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LECTURE

1; WHAT IS ABNORMAL PSYCHOLOGY?

Lectures

1-3 content

· Theoretical approaches to diagnosis, explanation, treatment of

‘abnormality’ or mental disorders

· Definitions of ‘abnormality’ or ‘mental disorder’

· Prevalence of mental disorders in the community (can’t measure easily

because not the same as asking about a broken leg)

· Introduction to Diagnostic and Statistical Manual of Mental Disorders

(DSM)

MENTAL

DISORDERS ARE JUST CONCEPTS…they are not real things that are examinable.

What is Abnormal Psychology?

· Scientific Study of Psychological Disorders /Mental Disorders /

‘Abnormal behaviour’

· Empirical method to study (try to be scientific).

· Different ways to define abnormal.

· Normality and abnormality is a concept.

· Mental disorders are a small section of what is abnormal.

· What is a disorder? It is not health.

· Different to health.

· Description (classification, diagnosis) in order to talk about the other

areas firstly you need to know what is this thing.

· These have an historical background.

· Trying to put together the symptoms to make it a syndrome.

· Causation

· Maintenance

· Treatment of Psychological / Mental Disorders or ‘Abnormality’

What is ‘Mental Disorder’? Historically…

· Historically: mental illness = ‘madness, insanity’

· gross distortion of external reality (hallucinations, delusions), or disorganisation

of speech, affect behaviour (confusion, memory loss etc.).

· Very exaggerated symptoms could not interact with the world in the ways

that others could.

· Similar to today with psychosis.

· They thought there was only one mental illness and that was madness.

· Small no. of there people.

· Similar to today’s diagnoses of schizophrenia, psychosis and dementia

· 18-19th Centuries: Small number of patients treated in mental hospitals

by ‘mad doctors’ or ‘alienists’ (forerunners of today’s psychiatrists)

· Anxiety, sadness, angst, etc.: not ‘ mental illness’ was not considered

a part of mental illness these were just symptoms about everyday life you told

the following people: Priests, friends, family assisted with problems of living

What is ‘Mental Disorder’?

· Today: 400+ different categories of ‘Mental Disorder’. From one madness

we go to 400 varieties.

· Listed in the Diagnostic and Statistical Manual of Mental Disorders

(DSM) or the ICD (published by World Health Association) Used in Europe mainly.

DSM USA, UK, AUS English speaking world.

· DSM and ICD contain descriptions od symptom clusters:

· Schizophrenia, Major Depression, Social Phobia, Borderline Personality

Disorder, Bulimia Nervosa, Obsessive-Compulsive Disorder, Substance Abuse

Disorder, Sleep Disorders, Sexual Dysfunctions, etc

· Treated by psychiatrist, psychologists, clinical psychologists, social

workers, counselors, psychotherapists, psychoanalysts, etc

symptoms

that we label as disorders; schizo etc

very big change in the past 100 years of what is mental health

Prevalence of mental disorder - what proportion of

people are suffering from mental help

· Not sufficient to find out the number of people seeking or receiving

treatment.

· Help-seeking: Cultural or financial reasons, education, knowledge,

beliefs.

· Help seeking; acknowledge you have a problem, thinking that getting help

will be helpful, many factors before seeking treatment.

Psychiatric Epidemiology (community studies) very

large studies

· Prevalence proportion: What proportion of the population has a

diagnosable disorder, within a specified time period? In the developed world at

a certain point of time. 10000 people large, large samples = representative of

the population. Very diverse. People are interviewed by trained research

assistant about symptoms from the DSM.

· Point-prevalence proportion; what proportion of the population at the time of collecting the data

do you have it right NOW. Current, at this point of time.

· One-year prevalence; symptoms in the past 12 months,

this many people have experienced the disorder

· Lifetime prevalence; how many experience at any time during their life, 20 years ago but

you have experienced it.

Prevalence of mental disorder – good

assessment of what is going on in the population

Incidence proportion: What proportion of healthy individuals

will develop the disorder, within a specified time period? Are they increasing

is it going up or down.

E.g.

every year, X per cent of Australians develop Y disease.

What proportion of individuals with a

diagnosable disorder sought help? What proportion received help?

Prevalence/incidence in various

sub-populations

Men

vs women, age, ethnic groups et

Prevalence of mental disorder

National Survey of Mental Health and

Wellbeing (ABS; 1997, 2007). Australians

National Comorbidity Survey; Epidemiologic

Catchment Area study.

