Overview and History:

What is psychopathology?--It is the field concerned with the nature and development of abnormal thoughts, feelings and behaviors.

Difficulties with this definition:

1) ambiguity- the field is defined by its' questions rather than its' answers

2) objectivity-the subject nature is personal making objectivity all the more important. Everyone has experienced some abnormal symptoms personally, interpersonally or in news reports. Two problems with this:

A) medical student syndrome

B) experiential vs. scientific frame of reference (Paul Meehl "Why I don't go to case conferences")

Class exercise: What is abnormal? What is normal?

Within the field of psychopathology we ask:

1. What is abnormal behavior?

Characteristics include:

A. Statistical infrequency-Normal curve Behavior is considered abnormal to the extent that it deviates from the average (MR as an example) BUT some very infrequent behaviors are not pathological (e.g. athletic ability). The statistical approach does not tell us which particular behaviors we should abnormal.

B. Violation of social norms- abnormality is treated as relative to some social standard (e.g. anorexia or OCD rituals) BUT some behavior clearly violates social norms but is not considered abnormal (e.g. prostitution) and other behavior is considered clearly abnormal but does not violate social norms. (e.g. simple phobia). ALSO cultural diversity can affect how people view social norms- what is normal in one society is abnormal in another.

C. Personal Distress- behavior is considered abnormal to the extent that it creates distress (e.g. depression and anxiety) BUT some disorders do not necessarilly involve distress (e.g. psychopathy) and some forms of distress are not abnormal (e.g. hunger). Also discomfort levels rely on subjective ratings and it is therefore difficult to compare one individual with another.

D. Disability or Dysfunction- behavior is abnormal to the extent that it causes some impairment in some important area of life (e.g. substance abuse) BUT certain diagnostic categories are not known to cause disability (e.g. transvestism with distress) and many disabilities Are not considered within the purview of "abnormal behavior" 9e.g. blindness.

E. Unexpectedness. Behavior is considered abnormal to the extent to which it is an unexpected response to environmental stressors. 9e.g. anxiety disorder) BUT certain behaviors may be quite markedly deviant but not be unexpected (e.g. addictive behaviors)

The best definition is probably a combination of A-E, that is behavior is abnormal to the extent that it represents a marked deviation from established societal norms and causes distress to self or others.

Who is concerned with abnormal behavior?

1. Clinical psychologists-Ph.D. or Psy.D who have further training in the area of assessment and diagnosis and the practice of psychotherapy. Psy.D. has more of a focus on therapy than research.

2. Psychiatrists- Mds who complete a residency in diagnosis and psychotherapy who prescripe psychotropics (current war over prescription privileges)

3. Psychoanalysts

4. Social workers (M.S.W)

5. Counseling psychologists- similar to clinical but less emphasis on research

6. Psychopathologists- individuals who conduct research into the nature and development of various disorders (can be clinical, biochemical, developmental, etc.)

History of Psychopathology

Earliest theories concerning the causes of abnormal behavior invoked supernatural forces.

Prevailing theory- Deviancy reflects the displeasure of the gods or possession by demons.

Early demonology (prior to 400 B.C.):

Theory: Evil beings (e.g. the devil) cause deviant behavior. Many cultures subscribed to this view (e.g. early chinese, Greeks and Hebrew, Biblical accounts of possession (Mark 5:8-13)

Treatment: Exorcism (or similar rites) Exorcism is the casting out of evil spirits by chanting ritual or prayer. In ancient times it also included such practices as flogging and starvation so that the body would not be attractive to evil spirits.

Somatogenic Theories: Some that is wrong with the soma (physical body) is the cause of disturbance in thought and action. (Psychogenesis-disturbance has psychogenic origins.)

Hippocrates (early fifth century; father of modern medicine, individual who separated modern medicine from religion magic and superstition)

-The gods do not send mental and physical disease in order to punish. Serious diseases are caused by natural factors (even mental disease) and should be treated like other diseases (e.g. colds) with natural remedies.

-The brain is the organ of consciousness, intellectual life and emotion=deviant thinking and behavior are indications of brain pathology.

Three categories of mental disorder:

1-mania

2- melancholia

3- phrenitis (brain fever)

-Normal brain functioning(and mental health) dependent on a balance among four humors(bodily fluids). Imbalane produces illness:

1. Blood (changeable temperment)

2. Black bile (melancholia)

3. Yellow bile (irritability and anxiety)

4. Phlegm (sluggish and dull)

Though the theory is wrong, the premise set the stage for modern medicine and the naturalistic or disease oriented approach to treatment that is used in modern medicine today.

Demonology (the Dark Ages, 200 A.D.) Followed the decline of the Greek and Roman empire). Several operative factors including:

1. Gain in influence of the church

2. Papacy was declared independent of the state

3. Missionaries, through the establishment of monastaries replaced physicians as healers- particularly of those with mental disorders.

A. Related development was treating the mentally ill as possessed by the devil (13th century until now)

Operative factors/premises appeared to include:

1. Withcraft is caused by the devil

2. 1484 papal bull by Pope Innocent VIII encouraging identification of witches. This marked the beginning of the Inquistion.

1510 Malleus Maleficarum (Hammer of the witches a guide to witch hunts became the textbook on witches) was published. Subjected accused to torture, convicted to life imprisonment and unrepentent to execution. Specified that sudden loss of reason was a symptom of demon possession which shoud be "treated" by burning. Estimates of 500-800,000 men, women and children died because of this.

3) The best known American witchcraft trials were in Massachusetts in 1692- hundreds of people falsely accused and imprisoned- 20 killed

Witchcraft was not the only explanation for mental illness at this time. In larger cities laws were being passed to "confine" the mentally ill. The laws did not mention witchcraft. First lunacy trials were actually held in Britain the 1200's. During that time it was established that:

1. Trials could be conducted under the Crown's right to protect the mentally impaired.

2. A judgment of insanity allowed the court to become guardian of the lunatic's estate.

3. Issues in the trials included defendent's orientation, memory, daily life etc.

4. Causal explanations included physical illness or emotional shock.

The Masturbatory Insanity Hypothesis

Theory based causal explanation

The beginnings of contemporary thought:

The return to somatogenic theories in the early 1500's (coocurred with the reemergence of a scientific or professional class. Autopsies were again allowed)

Some major advances/figures in this time:

1) Willam Griesinger- German physician- any diagnosis of mental disorder must specify a physical cause.

Emil Kraeplin was his student. Kraeplin devised a classification system of mental illness in 1883.

Discovered certain symptoms-which he called syndromes tend to cooccur.

Each syndrome has its own distinct genesis, symptoms, course and outcome

Two types of syndromes:

Dementia praecox-schizophrenia- caused by a chemical imbalance

Manic-depressive psychosis- irregularity in metabolism

Kraeplins idea of classifying symptoms in this way is the basis for our current classification scheme DSM-IV

Using Kraeplin's scheme we may not be able to cure disease but we can predict their course.

2) The discovery of the nature and origin of syphilis

In 1825 general paresis was given disease status- the syndrome included steady deterioration of mental and physical capabilities as well as delusions of grandeur and paralysis

1857- It was discovered that some people who had general paresis had previously suffered from syphilis (a venereal disease) The search for a cause was on and included seawater (sailors) liquor and tobacco (men).

1860's-1870's Louis Pasteur established the germ theory of disease

Disease is caused by infection of the body by minute organisms

1897- Richard von Krafft-Ebing inocualted paretic patients with material from syphlitic sores. The paretic patients did not develop syphilis which proved they had been infected earlier.

1905-The specific organism causing syphilis was discovered

For the first time a biological cause had been discovered for a form of psychopathology!!!!!

Psychogenesis (late 1700's until now) started in Austria and France

The psychogenic view- mental disorders are caused by psychological dysfunctions.

Came about as a result of the wave of "Hysteria" in that time

Proponents included:

Franz Mesmer- hysterival disturbances are caused by disturbances in the magnetic fluid of the body.

Used hypnosis or mesmerisn to achieve cures

This led to the study of hypnosis-Jean Charcot- scientifically showed how suggestion can lead to the amelioration of symptoms.- led to an increased interest in nonphysiological explanations of physiological problems.

Josef Breuer- The case of Anna O. Led to the "cathartic method"

Breuer's work was an immediate precursor to Freuds.

