continues, these safety behaviours should be reduced or eliminated IV. Problem Solving: - This approach begins with a problem orientation phase, in which individuals are encouraged to approach and deal with their problems constructively rather than worry about, avoid, or deny them - This phase involves teaching an individual to accept that the occurrence of problems is an inevitable part of life rather than being due to a personal deficiency, to view problems as challenges rather than as sources of threat or harm, and to view anxiety as a signal of a problem that needs to be dealt with rather than as a feeling to get rid of. V. Relaxation: - Relaxation strategies aim to reduce anxious arousal directly, and can be classified into two general types: mental relaxation and physical relaxation. - Training in mental relaxation often takes the form of guided imagery exercises. During guided imagery, the client and therapist work together to develop a personalized description of positive thoughts and images that promote a calm and peaceful state. - Progressive muscle relaxation involves tensing and then releasing various muscle groups and noting the difference in sensation between the two - Muscle groups where the client particularly experiences tension (e.g., neck, shoul - ders, back) are especially targeted, although the full body is relaxed, including the facial muscles. - Another common relaxation method is breathing retraining, which involves teaching patients how to breathe using their diaphragm rather than their thoracic (chest) muscles. - Mindfulness-based strategies combine the practice of sitting and moving (e.g., yoga, walking) meditation with a number of principles intended to promote psychological well-being, physical health, and stress management. Mindfulness- based strategies seek to cultivate a state of present-focused “being,” often contrasted with various forms of “thinking” (e.g., worrying) and “doing.” - Virtual Reality Strategy: These strategies use virtual environments to expose individuals to the objects they fear. These technologies are able to create vivid environments for use in exposure therapies that are otherwise too difficult to conjure in real life (e.g., battlefields in the treatment of combat-related PTSD) or too expensive for repetitive in vivo exposure (e.g., riding airplanes duringflight disturbance). - Eye movement Desensitization and Reprocessing (EMDR) o In EMDR, an individual remembers an actual or imagined negative life event while simultaneously focusing his or her attention on a stimulus that oscillates from left to right. Although EMDR is an effective method for treating PTSD, it has no clear advantage over traditional exposure or cognitive-behavioural therapy VI. Treatment of Panic Disorder: - CBT is the most well-studied and empirically supported treatment for panic disorder. A number of studies have shown that CBT is as effective as benzodiazepines and antidepressants in the short term. CBT also produces more powerful long-term results. - CBT is a cost-effective treatment option (Kar, 2011), particularly when administered in a group setting. In a meta-analysis of 43 controlled studies, CBT showed the largest effect sizes and the smallest drop-out rates compared to medication or the combination of drug and psychological treatments VII. Treatment of Specific Phobias - The main form of treatment for specific phobias is in vivo exposure - The results have been encouraging: approximately 80 to 90 percent of individuals are effectively treated with exposure - Exposure via virtual reality seems to be effective for a number of specific phobias, including fear of heights, public speaking, and flying VIII. Treatment of Social Anxiety - The most popular treatment for social anxiety disorder, cognitive- behavioural group therapy (CBGT), integrates both cognitive restructuring and exposure - The group setting itself provides ample opportunities for exposure. After working together as a group on various cognitive restructuring exercises, participants practise social interactions and role-play situations that are associated with social anxiety. IX. Treatment of Generalized Anxiety Disorder: - Benzodiazepines are commonly used to treat GAD. - CBT is the most highly recommended psychological therapy for GAD, and a number of variantsof CBT have been developed for treating this disorder. Michel Dugas (Concordia University), has been instrumental in developing the notion of intolerance of uncertainty (IU) and in testing new approaches aimed at reducing it in treatment - Research suggests that improving tolerance to uncertainty appears to be effective at alleviating anxiety symptoms by reducing worry. A meta-analysis conducted by researchers at the University of Western Ontario found that CBT results in a significant reduction of pathological worry (the core symptom of GAD), with the largest effects stemming from the intervention developed by Dugas and his colleagues X. Treatment of Obsessive- Compulsive and Body Dysmorphic Disorders - The main psychological treatment approach for obsessive- compulsive disorder (OCD) has involved exposure and ritual prevention (ERP). - With rise of Christianty, hysteria theories were replaced by supernatural explanations ●Dissociation and related complaints were a result of demonic possession, and exorcism was the favored treatment - After decline in acceptance of possession → psychologically based theories developed ● Alfred Binet ●Jean-Martin Charcot Pierre Janet ●Carl Jung ➔ Components of hysteria were examined as separate processes - Pierre Janet ●First to systematically study the concept of dissociation, which he viewed as a pathological breakdown in the normal integration of mental processes, occurring as a result of exposure to traumatic experiences (van der Kolk & van der Hart, 1989) - Joseph Breuer & Sigmund Freud ●1895 publication Studies in Hysteria ●Posited that trauma, often of a sexual nature, was a predisposing factor of hysteria and established a relationship b/w dissociation and hypnotic-like states ●E.g., Case of Anna O. ➔ 21-year-old woman treated by Breuer who developed visual and hearing problems, total paralysis