Lifetime prevalence of mental disorders

before age 21: 35-49 %

in adults 32-48% ( about 3 million)

Only about 1/3 of these people received help ( about 2

million)

Highest % sought treatment: Schizophrenia

48% (still only 50% who had the disorder had sought help)

large number of people suffer from mental disorders who receive no treatment

A public health problem of vast

proportions or

overestimation of the prevalence of mental

disorders?

**The Australian

study found that the 2/3rds that did not seek help said that they did not need

risk

of over estimation results from the definitions that we use.

DSM Definition of Mental Disorder in general –

categories of disorders

· A clinically significant behavioural or psychological syndrome or

pattern

· ... associated with present distress or disability or with a

significantly increased risk of suffering death, pain, disability, or an

important loss of freedom.

· ... must not be merely an expectable

and culturally sanctioned response to a particular event, for example, the

death of a loved one.

· ... whatever its original cause, it must currently be considered a

manifestation of a behavioural, psychological, or biological dysfunction in

the individual.

· clinical significance is meaningless very basic

· too much to cover no point engaging with them

last two points more important

first two receive criticism

an event like the loss of a loved one is

not depression it is an appropriate response

May

not be biological can just be psychological

Definition of Mental Disorder

Arises

from dysfunction within the individual

Socially

unexpected/inappropriate

Definition of Mental Disorder

1) Arises

from internal dysfunction:

depression vs normal sadness vs laziness

internal

dysfunction of: motivation? Emotion regulation?

Anorexia

Nervosa vs Religious fasting

Anxiety

disorders

Something

in his motivational system is not functioning and not letting him get out of

bed

Anxiety

more known about because it was used to prevent us from danger but now just

cases pain.

2) Dysfunction can be

socially expected/sanctioned

shamans,

mediums, A-type personality

socially

unexpected/inappropriate/unvalued

reasonable

vs unreasonable fear

normative

vs maladaptive alcohol/drug consumption

socially

inappropriate and no internal dysfunction and social deviance

biological illness there is not conflict if society does not agree because it

agrees that you have cancer

A behaviour not validated by society is

just social deviance.

100 years ago women sitting in uni

classroom it was not OK today socially acceptable.

**Mental disorder is a concept somewhere

between physical illness and deviance (Horwitz, 2002, Wakefield, 1992)

Continuum

Physical illness (some type

of dysfunction)……………………….social deviance on the other

What is not taking into account; normal

symptoms associated with an event. Just focuses on the symptoms. May not be about internal dysfunction may be

about a negative event. Main criticism about DSM. Spells it out at the start

but in DSM not consistent. Have symptoms have disorder. As in are they internal

dysfunctions or a reaction to a life event (context of the person)

Summary

· Historical definition of mental disorder (insanity)

· Today’s definition involves two components:

· Dysfunction internal to the individual

· Seen as socially unaccepted/harmful

· DSM fails to apply its own general definition of mental illness to

specific diagnostic categories

· Prevalence of mental disorder in the community may be overestimated

(because diagnosis is based on symptoms only, ignoring the question of

dysfunction)

LECTURE 2 – CLASSIFICATION AND DIAGNOSIS 1

Changes

in concepts of ‘mental disorder’

Introduced

DSM

Prevalence

of mental disorders in the community today

it an overestimation?

Analysis

of the definition of ‘mental disorder’ critics argues that too focused on

symptoms not enough on context

The medical/biological model – in medical

classification

· Classification and diagnosis is based on several assumptions:

· Illness is qualitatively different from health

· Different illnesses are

·  clearly distinguishable from each other

· occur independently from each other

· have specific, identifiable causal agents

· respond to specific treatment

Aetiologically based diagnosis is the

ultimate goal of medical (psychiatric) classification. Description described on

causation.

· a disease only called a disease when we know the cause

· Aetiology = causation

· until the cause is know we only have syndromes or disorders

The medical/biological model (very old started with

the Greeks)

Early

attempts for aetiologically based classification

◦ Hippocrates (c. 460-377 BCE/Greek) - Hysteria ("hustera" =

uterus). First person who tried to explain disease by natural causes ( not the

gods etc). Assuming causation not knowing.