History of modern clinical Psychology

1) Development of asylums.- Asylums began to appear in the fifteenth century as leprosariums began to be converted to refuges for the confinement of the mentally ill.

-Inmate were a mixture of beggars and MI (Paris in the 1500's had 100.000 people, 30,000 of whom were beggars)

-The only treatment was to get them to work

2) The priory of St. Mary of Bethlehem (founded 1243) was handed over to Henry VIII for the sole purpose of treatment of the mentally ill in 1547.

-origin of the word "bedlam"

-bigtime tourist attraction with good ticket sales

Viennese equivalent had special rooms where inmates could be "viewed"

3) First mental hospital in America was in Williamsburg in 1773. Its first keeper had formerly headed the public gaol.

This is really page 16

Example. An examination of the effect of therapy (three levels) in groups of patients divided on the basis of severity of illness

Type of therapy is the experimental variable

Severity is the grouping variable. This variable is not manipulated. It just is. Therefore we have the same problems interpreting its effect as we do with correlations.

If therapy is differentially effective for different groups the pattern of results will be different than if therapy is similarly effective for different groups. This differential effect is what tells us the most in experimental and mixed designs- if we see a differential deficit or advantage we can rule out other hypothesis (e.g. treatment differences are less likely to be caused by random error factors such as history or selection)

This type of effect is called an interaction

A direct effect is called a main effect

Diagnostic Assessment

First systematic classification scheme developed in Paris in 1889 but it was not used
First U.S. system, 1886, from the Association of Medical Superintendents of American Institutions for the Insane (forerunner of the American Psychiatric Association-

1913- AMSA adopted Kraeplin’s scheme (not used by all organizations)

1939 World Health Organization added mental disorders to the International List of Causes of Death

1948 WHO expanded the list.  It became the International Statistical Classification of Diseases, Injuries and Causes of Death - a comprehensive listing of all diseases including MI.

Wide acceptance of the classification of MI did not occur until the publication of DSM-1 in 1952

1969- WHO published the International Classification of Diseases, 1968- DSM-11- still true consensus had not been reached e.g. symptoms listed were not always similar, therefore diagnostic practices varied.

1980- DSM-111 was published
1987-DSM-111-R, these DSM categories were more empirically , as compared to theoretically derived.
-they also made explicit reasons for changes in diagnostic categories.

Work on DSM-IV began immediately after DSM-III was published- DSM-IV was designed to resolve differences between the DSMs and the ICDs (e.g. psychopathy appeared in the ICD but not the DSM-

These differences were published in a book call the DSM-IV Options Book (1991)

DSM-IV published 1994


DSM-IV

Starting with DSM-III
    1) use of multiaxial classification- each individual is rated seperately on five dimensions (axes)
        This forces the clinician to consider a broad range of information

Axis One- Clinical disorders and other conditions that may be the focus of Clinical Attention- all forms of mental illness except Mental Retardation and Personality Disorders

Axis Two- Personality Disorders and Mental Retardation

Axes One and Two constitute the classification of abnormal behavior
    They are seperated to make sure the effects of long term disorders are not     overlooked
        e.g. Heroin addict and antisocial personality disorder

The remaining three axes are not necessary in making a diagnosis (it is already made on One and Two

What do the other three Axes do?- make sure that factors other than the persons symptoms are included in making the assessment

Axis Three- General medical conditions believed to be related to the mental disorder in question (e.g. hypothyroidism) (e.g. major depressive disorder and hypothyroidism)

Axis IV- psychosocial and environmental problems that may be contributing to the disorder (e.g. occupational or economic problems)

Axis IV- current level of adaptive functioning- Ratings of current functioning give information about the need for treatment and prognosis.

_____________________________________________________________________


Axis 1

Mental disorders in Axis One

Axis One criteria are by number of symptoms and severity of symptoms.  To receive an Axis One diagnosis symptoms must be of sufficient severity to cause significant distress or impairment in social or occupational functioning.

Disorders usually first diagnosed in Infancy, childhood or adolescence-

These are the intellectual, physical and emotional problems seen in childhood and adolescence

They include:
    1) Anxiety disorders of childhood (e.g. seperation-anxiety disorder)
    2) conduct disorder/ oppositional defiant disorder
    3) mental retardation (coded on Axis II)
    4) pervasive developmental disorders (e.g. autistic disorder, Retts, CDD)
    5) Learning Disorders (speech, reading, writing and arithmetic)

2) Substance-Related Disorders- when the use of substances has changed behavior enough to result in significant impairment in social or occupational functioning

    -usually defined as the person is unable to control usage or diplays tolerance     and withdrawal.
    -Substance use can cause or contribut toother Axis One disorders (e.g.     Substance Induced persisting Amnestic Disorder)

3) Schizophrenia- characterised by disturbances in cognition, perception and emotion
   
    -Also known as psychotic-contact with reality is lost
    -typical symptoms are delusions (false beliefs) and hallucinations (nonreality     based perceptual experiences

    -emotions are typically blunted, flattened or inappropriate
   
    -causes serious impairment in social or ocuupational functioning (though not     ness. distress

4) Mood Disorders- primary diisturbance is in mood (either extremely high or low)

    1)  Major depressive disorder- typical constellation of sadness, discouragement,     loss of energy and suicidality

    2)  Manic Disorder- mood is euphoric or irritable, hyperactive and grandiose

    3) Bipolar Disorder- diagnosed if the individuals experiences episodes of mania     or of mania or hypomania and depression

5) Anxiety Disorders- central disturbance is irrational or overblown fear.

    1) phobia- fear and avoidance of a stimulus or situation even though the     individual is aware that fears are unreasonable

    2) panic disorder- sudden, uncontrollable unexpected attacks of intense apprehension with characteristic physical (cardiovascular) symptoms

    3) Agoraphobia- fear of being unable to escape from a situation or of being unable to obtain help in the event of the experience of a panic attack.

    4) Generalized Anxiety Disorder Persistent unreasonable feelings of apprehension for most of the time for at least six months

    5) Obsessive-Compulaive disorder- Obsessions-recurrent uncontrollable thoughts that the person experiences as ego-dystonic
Compulsions are irrisible behavioral impulses- Attempts to resist compulsions produce untenable anxiety.

    6) PTSD and ACST- characterised byexposure to a traumatic stressor (e.g. one’s own death or the possibility of death.

    Typical symptoms are; reexperiencing, avoidance and heightened arousal.


6) Somatoform disorders- physical symptoms with no known physical basis that seem to serve a psychological purpose- Does NOT mean the person is faking
   
    Somatization Disorder- many physical complaints (Briquet’s syndrome)
    Conversion Disorder- odd, usually neurologic symptoms
    pain disorder- severe and protracted pain
    hypochondriasis- misinterpretation of minor physical sensations as major     physical illness.
    Body Dysmorphic Disorder- Preoccupation with a imagined defect in appearance

7) Dissociative Disorders- sudden alteration in consiousness that affects memory and identity
        -Dissociative amnesia- forgetting of the past- either globally or a specific         time period
        - Dissociative fugue- the individual suddenly travels to a new locale and         assumes a new identity- is usally amnestic to the old identity
        -Dissociative Identity Disorder (nee MPD)- posseion of two or more         personalities, each complex and dominant one at a time.

8) Sexual and Gender Identity Disorders

        -Paraphilias- sources of sexual gratification are unconventional (e.g. foot         fetish)
        -Sexual dysfunctions- characterised by the inability to complete the usual         sexual response cycle
        -Gender Identity Disorders- experience of extreme discomfort with own         sex and identification with the opposite sex

9) Sleep Disorders-

    -Dyssomnias- sleep is disturbed in amount, quality or timing
    - parasomnias- an unusual event occurs during sleep (e.g. night terror)

10) Eating Disorders

    -Anorexia Nervosa- characterised by refusal to maintain normal body weight ,      fear of gaining weight and perceptual distortion
        Two types- binge-purging, restricted

    -Bulimia Nervosa-frequent episodes of binge eating (at least twice per week for     at least three months) coupled with compensatory activities (e.g. compensatory     vomiting)

11) Factitious Disorder- applied when people intentionally produce or complain of physical or psychological symptoms- usually for the purpose of assuming the sick role.

12) Adjustment Disorder- development of psychological symptoms following the occurrence of a major life stressor.