of both legs and her right arm, partial paralysis of her left arm, a nervous cough, and periods of disturbed consciousness in which she seemed to be quite a different person ●Freud began to doubt the accuracy of patients’ retrospective reports and decided their memories of trauma were fantasized and not real ●Believed that dissociation and other intrapsychic defences developed in order to protect individuals from their unacceptable sexual impulses ●Viewed conversion symptoms as expression of unconscious psychological conflicts ➔ Conversion of anxiety to more acceptable physical symptoms relieved the pressure of having to deal directly w/ conflict ➔ Primary gain: avoidance of conflict -- primary reinforcement maintaining the somatic symptoms ➔ Secondary gain: hysterical symptoms to help patient avoid responsibility and gain attention and empathy ➔ Still used today with munchausen syndrome - Study of dissociation dropped during early 20th century, picking up again from the 70s-90s ●Publication of popular accounts of cases of multiple personality → the inclusion of dissociative identity disorder in the DSM-III - Publication numbers dropping in the first few years of the 21st century ●Researchers believed that dissociative disorders were overdiagnosed → “bubble” of fashion ●Ongoing research and investigations continued to be conducted Dissociative Disorders - Characterized by severe maladapted disruptions or alterations of identity, memory, and consciousness that are experience as being beyond one’s control - Defining symptom: Dissociation → Lack of normal integration of one or more aspects of psychological function such as: ●Identity ●Memory ●Consciousness ●Emotion ●Sensorimotor functioning ●Behavior - Dissociation is not necessarily a pathological process ●E.g., Daydreams, absorption in movie or book… are common among the general population ●If normal functioning is not impaired and if the person can “snap out of it”, there is no concern of pathological dissociation ● A problem exists if the person is unable to control these drifts of consciousness or behavior and it affects the ability to function in everyday life - Stable individual differences in the degree of dissociative experiences; some people tend to dissociative more frequently than other - Dissociative tendency is related to other personality traits such as hypnotizability and absorption ●Waller, Putnam, & Carlson (1996) indicates that dissociative experiences falls into 2 groups 1. Mild, non-pathological forms → absorption and imaginative involvement, normally distributed on a continuum across the general population. 2.Severe, pathological types of experiences, such as amnesia, derealization, depersonalization, and identity alteration that do not normally occur in general population. → taxon or discrete category - 3 major dissociative disorders: ● Dissociative Amnesia ➔ Inability to recall important personal information ➔ Includes dissociative fugue, a rare condition in which individual unexpectedly leave home and may turn up in a distant city with no memory of past ● Dissociative identity disorder ➔ Presence of 2 or more personality states ➔ Formerly known as multiple personality disorder ➔ Classic case -- The Three Faces of Eve (thigpen & Cleckly, 1957) ● Depersonalization/derealization disorder ➔ Feeling of being detached from oneself and one’s physical and social environment ➔ Depersonalization experienced for a short period of time is very common and not pathological ●Other specified dissociative disorder ➔ Do not meet diagnosis criteria for other disorders above ➔ E.g., “identity disturbance due to prolonged and intense coercive persuasion” → follow from acts of torture and brainwashing ●Unspecified dissociative disorder ●Wherein only parts are remembered; 3. Generalized amnesia ●Wherein the person forgets all personal info from his or her past; 4. Continuous amnesia ●Wherein the individual forgets info from a specific date until present; and 5. Systematized amnesia ●Wherein the individual only forgets certain categories of info, such as certain people or places - The latter 3 patterns of memory loss are less common & commonly associated with a diagnosis of dissociative identity disorder - Dissociative fugue as a subtype of dissociative amnesia ●Rare type of amnesia for autobiographical info this is so profound that individuals also travel unexpectedly away from home ●Some individuals travel thousands of miles from their home before they recall their personal history ➔ Usually brief in duration, lasting from a few days to a few weeks ➔ Rare cases where the individual disappears for a prolonged period of time ➔ Reasonably well functioning, and may even successfully adopt a new identity and occupation if the disorder is prolonged ➔ May end abruptly or gradually with persistent confusion ➔ Often those who have recovered from the disorder report no memory of what occurred during the fugue state ●Understanding is limited ●Precipitating factors include life stressors ●Relatively common in dissociative identity disorder, and comorbid with depressive, bipolar disorders and substance abuse Depersonalization/Derealization Disorder - The individual has persistent or recurrent experiences of depersonalization and/or derealization - Depersonalization: ●Distinct sense of unreality and detachment from their own thoughts, feelings, sensations, actions, or body ●Relatively common in general population often during times of stress - Derealization ●Involves feelings of unreality and detachment with respect to one’s surroundings rather than the self ●Experience other people or objects in their environment as unreal, dreamlike, foggy, or distant ●May be subjective visual distortions in which they see objects as distorted, blurred, flattened, or larger/smaller - Is only diagnosed when severe depersonalization is the primary problem, and when the symptoms are persistent and cause clinically significant impairment or distress ●Experience recurring episodes of depersonalization, in which they feel as though they are living in a dream, observing their own mental processes or body from the outside, or as if time is moving slowly - Typically