◦ Paracelsus (16th Century/Swiis) – Vesania (toxins), Lunacy (moon), Insanity (inherited) all causes

◦ Henry Maudsley (1867) - “extreme

perversion of feeling and derangement of thought, failure of intelligence,

nocturnal hallucinations, and suicidal and homicidal propensities." - Masturbatory

insanity

when we assume causation we are usually

horribly wrong and then we apply treatment based on our assumptions it is dangerous.

If we don’t know the causation…and just

assume this is wrong

If we don’t know we describe the

symptoms at length

Emil Kraepelin (1856-1926)

we don’t have reliable knowledge about causation we should just describe symptoms

and not assume causation

just

describe symptoms

you

have identified a syndrome

describe

what you see including onset

the

course

episodic

aim

is to find the cause

eventually

you find the cause eventually the treatment

The medical/biological model

No reliable

knowledge about causation:

Use descriptive

approach, rather than classify according to hypothesised causes

clearly

describe symptoms – identify syndromes

with

similar onset, course, epidemiology, etc

have

specific aetiologies

respond

to specific treatment

example:

Acquired Immuno-Deficiency Syndrome (AIDS) an example of classifying symptoms =

syndrome. HIV-aids now disease status

Compendium of Psychiarty

1883:

manic-depressive psychosis (bipolar disorder); dementia praecox (schizophrenia)

differentiated

on basis of symptoms, onset, course, etc

The medical/biological model

General Paresis of the Insane (VERY DIFFERENT TO OTHER INSANITY’S) similar symptoms, bizarre

behaviours and hallucinations, the course became worse, terminal illness,

common in men, sailors, that hypothesis or description could help to explain

cause, sea water, smoking, etc. What they were seeing was actually the last

stage of syphilis. Looks like something separate but actually just a stage in another

disease.

· Observed symptoms, onset, course, epidemiology

· Hypothesised about possible causes

· Identified biological cause (1897; 1905, 1913) a bacterium that causes

syphilis

· Treponema Pallida bacterium

· NOT a separate mental illness, after all! – last stage of syphilis

· Louis Pasteur’s germ theory of diseases

· P. Broca (1824-1880), C. Wernicke (1848-1905) Identified associations

between specific syndromes (expressive vs receptive aphasia) and localised

damage to the brain

known causes = intoxication (exposure to toxins)

Most are still psychosis, 13 categories.

Diseases that look like psychosis or dementia.

Discovery of virus and bacteria was a turning

point…

All of this resulted in little gains, there are

no diseases

Did not have antibiotics till the 1940s

In comes Freud and The Psychoanalytic Model

LECTURE

3 – CLASSIFICATION AND DIAGNOSIS II

Oedipus conflict: extreme dependence on the mother results in

desire of the mother

Dad will find out therefore castration anxiety

Identify with the father therefore identify with

values of society

To resolve issues of your values and societies values and

if you cannot resolve these problems you will develop other problems

We all have problems with this development

Getting

resolved and unresolved in our psychy

Person

feels a huge amount of anxiety

lot of psychic pain = anxiety

Real

life anxiety = study for the exam

Unresolved

issues = psychic conflict

Distortions

= defence mechanisms

Displacement

you displace the target hate your father you hate authority

Reaction

formation display the opposite behaviour if you hate your father you love

him and dependent of him very dutiful etc. Homophobia reaction.

Projection:

conscious self can’t handle it therefore misplace it. Father does not hate me

everyone else does. Project your feelings to somewhere else they have the

problem not me.

Sublimation:

you use these emotion in a creative way

all have defence mechanisms

Our

defence mechanisms can be more or less successful but you can apply it very

rigidly or not very rigidly

Could

create other problems in themselves

Displacement

can lead to depression

Projection

they hate me therefore leads to paranoia if rigidly applied

Repression

keep everything in could lead to obsessiveness

symptoms do not tell us what the problem is

people with same underlying conflict could have different problems

both

using projection but not same problem

develop

underlying problem, symptoms develop over time

one on one correspondence with the cause

once

you become aware of the issue you are recovered can take many years

Psychoanalytic

approach is very different to the other ideas of health and abnormality

Almost

a backwards step

Psychoanalysis

dominated, it was revolutionary idea

suggested that there was no difference from normal to abnormal

real pathologising that cause you to become ill we are on a continuum

continuum very anxious not very anxious

Pathological

= end of the spectrum extreme manifestation of what is normal

Psychosis

and neurosis are on a continuum

dividing line, no clear categories with different causation

Extended

the client base of which to deal with

From

a couple of psychotic to most people

From

insane asylums you are treating in private practice etc

Made

a very bog different

What

mental health is, what is neurosis not just the domain of the dr anymore

1945

psychoanalysis is everywhere

from

this came DSM I

first

and second addition was very influenced by psychoanalytic theory

organic

vs reactive conditions

biological

basis

thought

to be reactive inter-psychic conflicts

DSM

I old fashioned

DSM

I person is adjusting to reality but develop strange defence mechanism s in

which to do it

Don’t

know anything about biology it was assumed it was a defence mechanism

Health and Illness are distinct =

biological /medical model

Problems of the psychoanalytic Model

1970s:

Psychoanalysis loses dominance, 1980s pretty much gone

needs

of third part players (i.e. health insurance), if I go to psychoanalysis and I

want them to pay they want to know when I am better because of the treatment

there is no clear line when you are healthy.

needs

of medical profession (psychiatry), needed to be developing in the times. It

was not testable by modern technology.

untestable

by modern empirical methods

clear cut offs between health and illness

concepts

are difficult to measure

DSM-I and DSM-II

problematic

reliability (e.g. inter-rater reliability)

problematic

validity (based on unproven theories about aetiology)

serious

problems to overcome, based on unproven theory

assuming

causation

everything

in manual is a defence mechanism

assuming

if you go to another dr they would get the same diagnosis, has to be reliable

DSM II back to Kraepelian

if we don’t know what causes it lets not assume

causation

mainly

now dealing with anxiety (psychoanalysis)

Categories

or dimensions

Were

going to start with personality disorders – it is not a category it is

continuous as a dimension

Uneasy

marriage between dimensions and categories

Changes

have been available online for the public to make

Easier

to get a diagnosis than DSM 4

Problems

with depression = easier to get a diagnosis now, exclusion of grief extracted

Easier

to get anxiety diagnosis, autism etc =

over diagnosis

ANXIETY DISORDERS

What is Anxiety?

The

experience of anxiety is the same in normal and abnormal anxiety

Activated

in response to perceived threat

Three interrelated anxiety systems:

Physical

system

Cognitive

system

Behavioural

system

Anxiety (Fear, Panic)

Physical Systems:

fight/flight:

sympathetic nervous system.

Mobilises

resources to deal with threat

Symptoms:

sweating heart rate, trembling etc

Cognitive system:

perception

of threat

attentional

shift and hypervigilence

difficulty

concentrating

Behavioural system

escape/avoidance

tendencies

aggression

Anxiety (fear, Panic)

normal

anxiety is necessary for survival

Eliciting conditions:

realistic/objective

threat to self

physical

vs social threat (Lovibond & Rapee, 1995)

specific

‘prepared’ stimuli (Seligman, 1971)

insects,

animals, heights, enclosed places, anger

novel

stimuli

threat

appraisal – expectancy of harm – automatically elicits anxiety

Threat Appraisal

Generates expectancy of Harm (what is the

harm that you are expecting)

Must distinguish between the

stimuli’s/situation and the outcome they are expecting. We all have

expectancies constantly. Probability and cost. Likelihood and how bad is it.

Highly likely and really bad then threat appraisal is high, expectancy high and

anxiety is high.

situation:

public transport

outcome:

embarrassment (social fear) Social Anxiety Disorder

outcome

accident death

Outcome:

germ or illness

Product of

perceived

probability

perceived

cost

Often based on past

experience

conditioning

reinforcement

observational

learning

instruction

Abnormal Anxiety/Anxiety Disorders

Individual differences in

trait

anxiety some people differ in their tendency to perceive threat for example

same ambiguous stimuli people will differ in their response to this

tendency

to perceive threat in ambiguous situations

specific

fears individual differences

= abnormal anxiety

Abnormal Anxiety/ Anxiety Disorders

abnormal

anxiety is not qualitatively different from normal anxiety

Same threes aspects:

physical

cognitive

behavioural

BUT excessive or inappropriate occurrence

Characterised

by over estimation of threat:

Cost or probability of harmful outcome

Physical fears: mainly

probability overestimation

Social fears: mainly

cost overestimation

Can overestimate the risk skin cancer might die but risk or

probability is over estimated. Suffer from negative over estimation.

disorder reflects an internal dysfunction

it interferes with daily life tells you that it

is dangerous when it is not

socially harmful inability to function

Separation Anxiety (has to be diagnosed before

age 18)

Evolutionary fears (heights, natural environment..)