13) Impulse Control Disorders- Characterised by inappropriate and out of control behavior.
        Intermittent Explosive Disorder-episodes of violent behavior that result in         the destruction of property or injury to another person.
        Kleptomania- repeated theft not for use of object or money
        Pyromania- purposeful firesetting for pleasure
        pathological gambling-preoccupation with gambling as a way to escape         life’s problems
        trichotillomania-irresistible impule to pluck out hair.

14) Delirium, Dementia, Amnestic and other Cognitive Disorders (often associated with aging)

    -Delirium clouding of consciouness, wandering attention and incoherent stream     of thought (may be caused by medical conditions or substance abuse)
    -Dementia- deterioration of mental capacities, especially memory
    -Amnestic syndrome- impairment in memory where ther is no dementia or     delirium (often linked to alcohol abuse)

15) Other disorders that may be the focus of clinical attention-seems to exist so that anyone entering the mental health system can be categorized
        Examples include:
            Academic problems
            Antisocial behavior
            Malingering

If a medical illness os caused or exacerbated by the psychological condition the diagnosis is psychological factors affecting a physical condition.
       



   










 




Axis II

Personality Disorders
    rigid, inflexible, maladaptive patterns of behavior and experience
        1) schizoid-person is aloof, has few friends and is indifferent to criticism
        2) antisocial personality disorder- manifested before age fifteen and         characterised by a persistent pattern of antisocial or aggressive acts.

MR
Onset before age 18
WAIS-R less than 70

Issues in Classification:

1) Classification produces loss of information
2) Classification is stigmatizing

Value of classification

1) Classification enables us to determine cause and make treatment specific to disorder
2) Classification allows us to further knowledge-we can study people who fit the definition

Is the DSM reliable and valid

Reliability
1) For each disorder there are essential features, associated features, lab findings, results from physical exams, relevant research findings re age of onset, course, prevalence etc

    This allows us to make cross-cultural comparisons.
        E.g. the core symptoms of depression and schizophrenia are consistent     cross-culturally BUT GUILT varies (frequest in Western cultures but infrequent     in Japan and Iran.
        Depression in Latino cultures more likely to involve somatic complaints
2) Specific diagnostic criteria are spelled out for each category=more explicit than other DSMs
Thus the reliabilities for the major categories are pretty good (although they vary, e.g. anxiety disorders)

BUT
1) some of the rules are a little arbitrary (e.g. number of symptoms required)
2) clinicians din’t always strictly adhere to the DSM in practice
AND
3) subjective judgments are still involved (e.g. GAF)

ALSO-
4) there is still some controversy over inclusion rules (e.g. should LD be considered a psychiatric disorder)

The bottom line is- We have a long way to go

Theories of Psychopathology

All theories of Psychopathology are based on paradigms.

    -Paradigms are sets of assumptions that go together to define how to     conceptualize, study, gather and interpret data.


The Biological Paradigm

    - an extension of the somatogenic hypothesis
    -called the medical model or disease model

Our whole description of mental illnesses uses medical model terms
    e.g.,  pathological, diagnosis & symptom
    -we also talk in terms of treatment, disease and cures

MEDICAL disorders can be very different in cause but they share one characteristic in common;
    -some biological process is disrupted or nor functioning normally

There is considerable evidence that biologiccal factors predispose the individual to psychopathology

BUT- we should also be mindful of the fact that this is just a paradigm
Other paradigms say we lose maore by taking this informatuion into accountn than we gain. ( e.g. existential accounts)

Given this what can we say about the biological paradigm:

Those working within the biological paradigm find causes to psychopathology within the body. 

Behavior Genetics- the study of individual differences in behavior that are attributable in part to differences in genetic makeup.
   
-examines the role of genes
        -thousands of genes make up chromosomes
            -chromosomes are the carriers of genetic information
            -they are passed from parent to child

            -there are 23 pairs

Genotype= the individuals total genetic makeup
Phenotype= observable characteristics

The phenotype changes over time and is a product of the interaction between the phenotype and experience.
    -intelligence is an example of phenotype.
    -clinical syndromes of mental illnesses also represent a phenotype
        -therefore it is not proper to speak of DIRECT inheritance of MI
        - what is inherited is a genetic diathesis or predisposition
            -the diathesis is inherited not the disease
        -the environment determines whether the diathesis will be activated or         become manifest.
        -therefore we speak of diathesis-stress theories of mental illness.

Behavior genetics relies on three methods to study MI

1) The family method- used to compare members of a family
    -useful in families because the average genes shared by two blood relatives is     known
        -e.g. children receive 50% of genes from each parent
            -people who share 50% of genes are called first-degree relatives
                =parents siblings and children
            -relatives who are not as closely related share fewer genes
            -nieces and nephews share 25% of their genetic inheritance with             uncles.
    -The starting point in family investigations is the individual who has the     diagnosis
    =the INDEX CASE or proband
    -relatives are then studied to determine the frqency the diagnosis applies to     them

If a genetic predisposition towards a disease is present relatives should have the disorder at a higher rate than found in the general population.
    Closer relatives should have higher rates than less close relatives

The twin method-
    Involves comparison of MZ and DZ twins
        -within and across twin comparisons
            -MZ twins develop from a single fertilized egg.
                -genetically ALMOST the same
            -DZ twins from separate eggs= 50% alike genetically

Twin studies begin with the twin with the disorder and then search for the presance of the disorder in the other twin.

    -Concordant twins are similar diagnostically
    -IF  a predispostion toward a disorder is INHERITED than MZ>DZ

BUT twin studies are usually confounded by similar environments
    e.g. twins are treated more similarly than siblings or even same sex siblings
ALSO twins that have the disorder are more likely to have parents that have the disorder (if genetic trasmission of a disorder is true)

What do scientists do?
  They use the equal environment assumption=
    -for whatever diagnosis being studied environmental forces that are causative are about equivalent for MZ and DZ twins.
        -therefore difference in concordance rates are due to genetics

Twin research allows us to draw better inferences about the contribution of genetic factors than the family method.

A better way?

Study adopted children who have never been reared by their biological parents.
BEST twins who are seperated from birth and never raised by their biological parents.

        - high concordance under these circumstances makes it more likely that the disorder is inherited.

Biochemistry in the nervous system

1) Neuron
    -cell body
    -dendrites
    -axons
    -terminal buttons

2) Appropriate stimulation causes a nerve impulse to travel through the dendrite, through the cell body and down the axon.

    -the nerve impulses cause the synaptic vescicles in the terminal buttons to     release neurotransmitters
    -nerve impulses travel across the synaptic cleft to the receptor site of the     postsynaptic neuron
    - any neurotrasmitter left in the synapse is pumped back into the presynaptic     neuron through a process called reuptake.

3) Neurotransmitters implicated in psychopathology

Too much or too little of any neurotranmitter causes psychopathology
The assumption behind psychopharmacology
Psychoactive drugs either increase the amount of a neurotransmitter at a receptor site OR block reuptake in the synatic cleft
It is also possible that too much neurotransmitter is related to too many postsynaptic recetors

    A) Norepinephrine- one of the catecholamines
        -involved in the production of arousal states
        -abnormally low levels are associated with depression
        -high levels associated with mania


    B) Serotonin
        -mediates the effects of reward and punishment
        - low levels associated with depression
            -Prozac increases neural transmission in serotonin neurons by             inhibiting the reuptake of serotonin

    D.  Dopamine
        -connected with reward centers and, possibly motor centers
        -low levels associated with schitzophrenis
        -high levels associated with Parkinson’s Disease
            -thorazine reduces the activity of dopamine neurons by blocking             their receptors

    E.  GABA- Gamma-aminobutyric acid
        -INHIBITS some nerve impulses
        -deficiency allows arousal to occur
        -involved in anxiety disorders
            -tranquilizers such as Valium stimulate GABA receptors
Biological approaches to treatment
   
    Prevention or treatment of mental disorder is possible by altering bodily         functioning.
1) one way is to provide the chemical
2) The other way is to prevent degradation of the chemical

The only way we can do One & Two is if we know the CAUSE of a disorder
    -we don’t always know cause
    -we don’t know if the biology produced the syndrome or is a consequence of the     syndrome
        Psychological syndromes have been shown to CAUSE somatic changes.
    -even if we know biology NONbiological therapies can be just as effective
        -so why give bio with the side effects

Problems with the biological approach:

One problem is reductionism= reducing complex emotional process to biological components
    -extreme form= Psychology is nothing more than biology
   
BUT is Psychology we know that the whole is larger than the sum of its parts

Irrational thought processes cannot whole be defined on the basis of biology
    e.g. where is the neuron for catastrophizing?       



