begins in adolescence and tends to be chronic in nature - High rates of comorbidity w/ anxiety, depression, personality disorders, and other dissociative disorders (Simeon, Knutelska, Nelson, & Guralnik, 2003) - Laboratory research suggests that individuals with depersonalization/ derealization disorder have reduced emotional reactivity to stressful or emotionally arousing stimuli (Sierra et al., 2002; Simeon, Guralnik, Knutelska, Yehuda, & Schmeidler, 2003; Stanton et al., 2001), as well as cognitive disruptions in perceptual and attentional processes (Guralnik, Giesbrecht, Knutelska, Sirroff, & Simeon, 2007). - Neuroimaging evidence: ●the inferior longitudinal fasciculus (ILF) may be critical for integrating visual and emotional information, since damage to this area has been associated with diminished responses to emotionally evocative images (Fischer et al., 2016). Dissociative Identity Disorder - Diagnostic criteria: ●Disruption of identity characterized by two or more distinct personality states ➔ Involves marked discontinuity in sense of self and agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensorimotor functioning ●Recurrent gaps in the recall of everyday events, important personal info, and/or traumatic events that are inconsistent with ordinary forgetting ●Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning ● The disturbance is not a normal part of a broadly accepted cultural or religious practice ●Symptoms are not attributable to the physiological effects of a substance or another medical condition - diagnosed when the patient presents with two or more distinct personality states, wherein a disruption of identity is indicated by discontinuities in one’s sense of self and corresponding changes in psychological functioning (altered emotional displays and behavior) - alternative personality states resemble different identities or personalities that periodically intrude into the consciousness and assume control of a person’s behaviour ●One personality state identifies as the “host” ●Subsequent states are identified as “alters” ➔ Each state is distinct and presents with different memories, personal histories, and mannerisms ➔ Some researchers have reported differences between alters in eyeglass prescriptions, EEG patterns, allergies, and other physical parameters (Nijenhuis & den Boer, 2009) ➔ Average number of personality states appears to be somewhere between 10 and 16 (Acocella, 1999; Coons, 1998) - Switching ●Changing from one personality to another ●Occurs in response to a stressful situation ●New presence may or may not be perceived, may lead to a change in tone of voice, demeanour, or posture of the individual ➔ Did not suggest that individuals were faking, but asserted that it is possible to alter a person’s personal history so that it is consistent w/ DID ➔ Believed that therapists’ leading questions, cue, and other demand characteristics play a role in the generation and maintenance ●Harold Merskey argued that DID is an iatrogenic condition ➔ Largely caused by therapists themselves during the course of therapy ➔ During hypnosis, therapists may plant suggestions in their patients that they have multiple personalities ➔ Merskey (1992) pointed to the sharp increase in diagnosed cases of DID following the release of films that portrayed this disorder, such as The Three Faces of Eve and Sybil - A critical issue dividing these two theories is whether or not DID actually develops in childhood as a result of abuse. Proponents of the socio-cognitive model point out that DID is usually diagnosed in adults and almost never observed during childhood, when it is supposed to begin (Piper & Merskey, 2004a). - Proponents of the trauma model point to a considerable amount of research evidence linking dissociative disorders with a history of trauma. ●Dalenberg and colleagues (2012) reported a moderately strong relationship between trauma and dissociation ●Highly aversive events are linked to later experiences of dissociation (Dalenberg et al., 2012) - Critics of trauma model ●methodological flaws and inconsistencies in research used to support this model (Lynn et al., 2014) ●document severe childhood physical and/or sexual abuse are based on adult patients’ retrospective reports, which are very difficult to corroborate (Kihlstrom, 2005) ●studies utilizing prospective designs and well-corroborated cases of trauma have at times failed to find the expected relationship between trauma and dissociation (Lynn et al., 2014) Treatment Psychotherapy: - Helping patients resolve emotional distress associated with past traumas and learn more effective ways of coping with stress (Harper. 2011) - Treatment of DID tends to be a quite prolonged and arduous process, going through a series of stages leading to the eventual integration of the various personalities (Kluft, 1999) ●First stage → trusting, safe environment ●Second stage → helping patients developing new coping skills and reaching a level acceptance of his or her past history ●Final stage → integrations of personalities ➔ Alters to merge into a single personality or at least a group of alters working together and are aware of each other - Main findings of effectiveness included lower levels of dissociation, depression, general distress, and post-traumatic stress disorder symptoms at the 30-month follow-up ●Little systematic research and methodological flaws Hypnosis: - Popular treatment to confirm the diagnosis, to contact alters, and to uncover memories of childhood trauma (Kluft, 1999) - Criticized bc of the potential of retrieving confabulated memories and personalities Medication: - Generally not useful - Helpful in treating comorbid disorders - Truth serum” or sodium amytal, a barbiturate causing drowsiness, has sometimes been used to help the individual recall previously forgotten memories or identify additional alters → other psychotherapies used at the same time Neurosurgical treatments: - Transcranial magnetic stimulation, particularly in the case of depersonalization/derealization ●Generation of a magnetic field at the level of the scalp using a metal coil, which influences the electrical activity in nearby regions