LECTURE

5; ANXIETY DISORDERS II

Treatment of Anxiety Disorders

Cognitive Behavioural Treatment (CBT)

Aim to reduce (biased) threat appraisal

How

likely is it that the event will happen?

How

bad would it be if it did happen?

Increase

(biased) coping appraisal

Cognitive Techniques

thought

diaries to identify automatic thoughts

thought

challenging:

socratic

questioning

what’s

the evidence (against) the thought/belief?

Pros

and Cons of having the thought/belief

Behavioural techniques:

exposure

to feared stimuli (public transport)

exposure

to feared outcomes (negative evaluation)

in vivo

vs imaginary exposure

flooding

vs systematic desensitisation

Reduced (biased) threat appraisal:

exposure

to feared stimuli:

reduces

judgements of likelihood of harm

exposure

to feared outcomes:

reduces

judgments of cost

Exposure is essential in anxiety

treatment, You must show client that what they expect is not that bad. Hand in

a credit not HD paper.

Fear is free flowing, ambiguous,

uncontrollable worry

Does

not have autonomic arousal systems, no fight or flight response this is

different to other anxiety disorders because it does not trigger high arousal

Worrying

associated with a no. of other disorders

Main

diagnostic criteria is worry

What

if what if what if you start worrying about the future

People

that worry more, more threats, more things to worry about

Duration

and frequency higher and usually at night or early in the morning when there is

nothing else to do that is what you do

***STUDY

THE TEXTBOOK FOR ANXIETY DISORDER***

Worry

Occurs in response to perceived future

threat

high

worriers: biased threat perception (Rapee, 1991)

Duration and frequency

high

worriers more frequent and uncontrollable

Focus: mainly social threat in adults,

more about physical threat in older adults

high

worriers: more daily hassles, minor events (Craske et al, 1989)

Contains both verbal thought vs imagery

high

worriers: relatively more verbal thought (Borkovec, 1994)

worrys

contain more verbal thoughts less image based

Percieved positive aspects (Egosyntonic):

motivates

action, helps problem solving, helps avoid negative outcomes, helps t distract

from potentially even more distressing topics (Dugass et al, 1998, Freeston et

al, 1994)

people

think that it is helping you are being pro-active

Percieved negative aspects (Egodystonic):

Worry

is uncontrollable can lead to mental or physical harm (Wells and Carter, 1999)

Cant

make it stop

Could

lead to mental and physical issues lack of sleep etc

Worry control: Problem solving distraction,

social support (Davey et

al, 1996, Szabo & Lovibnd, 2002;2006)

High

worriers: more thought suppression (Cartright-Hatton & Wells, 1995), less

problem solving success (Szabo & Lovibond, 2002;2006)

Distract,

solve, seek social support

High

worriers try and hide the thoughts

Worrying is like a dimension from normal

to abnormal same process

Problem solving theories

Worrying involves problem-solving

attempts (Davey, 1994)

Problem solving attempts of pathological

worriers are ‘thwarted”

biased

threat perception

threat

in every situation therefore you cannot deal with every problem and find the

solution

define

problem generate solutions evaluate solutions, positive or negative

500

solutions and the 500 reasons why it wont work

negative

evaluation very good in High worriers

positive

evaluation not very good

Social Problem Solving (D’Zurilla &

Maydeu-Olivares, 1995)

problem

definition

generation

of alternative solutions

solution

evaluation (positive/negative)

solution

section

last

two stages are problematic in high worriers (Szabo & Lovibond, 2002; 2006)

Avoidance Theories

Worry =

cognitive avoidance (Borkovec, 1994)

verbal

thought vs imagery

images

of possible negative event are highly aversive

anxiety

symptoms are highly aversive

reduced

imagery = > reduced arousal/anxiety

GAD

is associated with tension symptoms

Cognitive

avoidance interferes with emotional processing

> Fear structures are maintained

Experiential Avoidance

Experiential acceptance vs Avoidance

avoiding

image and feeling you are scared of

therefore

the fear is maintained

alter

internal experiences (Hayes et al 1996)

Fear of anxiety/Anxiety sensitivity (e.g.