The PA Paradigm

Id- contains the libido
operates by the pleasure principle
governed by primary process thinking- short term wish fulfillment through fantasy
unconscious processes
    most of the important determinants of the psyche are in the unconscious

Ego-develops after the id
secondary process thinking- governed by the reality principle
The ego has to mediate between the demands of reality and the demand odf the id
BUT the ego gets all its energy from the id
 like a horseback rider who relies upon the horse for momentum but must also gevern the horse.

Superego- our conscience
develops from the ego like ego from id
Occurs as children introject parental values

PSYCHODYNAMIC= the complex interplay of the three parts of the psyche


Personality develops through four psychosexual stages
    a different part of the body is most senstive to sexual excitement at each stage

birth-18mths= oral stage
18 mths -3 yrs= anal stage
3-5 or six = phallic
Six- twelve is latency
Genital 12-up

During the plallic stage The OEDIPAL crisis is reached for male
The Electra for female

Through the introjection of same sex parent values the superego develiops

People becomes fixated at any one stage due to over or undergratification of their wishes

We continue to act on our unconscious wished until the conflicts associated with the stage are resolved

Neurotic Anxiety occurs as a result of FEAR that our unconscious impulses were allowed expression
    e.g. dirt phobics are acting out of fear developed during toliet training as a result of overly strict or diapproving parents

The essence of neurosis is repression

Being unaware of conflicts (repression) is the core of neurotic anxiety

Individuals who are aware of conflicts don’t feel the tension and the need to act on conflicts

Defense mechanisms

We reduce the discomfort caused by anxiety by the use of defense mechanisms.

These include:
Repression (most common)- Unacceptable impulses are pushed into the unconscious
Projection (paranoia)
Displacement
Reaction formation (convertint an unacceptable feeling into its opposite
Rationalization
Sulimation

Defense mechanisms are grouped and are stage specific (Valliant)

Psychotic
Immature
Neurotic
Mature

Psychopathology results:

1) the defense mechanisms are inadequate at modulating the level of unconcious conflict

BUT remember there are specific forms of unconcious conflict associated with each stage

Therefore pathology is stage specific (e.g. phobias are the result of unresolved and displaced Oedipal fears)

Psychopathology is also the result of inappropriate use of defense mechanisms (e.g. overreliance on one particular defense mechanism)

Neofreudian Perspectives

Jung- Analytical Psychology

Jung introduced the terms personal and collective unconscious

The collective unconscious contains universally shared neural patterns= archetypes
They are both positive (e.g. persona) and negative (shadow)
masculine (animus) and feminine (anima)

Jung also introduced the personality typology “intraversion/ extraversion and described midlife as a transition from E to I.

People have to be understood in terms of their dreams and aspirations as well as their past.


Adler- Individual Psychology

Adler looked at the effect of the psychosocial environment on the individual

He specifically focued on how feelings of INFERIORITY and the development of an INFERIORITY COMPLEX influences behavior

Adlers work heavilly influenced our current educational practices

Ego Psychologists:

Erikson and psychosocial stages of development

Erikson is an ego psychologist= emphasizes the independence of the ego from the id and the adaptive functions of the ego

Erikson started the field of life-span development and extended Freuds notion of developmental stages throughout the life span

Erikson- Eight stages of psychsocial development
Trust vs. Mistrust            0-1
Autonomony vs. Shame        1-3
Iniative vs. Guilt            3-6
Industry vs. Inferiority        7-11
Identity vs role confusion        12-20   
Intimacy vs isolation        20-30
Generativity vs. Stagnation    30-65
Ego Integrity vs. Dispair        65+

Erikson is most famous for the term “identity crisis”

The identity crisis is the transition from childhood to adulthood- it is the time we create a sense of self

    What are we concerned with?
        What kinds of things are going to be important to us?
        What kind of person do we want to be?
    The identity crisis comes at the same time people are coming to terms with their
    sexualty so it can be a real difficult time

Other famous developmental (lifespan theorists) include Piaget
Piaget talked about cognitive development

His stages were:

1.  sensorimotor- principle of object permanence

2.  Preoperational- Developing capacity for symbols
        Thinking is egocentric, animistic

3.  Concrete operations

NeoFreudians or Object Relations Theorists

Object relations theories deals with early childhood relationships and the way we develop internal representations of the self and others.

Theorists include Kernberg, Mahler & Kohut

Object relations theory had been primarilly applied to the study and treatment of personality disorders

Anxiety Disorders

Depression and anxiety are the “common colds” of mental illness.

Anxiety is a psychpathological state AND part of “normal” existence.
    -without some anxiety we could do nothing

Anxiety used to be classified under “neuroses”= all neuroses were defined as reflecting a problem with repressed anxiety
    the problem with the concept of “neurosis” is that it became all inclusive and     meant nothing- everyone was characterised by neurosis

    -in DSM-IV neuroses are actually several categories (anxity disorders are just     one.

All anxiety disorders are characterised by subjectively experienced feelings of anxiety that cause marked distress or interfere with social or occupational functioning.

    There is often “comorbidity” among anxiety disorders Why?
        1.  The symptoms of various anxirty disorders are not entirely disorder         specific
        2.  Current theories of etiology apply to more than one disorder. So the         same cause could give rise to different disorders.

There are six principal categories of anxiety disorders

1) Phobias
2) Panic Disorder
3) Generalized Anxiety Disorder
4) Obsessive-Compulsive Disorder
5) Post-traumatic Stress Disorder
6) Acute Stress Disorder

1) Phobias
    A phobia is disrupting, fear-mediated, avoidance that is:
        A) out of proportion to the danger posed by a particular object or situation
        B) Recognised by the sufferer as groundless

The suffix is from the God “Phobos” who frightened his enemies

Most common are
    1) Specific phobias
    2) Claustrophobia
    3) Acrophobia

More exotic include:
    1) nictophobia
    2) thaphephobia (fear of being buried alive)
    3) triskaedephobia

Most phobias do NOT come to the attention of shrinks (do not cause distress or significant impairment in functioning)


1)  Specific phobias= unwarranted fears caused by the presance or anticipation of a specific object or situation
    Lifetime prevalence= 7% male
                  16% female

DSM-IV subdivides specific phobias according to source:
    1) blood and injections (most common among medical students
    2) situations (e.g. planes and elevators)
    3) animals
    4) the natural environment

Exactly what is feared can vary cross-culturally and also with current trends (e.g. Jaws)

2) Social Phobias= persistent irrational fear linked to the presance of other people (can be extremely debilitating)
    -typically it is characterised by avoidance behavior and is related to fears of evaluation or embarrassment in social situations

    -social phobias can be generalized or specific (generalized tied to ETOH abuse     and early onset)
    -fairly common Lifetime prevalence = 11% men
                               15% women
    -HIGH comorbidity with other anxiety disorders (e.g. GAD)
    -onset usually during late adolescence
    -specific fears vary by culture (e.g. in U.S. is fear of evaluation

Etiology

P/A

Freud- phobias are a defense against the anxiety produced by repressed id impulses
    anxiety produced by the id impulse is displaced to an object with which it has a     symbolic connection.
    -By avoiding the phobic object the individual is able to avoid dealing with     repressed conflicts

SO a phobia is the ego’s way of warding off a confrontation with the real problem- a repressed childhood conflict

e.g. case of Little Hans was Hans’ intense fear of his father displaced onto horses.

Evidence restricted to case reports

Behavioral Theories

Primary assumption is that phobias are learned

Classic experiemnt is Watson & Raynors study of “Little Albert”
    -based on Mowrer’s two-factor theory of avoidance conditioning

The problem with this theory is that the research evidence suggests that fear can be acquired without conditioning
    e.g. many people report airplane phobias without a prior untoward incident
        -50% of people with dog phobias have no untowrd prior incident.

I
Also attempts to replicate Watson & Raynor have been unsuccessful

What other theories

1) Seligman preparedness theory
2) Bandura= modeling= vicarious learning= watching others “suffer” can induce a fear     reaction in us.