of the brain ●reported that 20 sessions of rTMS to the right ventrolateral prefrontal cortex significantly improved symptoms of depersonalization in six out of seven cases (Jay et al., 2016) Somatic Symptom and Related Disorders - Somatic symptom disorder: ●One or more somatic symptoms (e.g., chronic pain, fatigue) that are distressing or cause significant disruption of daily life, accompanied by disproportionate concerns about seriousness, anxiety, and/or excessive time and energy devoted to health concerns; a diagnosed medical illness may or may not be present - Illness anxiety disorder: ●Preoccupation, anxiety, and worry about having or acquiring a serious illness in the absence of significant somatic symptoms and despite the fact that thorough evaluation fails to identify a serious medical condition - Conversion disorder: ●Symptoms affecting voluntary motor or sensory functions (e.g., blindness, paralysis, loss of feeling) that are incompatible with recognized neurological or medical conditions - Psychological factors affecting other medical conditions: ● The individual has a medical condition (e.g., asthma, heart disease, diabetes) that is adversely affected by psychological or behavioural factors (e.g., anxiety exacerbating asthma symptoms, stressful work environment causing high blood pressure) - Factitious disorder: ●Faking or inducing symptoms of illness to gain sympathy, medical care, and attention (e.g., taking excessive laxatives, contaminating urine samples, intentionally injuring oneself) Prevalence: - Little prevalence info is available therefore we must apply existing studies on somatoform diagnoses as well as most cases of hypochondriasis ●studies assessing the prevalence of somatization disorder found an average prevalence of 0.4 percent in the general population, whereas the prevalence of ●which may or may not be due to a diagnosed medical disease or illness, must be very distressing to the individual and result in significant disruption of daily life ●Anxiety about health, excessive worry, and devote excessive tie and energy to thinking about them - Patients tend to strongly resist suggestions that psychological or social factors might contribute - Their accounts can be very persuasive and potentially expose them to danger as a result of invasive or risky diagnostic procedures (e.g., X-ray examinations or invasive probes), surgery, hospitalization, side effects from potent medications, or treatment by several physicians at once, perhaps leading to complicated or even hazardous care (Woolfolk & Allen, 2010) - Multidisciplinary assessment is often required ●Physicians need to test for presence of medical conditions ●Psychologists need to assess emotional, cognitive, behavioral, and social issues - These patients are often prone to periods of anxiety and depression that they cannot express or cope with adaptively (Löwe et al., 2008). In addition, these individuals often report histories of substance abuse and personality disorders (Bornstein & Gold, 2008; Noyes et al., 2001) - Often display excessive sensitivity to minor bodily symptoms ●Serve to confirm that an illness is in fact present ●Focus on the long-term process of illness and disease - Pain is the most frequent bodily symptom associated with somatic symptom disorder ●Somatic symptom disorder with predominant pain ●Pain is an individual and subjective experience, and both its onset and course are known to be affected by a number of psychological factors, including stress, anxiety, and depression. These psychological dimensions of pain establish an important role for psychologists in understanding and controlling pain (Wiech & Tracey, 2009). - Claassen-van Dessel and colleagues (2016) reported that fewer patients with medically unexplained symptoms were diagnosed with a somatic symptom disorder when assessment was based on DSM-5 criteria (45.5%) compared to DSM-IV requirements for somatoform disorders (92.9%) Illness Anxiety Disorder: - Previously diagnosed as hypochondriasis - Preoccupied with the fear that they may have a serious medical diseases even though medical examination reveals that there is nothing seriously wrong - Difference b/w somatic symp. & illness anxiety ●Illness anxiety → do not experience bodily symptoms & are primarily concerned with the idea that they are ill ●Somatic symp. → significant symptoms such as pain and may actually may have a diagnosed medical illness - To be diagnosed with this disorder, the illness preoccupation must have been present for at least six months, although the particular illness that is feared may have changed during that time Factitious Disorder - Individuals with factitious disorder (also called Munchausen syndrome) deliberately fake or generate the symptoms of illness or injury to gain medical attention ● A recent analysis of 372 studies suggests that most patients choose to self- induce illness or injury, rather than falsely report or simulate symptoms (Yates & Feldman, 2016) - To be diagnosed with this disorder, there must not be any obvious external rewards for this behaviour, such as receiving insurance money, evading military service, or avoiding an exam. Instead, the motivation of these individuals seems to be to gain sympathy, care, and attention that accompany the sick role - Factitious disorder imposed on another (Munchausen syndrome by proxy) Etiology of Somantic symptom disorders - Traditional psychoanalytic explanations proposed that these disorders resulted from conversion of the anxiety associated with unconscious conflicts and unacceptable sexual drives into somatic symptomatology and distress. However, this view is not widely held today - Kirmayer and Looper (2007) have proposed an integrative biopsychosocial model to explain the development of somatic symptom and related disorders. ●a number of physiological, psychological, and social factors may interact in a series of vicious cycles, with different somatic symptom disorders resulting from different patterns of interaction Physiological Factors: - E.g.,chronic stress produces activation of the hypothalamic-pituitary-adrenal (HPA) axis, producing high levels of cortisol, which can adversely affect the immune system and also produce feelings of fatigue, pain, and general malaise (Kirmayer & Looper, 2007) Cognitive Factors: - Individuals with somatic symp disorder spend substantial time monitoring their bodies thus they are more likely to notice a change ●tend to interpret bodily sensations in a distorted manner, magnifying their seriousness or importance and attributing them to serious illnesses, leading to increased distress and further physiological arousal (Barsky, 1992; Vervoort et al., 2006) - Cognitive-behavioral model of health anxiety ● Abramowitz, Deacon, and Valentiner (2007) theorize that the development of dysfunctional beliefs about illness leads an individual to become attentionally biased to misinterpret information in a self-alarming and personally threatening manner ●Distorted interpretation produces anxiety and uncertainty, which prompts safety-seeking behaviors ➔ individuals with health-related anxiety often avoid illness-related information, frequently check symptoms, and repeatedly seek help from medical professionals to receive reassurance regarding their concerns (Hadjistavropoulos, Craig, & Hadjistavropoulos, 1998) ➔ proposed that these behaviours impede corrective learning about a patient’s health and reinforce dysfunctional beliefs about illness, thereby completing a vicious cycle and maintaining anxiety (Abramowitz et al., 2007) ● Bipolar and related disorders involve periods of depression cycling with periods of mania Depressive Disorders ● Include a set of conditions that share as common features the presence of sad, empty, or irritable mood, along with a number of additional somatic and cognitive symptoms that significantly impact the individual's functioning Major Depressive Disorder ● Often referred to as the "common cold" of mental disorders because it is so prevalent ● Leading cause of disability worldwide and is the second leading contributor to the global burden of disease ● Depression costs the NA economy $60 billion per year, more than half of that in lost productivity and named depression an "unheralded business crisis ● MDD is a very real and serious disorder that involves biological, emotional, cognitive and behavioural changes; and can impair functioning in all areas of a person's life Prevalence and Course ● Affects 1.35 million people in Canada or 5% of the population ● MDD is recurrent ● Approximately 50% of individuals who experience one episode of depression will have a second, and up to 90% of those who experience two or three episodes will have future recurrences ● Episodes last between 6 and 9 months on average, although they can last years ● Average age of first onset MDD is early to mid 20s o Increasingly being recognized as a disorder that affects children and adolescents o Rates of depression grow steadily and equally for both sexes throughout childhood, but then begin to diverge at about 10 ● Rates of depression then continue to increase dramatically throughout adolescence for girls, whereas they tend to level off for boys ● Individuals with MDD often suffer from one or more additional mental disorders ▪ The most common class of comorbid disorders is the anxiety disorders, affecting more than 50% of patients with MDD ▪ Depressed individuals with comorbid conditions experience a more severe and chronic depression, and their response to treatment is slower and less complete Persistent Depressive Disorder ● Defined as a chronic low mood, lasting for at least two years, along with at least three associated symptoms ● Prevalence in the population is approximately 3% ● Also experience recurrent episodes of MDD superimposed on their chronic low mood ● Klein and others have found that persistent depression, in all of its manifestations, has higher levels of impairment, a younger age of onset, higher rates of comorbidity, a stronger family history of psychiatric disorder, lower levels of social support, higher levels of stress and higher levels of dysfunctional personality traits than does episodic MD o Individuals with persistent depression are also less likely to respond to standard depression treatment than are those with episodic MD Bipolar Mood Disorders ● Mania, a distinct period of elevated, expansive or irritable moos that lasts at least one week and is accompanied by at least three associated symptoms ● Hypomania, a less severe form of mania that involves a similar number of symptoms, but those symptoms need to be present for only four days ● Symptoms of mania include: o Increased energy o Decreased need for sleep o Racing thoughts o Pressured speech o Problems with attention and concentration ● Judgement is also impaired, and these individuals may go on spending sprees, engage in substance abuse of risky sexual behaviour or may even become aggressive ● Some individuals can experience both manic/hypomanic and depressive symptoms at the same time (called a mixed state) ● At least three symptoms of the opposing episode state are required to meet criteria for mixed features ● As the episode progresses, symptoms may become more severe and start to be experienced as disturbing and even frightening ● At their most extreme, these individuals can experience a break with reality, psychosis Bipolar I and Bipolar II ● Bipolar I, an individual has a history of one or more manic episodes with or without one or more major depressive episodes o A depressive episode is not required for the diagnosis of bipolar I disorder but most patients have both manic and depressive episodes ● Bipolar II disorder, defined as a history of one or more hypomanic episodes with one or more major depressive episodes o Can be more difficult to diagnose because hypomanic episodes may be experienced as a period of successful high productivity, and indeed many people with bipolar II are reluctant to take mood-stabilizing medication because they experience their hypomania as enjoyable ● For both disorders, the hypomanic/mania episodes typically last between two weeks to four months, while the depressive episodes last between six to nine months ● Rates of suicide range between 10-15 percent ● Lifetime prevalence rate in the population of bipolar I disorder