Sue Mineka combined 1 & 2 in her work with rhesus monkeys =showed that fear could be acquired through modeling only to certain stimuli


Behavioral theories cannot tell us why some individuals have phobias who have not been exposed to modeled fear OR why some people who HAVE been exposed do not display phobias

Cognitive Theories

Anxiety is linked to selective attention to negative stimuli
    e.g. social phobia is tied to selective attention to evaluative cues and increased self-consciousness
    -the Stroop paradigms would speak to this

Biological Theories

1) Research indicates that there are stable differences in autonomic system functioning
        (=stable-labile ANS)
2) Genetic studies indicate higher genetic contribution to some phobias than others
    e.g. blood & injection show 64% concordance with first degree relative
        -prevalence in pop is 3-4%
    -prevalence is also higher in 1st degree relatives for social and specific phobia

Therapies- Most people do NOT sek treatment

P/A all p/a therapies attempt to uncover repressed sonflicts assumed to underlie fears
        the phobia is a symptom-it is not dealt with directly
    -uses free association to find unconscious conflict
    -ego psychologists talk about a “corrective emotional experience in therapy


Panic Disorder- Sudden and often unexpected feelings of intense apprehension and impending doom coupled with typical physiological sensations (cardiovascular, respiratory, feelingas of choking and smotherieng, nuasea, sweating and trembling, dizziness)

Typical accompanying feelings
1) fears of loss of control
2) Depersonaliztion
3) Derealization

May occur frequently (DSM criteria is at least 2 attacks followed by at least one month of worry about another attack
Typcally only last for minutes (feels like hours)
When strongly associated with certain situations called “cued panic attacks”
    if ONLY cued are usually a phobia

Lifetime prevalence= 2% males 5% females

Typically begins in adolescence and is associated with the presance of a stressful lifestyle

occurs cross-culturally e.g. kayak angst in eskimos

Panic Disorder is diagnosed with and without agoraphobia

80% of patients diagnosed with other anxiety disorders have panic attacks
also highly comorbid with ETOH and MDD

Etiology
1) genetics= gretaer concordance in MZ than DZ
2) biology= A. overactivity in the noradrenergic system
        B Hi lactate (e.g. muscular exertion)) can produce panic
        C.  Hi CO2 can produce panic (=hyperventilation?)
            The research does not support C

3) Psychological= fear of fear -PD is a fear of having a panic attack
    A) people have physiological sx and misinterpret them in a catastrophic way leading to a panic attack. (E.g patients misled about room levels of CO2
        -there is some evidence to support this
    B) control- Panic Disorder results from a fear of losing control
        -perceived control appears to be most important
            In one study 80%

Therapy
1)  Rx effective but A) relapse occurs following discontinuation of drug
        B) some drugs (e.g. benzos addicting and have cognitive and motor         effects.
2) Exposure (Barlow) can be quite effective- esp in vivo for agoraphobia
3) CBT involving reinterpretation of cognitive sensations= 3 components
    1=relaxation, 2= Beckian 3= exposure to internal physiological cues
        patient experiences panic under safe conditions and learns to apply         cognitive and relaxation tactics
            Patient learns that internal cues are harmless and can be             controlled

CBT more effective in the long term than RX




Generalized Anxiety Disorder- characterized by persistent anxiety and chronic, uncontrollable worry occurring more days than not for at least six months
    -aka “free floating anxiety
    -somatic complaints are frequent=hyperactive ANS activity    
    -also frquent is anger or irritibility

    - typically do NOT seek treatment
    -lifetime prevalence is about 5%
    -typically begins in midteens and is 2ce as common in females than males

Etiology

P/A= unconcious conflicts between ego and id (usually sexual or aggressive)
    -the anxiety is unconscious and reflects unacceptable id impulses= the person is     anxious and does not know why
        -in some ways the phobic is better off because the anxiety is displaced         onto a specific object anbd can be avoided
            -the person with GAD has not developed this defense

C/B

Strict behavioral
Anxiety response is conditioned to a range of stimuli (not just one as with phobia)

More cognitive= Anxiety represents a perception of lack of control over the environment
    -when we experience uncontrollability we get anxious
    -research (e.g. CO2 studies) supports this view and emphasize PERCEPTION of     control
        -research also supports the view that predictibility increases the         perception of control

    Other cognitive factors affecting GAD
        -misperception of benign events as harmful
        -interpretation of ambiguous events as threatening

Biological- Mixed genetic evidence
    There IS some evidence that indicates GAD results from defects in GABA     system
        -benzos reduce anxiety by blocking release of GABA

Therapies

1) Systematic desensitization
2) Assertiveness training to address helplessness
3) Training in reappraisal
4) Anxiolytics are the most widely prescribed treatment-
    -problem here is SE and tolerance and withdrawal
    -bigger problem is relapse following drug withdrawal (attributionally mediated)



OCD

    Wegner black bear experiment

Characterized by the presence of obsessions or compulsions or both that is severe     enough to be time consuming (more than an hour a day) or cause marked     distress or significant impairment
        -affects 2-3% of the population

    obsessions- recurrent, intrusive thoughts that the person recognizes as irrational     and uncontrollable and cause distress
        -EVERYONE has some obsessive thoughts.  These interfere with normal         functioning
        -most frequent involve contamination fears, fears of expressing some         aggressive or sexual impulse or fears of bodily dysfunction

    compulsions- repetitive behavior or mental act, the goal of which is to reduce     distress (distress is usually associated with an obsession)
        -Person spends significant amounts of time engaged in the obsessive         behavior- e.g 100s of times per day

        Common compulsions involve cleanliness and checking behavior

        -true compulsions are experienced as foreign behavior
            -NOT something like eating-this is pleasurable
        -has devastating effects on individuals and people in their environment

Etiology

P/A

Instinctual sexual or aggressive impulses that are not under control because of poor toileting

Adler- compulsive acts represent attempts at mastery

Behavioral and CognitiveTheories

To account for compulsions

1. compulsions are learned behaviors maintained by their consequences (fear reduction)
    -research partially supports this for compulsions but not obsessions
2. Compulsions may reflect a memory deficit for ACTIONS PERFORMED (not a global deficit)
    -compulsive checkers DO have poorer recall of prior actions

To account for obsessions
    -deficits in ability to suppress unwanted thoughts- Wegner
        -also the more we try and inhibit a thought the more potent it is

Biological factors-

Genetics- Higher concordance among first depree relatives (=30%)

PET scans show abnormalities in frontal lobe functioning-excess focus on self
        And basal ganglia-motor problems (Tourettes)


Therapy

Extremely difficult to treat

1. Most prevalent is exposure and response prevention
2. Second most common is SSRI
3. Psychosurgery is used in refractory cases

Interestingly enough both 1 & 2 produce changes in the caudate nucleus

PTSD 1-3% of the pop = 2 million people(including children)
20% of Vietnema vets, 47% of rape victims

Extreme response to a severe stressor (the stressor must be outside the range of normal human experience
Characterized by:
a.  Increased anxiety
b. Avoidance
c.  Numbing of emotional responses


Three types of symptoms
1.  Reexperiencing the traumatic event- frequent recall and nightmares
2.  Avoidance of stimuli associated with the event- may cause emotional numbing (amnesia for the event and decreased responsiveness to others)
3.  Symptoms of increased arousal- hypervigilance, exaggerated startle response

Associated symptoms = guilt, depression, substance abuse, psychophysiological disorders, depersonaliztion and derealization

Etiology

P/A-PTSD symptoms are a result of repressed memories

Biological- trauma activates the noradrenergic systemcausing levels of NE to be higher in PTSD folks

Learning Theory= classical conditioning of the fear response 
    -symptoms follow Mowrers two factor theory

No theory of PTSD explains why some folks develop PTSD after a trauma and other don’t- (although social support helps)

Acute stress disorder is diagnosed when symptoms interfere with social or occupational functioning for one month or more

Tx=Imaginal exposure to confront fears and extinguish fear response
-group therapy for social support






   



Mood Disorders- Any disorders; cognitive, affective, motivational and vegetative (including motor) sx

General characteristics-

Depression- emotional state characterized by sadness and apprehension, feelings of worthlessness and guilt, social isolation, loss of interest or pleasure, difficulties in concentration and memory and difficulties with sleep, appetite and energy

    --sx are cognitive, affective, motivational and vegetative

    -in children manifests itself with somatic complaints
    - in the elderly difficulties with concentration and memory

    -the average untreated MDD episode lasts from 6-9 months.

Mania- mood state characterized by intense elation or irritibility accompanied by hyperactivity, grandiosity, flight of ideas and difficulty concentrating and difficulties with sleep

    -sx are cognitive, affective, motivational and vegetative
    -episodes last from days to months and symptoms appear suddenly (within one     or two days)

Two major mood disorders in DSM-IV: unipolar depression and bipolar disorder

Unipolar depression requires the presance of at least five symptoms for at least two weeks
    - either depressed mood or loss of interest and pleasure MUST be one of the     symptoms.

-very widespread (lifetime prevalence= 17%)
    -2wce to 10 times as common in women
    - more frequent in low SES
    -most frequent among youg adults
    -tends to be recurrent, 80% experience another episode within one year
        -15% becomes chronic depression (duration=>2 years)
    - prevalence has been increasing (=higher societal stress levels)
    - if psychotic features are present, they are usually mood congruent


Bipolar I Disorder- The essential feature is a clinical course characterized by the occurrence of one or more manic, hypomanic or mixed episodes
    -3 or more symptoms for at least one week
`
    -mania, hypomania or a mixed episode MUST have occurred
    - r/o GMC’s and substance abuse
    - sx are cognitive, affective, vegetative and motivational
    - a past MDD episode MAY have occurred

    - much rarer than MDD= lifetime prevalence .4-1.6%
    - 10-15% of MDD develop Bipolar I
    - is recurrent= over 50% experience 4 or more episodes and 90% experience     more than one
    -80% return to normal functioning between episodes
    - 10- 15% commit suicide

Bipolar II (Recurrent Major Depressive Episodes with Hypomanic Episodes)

    - essential feature is a clinical course characterized by the occurrence of one or
    more major depressive episodes accompanied by at least one hypomanic     episode

        - the individual CANNOT have had a manic or mixed episode
        - individuals are often not aware of the hypomanic episodes

        - prevalence around .5%
        -completed suicide 10-15%
        - tends to be recurrent and 10-15% have 4 or more episodes

Mood Disorders can also be chronic- two types:

    -Cyclothymia- For at least a 2 year period the person has fluctuating symptoms     of hypomania and depression but symptoms are never severe enough to meet     the criteria for Bipolar 1 or Bipolar II
        -the person is never symptom free for more than 2 months

    -Dysthymia= chronic depression for at least 2 years


Etiology

P/A-
    Classical P/A= depression results from over or under gratification or oral needs
        -this causes people to be excessively dependent on others for         maintenance of self-esteem

    adult depression is a result of childhood loss of a loved one- either through     death or withdrawal of affection
            -the child introjects the loved one to undo the loss
                -BUT the child is angry at the loved one for the                 abandonment and feels guilty for real or imagined sins                 against the lost person
                -this pruduces the feelings of guilt and self-blame                 characteristic of depression
                - in P/A theory depression is literally griefwork gone astray
            
            -research suggests the depressed people ARE high in needs for             dependency
            - also depression IS more likely following a loss
            -BUT depressed people express hostility towards others NOT             inwardly

Biological Theories

Genetics
    For bipolar disorder- concordance rates MZ twins = 72%, DZ = 14%
              -unipolar MZ 46%, DZ = 20%

    -there is a higher rate of mood disorder (unipolar and bipolar) in first degree     relatives of individuals with bipolar rather than unipolar depressive disorder
linkage analysis= involves studying the occurrence of mood disorders over seveal generations in conjuction with another characteristic whose genetic marker is clearly understood (e.g. red-green color blindness)
    -when the chromosomes for the mood disorder are closely linked with the other     characteristic, you can more easily see the heritibility component of the mood     disorder
        -1987 study of the Amish indicated that bipolar disorder results from a         dominant gene on the eleventh chromosome (not replicated)

Neurochemistry

Two neurotransmitters implicated

    1.  Excess NE leads to bipolar disorder
    2.  Low levels of serotonin lead to unipolar depressive disorder

These theories derived mostly from drug research
    -trycyclic antidepressant prevent the reuptake of serotonin and NE
        -this leaves more of the neurotransmitter available making it more likely         that the neuron will fire
    -MAO- Inhibitors keep monamine oxidase from deactivating NE and serotonin
        -this also increases levels of NE and serotonin
    -SSRIs are specific to serotonin and indicate a specific link between serotonin     levels and unipolar depression

Studies with of neurotransmitters
    -urinary levels of NE are increased during mania and decreased     during depression
        -increasing NE levels can precipitate a manic episode
        -A problem with this is that increased activity levels can also account for these data

Studies with NE metabolites

urinary levels of NE metabolites are also higher in mania and lower in depression
    -this could also reflect differences in activity level

Studies with serotonin metabolites
Serotonin metabolites are lower in the CSF of depressed patients

Ingesting tryptophan, a serotonin precursor, also helps with depression
    -diets low in tryptophan can trigger depression recurrence

a big problem with studying metabolites is we cannot assess levels of the neurotrasmitters in the brain (these neurotrasmitters also exist outside the brain)


A second way of studying the effects or NE and serotonin is to look at the effects of drugs on brain levels of the neurotransmitters
    -a problem with this approach is that drus have multiple effect- they don’t just     effect one neurotransmitter

Drugs do effect NE and serotinin levels BUT
    -research has shown that neurotrasmitters return to their previous levels after     several days of use
SO
    a simple increase or decrease in neurotransmitter levels cannot be accounting     for the action of the drug
    New research suggests that the mechanism of action is actually on the postsynaptic receptors
(e.g SSRIs seem to increase the sensitivity of the receptors to serotonin)

lithium appears to work by affecting the proteins that carry information across the synapse (thus it amplifies the neural signal)

The neuroendocrine system

1)Research implicates the hypothalamic-pituitary-adrenocortical axis

How do we know this
    1) depressed patients have relatively high levels of cortisone (an adrenocorticol     hormone) -perhaps caused by an oversecretion of a hormone from the     hypothalamus
        -high levels of cortisol led to the development of the DST
            -Dexamethasome suppresses cortisol secretion
                -Some depressed patients fail to suppress cortisol when given DST (perhaps reflecting overactivity in the HPA axis)
                    -failure to suppress ends when depression ends


2) Both depressed and bipolar patients often show thyroid problems
    -hypo= depression
    -hyper can induce mania
        

Cognitive Theories

1.  Negative schemata (consist of the tendency to view the world in a depressogenic manner)
lead to
2) Cognitive bias and disortions and automatic thoughts

    Examples of biases:
        1.  Arbitrary inference
            A conclusion drawn on insufficient evidence
        2.  Selective abstraction- a conclusion drawn on the basis of one bit of         evidence (usually negative) instead of all the evidence
        3.  Overgeneralization- a sweeping conclusion drawn on the basis of s         single, perhaps trivial, event.
        4.  Magnification and minimization- exagerations in evaluating         performance

The research DOES suggest that depressed people manifest these symptoms BUT

other research suggests that depressed people are more accurate in their thought processes while nondepressed people are the ones who are inaccurate (usually in a self-aggradizing fashion).

Hopelessness Theory-
began with Seligman’s dogs who looked depressed after helplessness engendering experiences

Revised theory= The particular pattern of attributions an individual makes will determine their likelihood of displaying helplessness deficits
        -the pattern is internal, stable and global attributions for negative life
        events of high importance.

Results of the Abramson, Metalsky and Alloy midterm study.

Another revision = hopelessness theory

Difficulties with hopelessness theory
1) Are the cognitive diatheses causes or symptoms
2) What type of depression are they talking about- We say it is hopelessness depression- others say that makes the model circular and useless.