is approximately 0.8 percent and of bipolar II disorder is 0.5 percent o Rates do not differ between men and women o Men age of onset bipolar is 20 years ● Growing consensus that bipolar disorder can onset in childhood and current estimates place the prevalence of bipolar disorder in children at 0.5 percent ● Experts believe that children and adolescents with bipolar disorder are under diagnosed and undertreated due to a lack of understanding about pediatric bipolar disorder Cyclothymia ● A chronic, but less severe form of bipolar disorder ● Involves a history of at least two years of alternating hypomanic episodes and episodes of depression that do not meet the full criteria for MD ● Prevalence is 0.4 to 1%, and is equal in men and women, though women more often seek treatment ● Because the mood swings are relatively mild and the episodes of hypomania may be enjoyable, individuals with cyclothymia often do not seek treatment o This group is at risk for developing full-blown bipolar disorder o Anti depressant medication should be used with caution in this group as these medications can trigger manic episodes in vulnerable patients Cognitive Theories ● Beck's great insight was proposing that a person's emotional response to a situation is determined by the manner in which that situation is appraised or evaluated o People with depression are more likely to appraise situations negatively than those not prone to depression and, hence, will be more likely to experience negative mood in response to situations o Depressed individuals apply cognitive distortions to situations that lead to negative mood ● Examples of common cognitive distortions include: ▪ All or nothing thinking: Seeing things in black or white. If your performance fall short, you think of yourselves as a failure ▪ Overgeneralization: You see a single negative event as a never- ending pattern of defeat by using words such as "always" or "never" when you think about it ▪ Magnification (catastrophizing): you exaggerate the importance of your errors or problems. Ex. You forget someone's name when you are introducing him or her and you tell yourself "this is terrible" ▪ Jumping to Conclusions: You interpret things negatively when there are no definite facts to support you conclusion. o According to Beck's model, the foundation of the depressed person's negative cognitive style is the depressive schema o Schemas are hypothetical structures in the mind that contain core beliefs about the self, the world, and the future, the cognitive triad ● Schemas develop from our early experiences with the world and represent stored memories, images, and thoughts from these experiences ▪ They then guide the selection, encoding, organization, storage and retrieval of information ▪ Key feature of the depressed individual's schemas are their rigidly negative quality o Beck's theory is complementary to psychodynamic theory o Beck's Cognitive model is a diathesis-stress model ● Proposed that the negative cognitive schemas of the depression-prone person remain inactive in the mind, and thus serve as silent vulnerability factors (diatheses) that do not express themselves until activated by stressful life event that matches the theme of the schema Interpersonal Models ● Key feature of depression is problems in interpersonal relationships. o People with depression have deficient social skills in relation to non- depressed people o Depressed people engage in less frequent eye contact, have less animated facial expressions, and show less modulation in their tone of voice than do none depressed people ● Evidence that skill deficits cause depression is not compelling ● Emerging evidence that a particular type of impaired social skill- negative feedback seeking-may serve as a risk factor for depression o Negative feedback seeking: the tendency to actively seek out criticism and other negative interpersonal feedback from others that is consistent with their self-schemas ● Research shows that depressed individuals do indeed seek more negative feedback from others and are more rejected by others than non-depressed individuals ● Research also suggests that that individuals who are high in negative feedback seeking are at risk for developing future depression ● Excessive need for interpersonal attachment, support and acceptance leads to behaviours that cause and maintain depression o Excessive Reassurance Seeking: the tendency to repeatedly seek assurance about one's worth and lovability from others, regardless of whether such assurance have already been provided o Interpersonal model of depression, the depression prone person may excessively seek reassurance after a negative event, such as an argument ● Though they may be given reassurance, they tend to doubt its sincerity and continues to demand more reassurance ● Stress Generation Hypothesis: depressed individuals have been found to generate stressful life events in the interpersonal domain, including fights, arguments, and interpersonal rejection; that is, depressed individuals contribute to the occurrence of these events due to their maladaptive interpersonal behaviours o Research has found that excessive reassurance seeking, in particular, may be in large part responsible for the generation of interpersonal stressors, which then serve to maintain and perpetuate depression Life Stress Perspective ● Stressful life events tax our psychological and physical resources and can cause significant increases in sadness, anxiety, and irritability o Can trigger a downward spiral into MD o Personality and cognitive vulnerability characteristics, or "diathesis", make some individuals more likely than others to develop depressive or main episodes in the face of life events ● Individuals with depression are nearly three times more likely than those without depression to have experienced a stressful life event prior to onset o Nearly 75% of individuals with MD have suffered at least one severe loss event in the three to six months prior to onset of their depression ● Individuals with bipolar disorder, negative loss events preferentially predict increases in depressive symptoms whereas life events related to regard and