Suicide

One of the most serious symtoms and consequences of mood disorders is suicide
    More than 50% of people who try and kill themselves are despondent at the time     of the act

-BUT not all people who go on to kill themselves are depressed (e.g. 13% of schizophrenic patients go on to kill themselves, also a relationship with alcoholism and personality disorders

Who kills themselves- Older white males have the highest suicide rate BUT
    -suicide is third after accidents and homicides in reasons for death ages 15-24
        -this rate is rising-especially among African-Americans
    -more than 3000 15-19 year olds kill themselves each year and children as     young as six try it ( and have succeeded)
   
    -majority if people who kill themselves have diagnosable MI (MDD or ETOH)
    - Physica Illness, either chronic (e.g. MS, or terminal, e, g. AIDS is a contributing     factor in at least ½ of all suicides

Myths about suicide:
1) People who talk about suicide don’t commit suicide (3/4 do)
2) Thinking about suicide is rare 40-80% of us think about suicide at least once in our     lives
3.  Suicidal people clearly want to die
4. People of certain ethnic or social classes are particularly likely to commit suicide
5. All people who commit suicide are depressed
6.  To commit suicide is psychotic
7. Asking a person an bout suicide will “push him over the edge”


Schneidman- The Ten commonalities of suicide

1.  The common purpose is to seek a solution
2.  The common goal is the cessation of consciouness
3.  The common stimulus is intolwerable psychological pain
4.  The common stressor is frustrated psychological needs
5.  The common emotion is hopelessness/helplessness
6.  The common cognitive state is ambivalence
7.  The common perceptual state is constriction
8.  The common action is egression
9.  The common interpersonal act is communication of intention.
10.  The common consistency is lifelong coping patterns

Schneidman- Suicide prevention
1. Reduce the intense psychological pain and suffering
2. Expand the constricted view
3.  Encourage the person to pull back even a little from the self-destructive act



Personality Disorders- Coded on Axis II
        -placed on a separate axis to make sure that clinicians would pay             attention to their presence
        -you can, and often do, have a comorbid diagnosis on Axis II

We all possess SOME maladaptive personality traits that give us difficulties at time

Personality disorders reflect a maladaptive STYLE of relating to other people
    -a diagnosis is not made unless the difficulty is long standing, pervasive and     dysfunctional
        e.g. we’re all paranoid at times but to have a paranoid personality             disorder we must deal with the WORLD in a paranoid manner.

    -defined in DSM-IV as enduring patterns of perceiving, relating to, and thinking     about the environment and oneself that are exhibited in a wide range of personal     and social contexts
    -must be displayed in at least two of the following areas:
        1. Cognition (ways of perceiving and interpreting onesself, other people         and events.
        2.  Affectivity (range, intensity, lability, and appropriateness of emotional         response
        3.  Interpersonal functioning
        4.  Impulse control
    - pattern must be stable and of long duration-onset can be traced to     adolescence or early childhood
        -the code phrase in the DSM is “begins in early adulthood and is present     in a variety of contexts”
   
DSM-IV groups personality disorders into three clusters

Cluster A= Odd/Eccentric= paranoid, schizoid and schizotypal personality disorder
Cluster B= Dramatic, Emotional or Erratic= antisocial, borderline, histrionic and                  narcissistic
Cluster C=Anxious/Fearful= avoidant, dependent, obsessive-compulsive



The Odd/Eccentric Cluster

1) Paranoid Personality Disorder (need at least 4 symptoms)

    -essential feature is a pattern of pervasive distrust and suspiciousness of others     such that their motives are interpreted as malevolent
    -person expects to be mistreated and is constantly on the lookout for signs of     abuse
    -usually preoccupied with doubts about others loyalty

    -about a 1% prevalence rate
    -occurs more often in men
    -often comorbid with schizotypal, borderline and avoidant

    -r/os include schizophrenia, other psychotic disorders and substance abuse.

2) Schizoid Personality Disorder
    -essential feature is a pervasive pattern of detachment from social relationships     and a restricted range of emotion in interpersonal settings.
    -seem to lack the desire for emotional intimacy, are “loners”
    -appear indifferent to praise or criticism
    -display constricted and restricted affect

    -prevalence less than 1%
    -slightly more common in men than women (causes more impairment in men)

    -r/os include schizophrenia, other psychotic disorders and substance abuse

3) Schizotypal personality disorder.
    -diagnosis derived from studying adopted children of schizophrenic parent in     Denmark
        -children often displayed odd behavior but were not schizophrenic.
        -disorder first appeared in DSM-III

        -essential feature is a pervasive pattern of social and interpersonal         deficits marked by acute discomfort with, and reduced capacity for, close         relationships as well as by cognitive or perceptual distortions and             eccentricities of behavior.

        -show the interpersonal difficulties of the schizoid PLUS social anxiety          (this is what differentiates it)
        -also show odd beliefs or magical thinking and illusions
        -may show speech and appearance oddities
        -ideas of reference (not delusions) and paranoid ideation are also             common

        -prevalence is aroud 3%
        -more common in men than women

HUGE comorbidity with other PD dx (e.g. 59% also meet criteria for paranoid personality disorder)

r/os include schizophrenia, other psychotic disorders and substance abuse

Etiology

Odd/eccentric disorders are less severe variants of Axis 1 Disorders

SOME family studies have shown that relatives of schizophrenic patients are at increased risk for schizotypal PD
BUT other studies also find increased rates of schizotypal in relatives of people with unipolar depressive disorder

SOME family studies have also found increased risk of paranoid personality disorder in relatives of schizophrenics

THE TAKE HOME MESSAGE= the genetic evidence is unclear.

Neurological studies show deficits in cognitive and neuropsych problems as welll as structural abnormalities that are also seen in schizophrenia.


Dramatic/erratic cluster- These are disorders characterized by highly variable behavior and exaggerated displays of emotion

They include:
1. Borderline
2. Histrionic
3. Narcissistic
4. Antisocial

1. Borderline- adopted as a dx in 1980 The essential feature is a pervasive pattern of instability of interpersonal relationships, self image, affects and marked impulsivity that begins in eary adulthood and is present is a variety of contexts

Need five or more symptoms such as:

1) frantic efforts to avoid real or imagined abandonment
2) a pattern of unstable and intence interpersonal relationships
3) identity disturbance = unstable self image or sense of self
4) impulsivity in at least 2 areas that are potentially self-damaging
5) recurrent suicidal behaviors or threats or self-mutilating behavior
6) affective instability due to marked reactivity of mood
7) chronic feelings of emptiness
8) inapproporaite intense anger or difficulty controlling anger
9) transient paranoid ideation or severe dissociative symptoms

    -typically begins in adolescence
    -prevalence is 1-2%
    -likely to have a comorbid mood disorder or substance abuse disorder

r/os = substance abuse, bipolar and almost any other PD

2) Histrionic personality disorder- the essential feature is pervasive and excessive emotionality and attention-seeking behavior beginning by early adulthood and present in a variety of contexts

Need at least 5:
1) uncomfortable in situations in which he or she is not the center of attention
2) interactions are often characterized by inappropriately seductive or provacative behavior
3) displays rapidly shifting and shallow expression of emotions
4) consistently uses ohysical appearance to draw attention to self
5) speech is excessively impressionistic and lacking in detail
6) tends to dramatize and show exaggerated expression of emotion
7) is suggestible
8) considers relationships to be more intimate than they are

    -prevalence is 2-3%
    -more common in women than men
    -comorbid with mood disorders and health problems
    -highly comorbid with BPD

r/os= substance abuse, mood disorders and BPD
3.  Narcissistic PD= The essential feature is a pervasive pattern of grandiosity, need for admiration, and lack of empathy beginning in early adulthood and present in a variety of contexts.

Need at least 5:
1. Grandiose sense of self-importance
2. Preoccupation with fantasies of unlimited success
3.  Believe themselves special and can only be understood by very important people
4.  Requires excessive admiration
5. Has a sense of entitlement
6.  In interpersonally exploitative
7. Lack empathy with wants and feelings of others
8.  Is often envious of others or believes others are envious of him or her
9.  Is haughty and arrogant

    -prevalence is less than 1%
    -often comorbid with BPD

r/o bipolar, substance abuse

Antisocial PD= The essential feture is a pervasive pattern of disregard for and violation of the rights of others that begins in CHILDHOOD or EARLY ADOLESCENCE (by age 15) and is present in a variety of contexts
    - the individual must be at least age 18 to be diagnosed

    -APD involves a repetitive pattern of violation of the basic rights or others or age     appropriate social norms that often begins with conduct disorder in childhood.

Need at least 3:
1) failure to conform to social norms as evidenced by repeatedly performing acts that are grouds for arrest
2) repeateded deceitfulness
3)  Impulsivity or failure to plan ahead
4) irritibility and aggressiveness, as indicated by repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Concictent irresponsibility as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
7.  Lack of remorse as indicated by being indifferent to or rationalizing harm done to another

r/o = schitz, bipolar and substance abuse

    Does NOT apply to all criminals (only 15-25% of convicted felons meet the     critieria
    -prevalence 3% of adult American men and 1% of women
    -often comorbid with a substance abuse diagnosis

Etiology of dramatic/erratic cluster

Genetics and antisocial
Kohut/ Mahler and Narcissistic, histrionic
Hernber and BPD and unstable object introjects


Cluster 3- Anxious/Fearful Cluster

Avoidant Personality Disorder

1) The essential feature is a pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts

Need at least four:

1) avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejuection
2) is unwilling to get involved with people unless certain of being liked
3) shows restraint within interpersonal relationships because of the fear of being shamed or ridiculed (always doubting others sincerity
4) is preoccupied with being criticised or rejected in social situations
5) is inhibited in new interpersonal situations because of feelings of inadequacy
6) views self as socially inept, personally unappealing, or inferior to others
7) is unually reluctant to take personal risks or engage in new activites because of fears of embarassment.
        -1% prevalence
        -often comorbid with dependent and BPD
        -VERY often comorbid with generalized social phobia

Dependent Personality Disorder

1) The essential feature is a pervasive and excessive need to be taken care of which leads to submissive and clining behavior and fears of seperation.

Need at least five:

1) has difficulty making everyday decisions without excessive amount of advice and reassurance from others.
2) needs others to assume responsibility for most major areas of his or her life.
3) has difficulty expressing disagreement with others because of fear of loss of support or approval.
4) has difficulty expressing disagreemnet with others because of fear of loss of support or disapproval
5) has difficulty initiating projects or doing things on his or her own because of a lack of self-confidence NOT motivation
6) goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things which are unpleasant.
7) feels uncomfotable or helpless when alone because of exaggerated fears of being unable to care for him or herself.
8) urgently seeks another relationship as a source of care and support when a close relationship ends
9) is unrealistically preoccupied with fears of being left to take care of him or herself.

    --prevalence about 1.5%
    -more women than men
    -first degree relative high in mood and anxiety disorders
    -often comorbid with BPD and avaoidant as well as Axis One and health     problems


3) Obsessive-compulsive personality disorder

1) The essential feature is a preoccupation with orderliness, perfectionism and mental and interpersonal control, at the expense of flexibility, openness and efficiency

Need at least four:
1) is preoccupied with details and rules to the extent that the major point of the activity is lost.
2) shows perfectionism that interferes with task completion
3) is excessively devoted to work and productiivity to the exclusion of leisure activities and friendships (not accounted for by economic necessity)
4) is overconscientious, scrupulous and inflexible about matters of morality, ethics or values
5) is unable to discard worout or worthless objects even when they have no sentimental value
6) is reluctant to delegate tasks or work with others unless they submit to his or her way of doing things
7) adopts a miserly spending style to self and others
8) shows rigidity and stubbornness

Etiology

Two types of symptoms:
1) difficulties with dependence
2) difficulties with attachment

Ainsworth= these disorders reflect an anxious attachment style
P/A= fixation at the anal stage

Therapy
1) Psychotropics for mood symptoms
2) Object-relations therapy= reparenting
3) Cognitive therapy looking at maladaptive schemata

Substance Related Disorders  2 categories

Distinguish between substance use, abuse and dependence
1) Substance abuse
    need at least one:
        A.  Failure to fulfill major obligations e.g. absence from work or neglect of         children
        B.  Recurrent substance use in physically dangerous situations (e.g.         driving or operating machinery)
        C.  Recurrent substance related legal problems (e.g. arrests)
        D.  Continued substance use despite persistent or recurrent social or         interpersonal problems caused by the substance (e.g. arguments with         spouse about intoxication)

2) Substance dependence
    need at least three
    A. Tolerance
        1.  Need for markedly increased amount of the drug to achieve the              desired effect
        2.  Markedly diminished effect with the same dose
    B.  Withdrawal (includes using the drug to avoid withdrawal)
    C.  The substance is taken in larger amount than intended or for longer periods           than intended
    D.  There is a persistent desire or unsuccessful efforts to cut down on substance            use
    E.  A great deal of time is spent in activities necessary to obtain the substance
    F.  Important social, occupational or recreational activities are given up or           reduced because of substance use.
    G.  The substance use is continued despite knowledge of having a recurrent           psychological or physical problem that is caused by the substance

Solomon= Opponent Process Theory

1995 Survey 52% had used ETOH in the past month
        28.8 had used cigarettes
        4.7 had used marijuana
        less than 1% had used other drugs







People who start drinking early (in teens) usually develop first withdrawal symptoms in their thirties
Abrupt withdrawal from alcohol can be fatal in highly dependent people
    -Symptoms include anxiety, insomnia, restlessness and depression
    -In rare cases the person experiences delirium tremens
        -= the person may become delirious and experience tactile and visual         hallucinations
lifetime prevalence> 20% for men and 8% for women
    -but rates for younger women approach male rates
    -highest rates among whites and latinos are in 18-29 year old group
    -highest rates among Afican American are in 30-44 year old group
    - common among Native Americans and associated with 40% of deaths and     virtually all crimes
    - for women time between heavy drinking and abuse is especially brief
        -women are more likely than men to be steady drinkers, to drink alone but         are less likely to engage in binge drinking.

The financial cost of ETOH abuse is est. At 125 billion

Short-term effects- strongly related to the drinkers expectations (e.g. some people report that ETOH acts as an aphrodiasiac BUT it actually inhibits sexual performance)

ETOH has a biphasic effect
Initial effect is stimulating but than acts as a depressant

ETOH stimulates GABA receptors= anxiolytic effect
    -Also increases serotonin and dopamine levels =reinforcing effect
    -Also inhibits glutamate receptors= cognitive effect

Long-term effects
Almost every organ is affected by ETOH.  Produces:
1) malnutrition
2) amnestic syndrome
3) Cirrhosis (9th leading cause of death in U.S.)
4) hemorrage, including capillary hemorrage
5) FAS
6) Destroys families








Smoking

Nicotine is the addicting agent
the other harmful products include carbon monoxide and tar
        
Smoking is directly or indirectly responsible for 1-6 deaths in the U.S. and kills more than 1100 people each day
    -kills more people than AIDS, car accidents, cocaine, crack, heroin, homocide
     and suicide combined
    -of the 1000 children and adolescents who begin smoking every day 750 will die a smoking related death
    -besides death associated with chronic URI, various cancers

the financial cost to the U.S. of smoking is around 178 million dollars a day
- second hand smoke causes 50,000 deaths a year

About 25% of American adults still smoke (40% in 1965)
    -BUT the rate is incresing among teenagers
    -BUT prevalence has declined less among women than men

    -prevalence is lowest among college graduates and those over age 75

Health risks decline to near normal levels 5-10 years after quitting

Marijuana
    -hashish is derived from the resin of marijuana plants
    -marijuana legal until 1920

    - the active chemical is THC and is more potent than it used to be
    -THC directly affects cannibis receptors in the brain

Use has increased in the 1990s (was on the decline)
    -effect range from mild relation to hallucinations and severe mood swings but        almost always involves some cognitive and psychomotor impairment
    -Long term use may cause STM impairment

Therapeutic effects

Psychological vs. Physiological addiction

Cocaine (Freud) also used to be legal

    types of use =snoting, freebase and injection

act as an anesthetic
also blocks reuptake of dopamine=euphoria
is a vasoconstrictor= strokes

EXTREMELY addictive (esp. crack) and causes a severe withdrawal syndrome

prevalence= .8% for 18-34 year olds

chronic use =mood swings and paranoia

crack babies

Depressants= a drug that acts on the CNS to reduce pain, tension, anxiety- a relaxant

1) opiates induce reverie and reduce anxiety and pain
    1) opium
    2) morphine
    3) heroin (stronger and more addictive)
    4) methadone satisfies cravings w/o a “high”

“Imagine that every cell in your body has a tongue and they are all licking honey”
1) N/V
2) rapid tolerance
3) withdrawal begins in 4-6 hours ax, craving and physio sx

2) Tranquilizers and barbiturates (Nembutal & Seconal)
dependence often begins with insomnia

3) Stimulants (other than crack)
amphetamines (paranoid schizophrenia)
caffeine

4) Halluciongens
marijuana (THC)
causes
1) decreases in testosterone
2) supporession of immune reactions
3) lung damage
4) impaired judgment and apathy

Drugs and brain chemistry

Drugs and personality factors

Treatment
1) Detox
2) 12 step programs
3) Biological treatments (e.g. Antabuse)
4) CBT (e.g. aversion therapy or operant conditioning)
5) replacement therapy = patch or methadone