goal attainment preferentially predict increases in manic symptoms o Results are consistent with the findings that individuals with bipolar disorder show a preferential sensitivity to rewarding stimuli Depression Childhood Stressful Life Events ● Those who are victims of physical, sexual and/or emotional abuse are two to five times more likely to develop depression in young adulthood than those without this history ● Why is childhood trauma a strong predictor of depression? o Cognitive theories suggest that early maltreatment is internalized by the child in the form of negative cognitive schemas, such as "I'm unlovable" o Studies suggest that childhood trauma is related to the development of negative cognitive schemas about the self that are then related to the development of depression o Biological theories suggest strong and pervasive effects of child abuse on the brain ● Ex. Child abuse is associated with the death of cells in the hippocampus and amygdala, two areas of the brain that are critically involved in the regulation of mood and emotional memory ● Research has shown that child abuse is associated with dysregulation of the body's biological stress response system - the hypothalamic-pituitary- adrenal axis ▪ Child abuse even leaves marks at the genomic level; that is, it affects the way different genes turn on and off over the lifespan Biological Causal Factors ● Examines how dysfunction in the brain and body contributes to the etiology of mood disorders ● Examines studies involving genetic, neurochemical, neuroendocrine, neurophysiological and neuroimaging levels of analysis Genetics ● Both MDD and Bipolar run in families, and it is estimated that first-degree relatives of people with MDD are two to five times more likely to develop depression than are individuals from the general population o For bipolar, first degree relatives have 7-15 time greater risk of developing any mood disorder than does the generally population o DOES NOT PROVE that this link is genetic, as family members also share the same environment, and environmental influences are very strong in promoting risk for mood disorders ● Adoption study, found rates of 32% for bipolar disorder in the biological parents of affectively ill adoptees as compared to 12 % in the adoptive parents ● Twin studies, Monozygotic (identical) twins share 100% of their genetic material, whereas dizygotic (fraternal) share 50% of their genetic material, just like regular siblings o Higher concordance rater for unipolar MD in MZ twins (40-59%) than in DZ twins (20-30%) o Concordance rates for bipolar disorder are 65% in MZ twins and 14% in DZ twins o Heritability estimate for MDD is 0.36 ● An indication of the relative contributions of differences in genetic and non genetic factors to the total variance in the disorder in a population o Heritability estimate for bipolar is 0.75 (75% of the pie) ● Individuals with a family history of the disorder tend to develop the disorder earlier ● Serotonin transmitter gene (HTT) located on chromosome 17 o Serotonin is important for regulating mood and is the chemical targeted by many antidepressant medications, such as prozac o Appears to have effect on MDD by heightening individuals reactivity to stress Neurotransmitters ● Chemical substance manufactured at the neuron and released at the synapse ● Can have excitatory effects on post-synaptic neurons, thus increasing their chances of firing new action potentials, or they can have inhibitory effects thereby reducing the chances of their firing ● Researchers discovered dysfunction in two neurotransmitter systems in depression: the catecholamine norepinephrine and the indoleamine serotonin (5-HT) o Both were found to be responsible for the functions that are disturbed in depression such as sleeping, appetite, energy and activity level o First antidepressant medications worked by increasing levels of these two monoamines ● Most who have unipolar depression do not show reductions in NE activity o Low NE activity appears to be a key feature of both bipolar and severe unipolar depression ● Brain imaging techniques have shown that depressed individuals have fewer 5-HT receptors ● Monoamine Oxidase Inhibitors, work by inhibiting an enzyme that breaks down monoaminergic neurotransmitters in the presynaptic cell ● Selective Serotonin Reuptake Inhibitors, currently the first line treatment for unipolar depression because of their relatively mild side effects, their high safety profile and their ease of administration ● Other classes of antidepressants: ▪ Serotonin-norepinephrine reuptake inhibitors (SNRIs) ▪ Mirapex, increases dopamine transmission ▪ GABA, those that have miscellaneous actions ● Downside of medications is that they are associated with a high risk of relapse Medications to treat Bipolar Disorder ● Lithium o Used as mood stabilizing treatments o Use of lithium requires regular monitoring by a psychiatrist and blood tests because the therapeutic window is very narrow ● This means that the dose required to attain a therapeutic effect is only slightly less than the toxic dose o Patients also require tests to monitor thyroid and kidney function due to lithium interfering with the regulation of sodium and water levels o Common side effects include dehydration, weight gain, acne with scarring, thinning of hair and hand tremor ● Anticonvulsants o ~40% of patients with bipolar do not respond to lithium or cannot tolerate the side effects o Anticonvulsant drugs used for epilepsy are often prescribed alone, with lithium or with an antipsychotic drug to control mania o Work by increasing the synthesis and release of the neurotransmitter gamma- aminobutyric , which plays a general inhibitory role in the brain o Common side effects include: dizziness, drowsiness, nausea, tremor, rash and weight gain ● Antipsychotics o Used to treat schizophrenia, may be used as a short term treatment during acute manic or severe depressive episodes o Antagonists of multiple neurotransmitter receptors, including serotonin and dopamine o Common side effects include: blurred vision, dry mouth, drowsiness, muscle spasms or tremor, facial ticks and weight gain ● Antidepressants o Often used to treat the depressive phase of bipolar disorder Combinations of Psychological and Pharmacological Treatments ● Most cases for depression, treatment choice should be based on the relative risks of pharmacotherapy versus psychotherapy, responses to past treatments, and patient preference ● Evidence that combination of IPT and medication is superior to either alone ● Patients with persistent depression, there is evidence that the combination of BASP and medication is superior to either alone ● Evidence that adding CBT to those who fail to respond fully to medication improves remission rates and helps in preventing relapse ● Evidence that a combination of CBT and medication is superior to either alone in the treatment of adolescents with depression Adjunctive Psychotherapy for Bipolar Disorder ● Most effective for bipolar is medication ● High risk for relapse ● Often continue to show significant impairments in work, family, and social relationships even while medicated o For this reason psychological treatments have been developed Family-focused therapy (FFT) ● Consists of education for patient and family, as well as communication and problem solving training involving all members of the family Interpersonal and Social Rhythm Therapy (IPSRT) ● Based on theory that disruptions in daily routines and conflicts in interpersonal relationships can cause relapses of bipolar episodes ● Taught to regulate routines and cope more effectively with stressful events Cognitive therapy (CT) ● Similar to CBT, patients are taught strategies that address the unique issues faced in bipolar disorder including: o How to regularize their sleep and daily routines o How to regularly monitor their mood to help identify early triggers for manic episode relapses o Importance of medication compliance ● Systematic Treatment Enhancement Program (STEP) o Large scale, multi-site, randomized, and controlled study developed to test the efficacy of the above three adjunctive psychosocial treatments head to head ● Results indicated that patients receiving any one of these psychotherapies were significantly more likely to have recovered after one year of treatment, and they recovered more quickly than patients who received only clinical management with their medication Phototherapy For Seasonal Affective Disorder ● Treatment for SAD ● Patients sit in front of a small box that contains fluorescent bulbs of tubes (mimicking the sun) ● May precipitate manic episodes in individuals with bipolar SAD Neurostimulation and Neurosurgical treatments ● Treatment resistant depression is defined as a failure to achieve remission following at least two trails of antidepressant medication at an appropriate dose and duration o Associated with severe impairments in social, educational, occupational and health functioning and these individuals have a significantly lower quality of life that non-treatment-resistant depressed patients ● Electroconvulsive Therapy (ECT) o Often used indiscriminately from its discovery of medications used to treat psychological disorders o Previously administered without anaesthetics, and electrical current used was much higher than the ones used now o Patients are now administered a general anaesthetic and muscle relaxant so that they do not convulse during seizure ● BP cuff is placed around the ankles to prevent muscle relaxant from reaching the foot ● Also wear mouth guards to protect tongue and teeth ● Electrical current is then applied to the brain ● Transcranial Magnetic Stimulation (TMS) o Uses magnetic field to alter brain activity o Large electromagnetic coil held against the scalp ● Electric current creates a magnetic pulse that travels through the skull and causes small electrical currents in the brain ● Non-invasive and painless ● Lasts about a half hour and is repeated several times per week ● Vagus Nerve Stimulation (VNS) o Vagus nerve runs from brain stem through neck and down to the chest o pulse generator is surgically implanted in the patients chest on the left side ● Lead wire attached to generator runs under the skin up to the neck and is attached to the vagus nerve, which then delivers them to the brain o Implant is permanent and typically delivers stimulation every 5 minutes for 30 seconds ● Not felt by all patients ● Deep brain stimulation o Involves surgically implanting wires directly into the brain that then run from the head, down the side of the neck and behind the ear to a pulse generator, which is implanted subcutaneously below the clavicle o Pulse generator is calibrated by a neurologist to deliver a particular dose of electrical current into the brain Suicide ● Have been influenced by themes such as religion, honour and the meaning of life ● Now viewed as a mental health concern associated with depression or other psychiatric disorders, inescapable psychological pain or severe stress ● 10th leading cause of death in Canada ● Rate of completed is three tines the rate for men than it is among females ● Among youths 15-24, second highest cause of death Definition ● Suicide Ideation: thoughts of death and plans for suicide ● Many may express ideas without ever progressing ● Suicidal gestures: behaviours that look like an attempt but are clearly not life- threatening o Often do not have intent to die, but may want to alert others to their suffering ● Suicide attempt: carrying out a plan, which is unsuccessful but with clear intent ● Self harm often happens in private, done as a way of coping with extreme emotional distress Epidemiology and Risk Factors ● Strongest risk factor is being male o In all age groups, men are three times more likely than women to complete o Women are three times more likely to attempt it o Considerable cultural, ethnic and regional variation in suicide rates ● Canada and US fall mid range ● Highest rates found in Germany, Scandinavia, Eastern Europe, and Japan ● Lowest rate Italy, Spain and Ireland o Aboriginal communities have rate two to four times greater than the rest of the country ● Leading cause for First Nation males between 10-44 ● Nunavut, 88 per 100 000 Causes ● Untreated mental disorder ● Mood disorders, alcohol, substance abuse