Buhr & Dugas, 2009)

Distress intolerance (e.g. Huang, Szabo

& Han, 2010)

Emotional regulation

Clearly

identifying emotion, tolerating emotion, having skills to modulate emotion

Mennin

et al., 2005, Roemer et al., 2005)

People

avoid experiencing different emotions people with GAD have a strong fear about

experiencing anxiety, low tolerance about distress in general

They

cannot handle being upset

Don’t

want to feel distressed sad angry anxious they cant handle it

Cant

regulate emotions in general

Can’t

identify emotions

Difficult

modulating feelings just want to get rid of it they use worry to deal with it

to avoid the experience

Intolerance of Uncertainty

Intolerance of uncertainty (Ladouceur et

al., 2000)

uncertainty

reflects badly on a person, cause, frustration and stress and prevents action

worry

to reduce uncertainty

leads

to preoccupation with details

interferes

with problem solving

try

to avoid uncertainty

Metacognitive Theory

Worry (Type 1) and Metaworry (Type 2)

(Wells, 1995, Wells & Carter, 2001)

Type I Worry:

perception

of threat and positive beliefs about worry – worry to cope with threat

(possible exit by problem solving or reassurance)

Type II Metaworry:

worry

and negative beliefs about worry - metaworry – ineffective thought-control

strategies – increased anxiety and worry

Meta worry =

worrying about worry it is a vicious cycle negative affect increases interferes

with trying to solve and then you push out the thoughts etc. Usually

ineffective way to prevent worry.

Treatment

basically is based of exposing them to the worry to deconstruct

50-60% to help

improvements

LECTURE

6; ANXIETY DISORDERS III

Immediate post-trauma phase

50-60%

of people experience traumatic event

25%

develop post traumatic problems

PTSD,

depression, anxiety, substance abuse

PTSD

prevalence: 5-11%

Normative

response to trauma is to get over it

People

are distressed immediately after traumatic experience

This

is a perfectly normal reaction

Distress

drops substantially within 3 months in about 75% of people

Risk for late problems

Critical

to identify people who need assistance to prevent post trauma problems

Risk factors

pre

trauma

post

trauma

Pre-trauma factors

childhood

trauma

prior

psychiatric history

family

instability

substance

abuse

social/economic

disadvantage

Trauma factors

degree

of life threat (injury, death) or loss

severity

of exposure to traumatic elements

location

of trauma (safe place vs elsewhere)

individuals

role in the trauma (victim, helper)

meaning

(e.g. uncontrollability)

Post trauma factors

social

support

coping

style

ongoing

stressors

Theoretical models of PTSD

Behavioural theories:

based

on Mower’s two-factor theory of fear

Cognitive theories

information

processing

attempts

to incorporate traumatic events into existing schemas (Horowitz, 1986)

cognitive

biases regarding meaning of trauma

cognitive

biases regarding meaning of symptoms

Treatments

Biological treatments

benzodiazephines, antidepressants

Cognitive behavioural therapies for PTSD:

core

treatment components

assess

suitability

psycoeducation

anxiety

management techniques

cognitive

restructuring

prolonged

exposure

CBT is more

effective than medication or supportive psychotherapy (Foa & Medows, 1997;

Harvey et al, 2003)

Eye Movement Dessensitization and

Reprocessing (EMDR) (Shapiro, 1989;1995)

now

used to treat a variety of anxiety disorders

eye

movements are the crucial components of the procedure and essential for its

effectiveness

training

has to be provided by EMDR Institute

Research evidence

EMDR

is best seen as an exposure technique

Eye movements

are not necessary for effectiveness

Lecture

9 Child Abnormal Psychology lecture series

Child

Abnormal Psychology part I

To understand maladaptive behavior:

what is normative?

milestones and sequences in development

Based

on Achenbach, T. M. (1982).

Developmental

psychopathology - Most Common Diagnoses

‘Internalizing’ Disorders; Anxiety disorders, Mood

disorders

‘Externalizing’ Disorders; Oppositional Defiant Disorder

(ODD), Conduct Disorder (CD), Attention Deficit Hyperactivity Disorder (ADHD)

Developmental Disorders; Autism, Mental Retardation, Learning Disorders

Major Depression – Epidemiology

less than 1% in preschoolers

2-3% in school-age children (similar in

both genders)

15-30% in adolescence (age 14-18)

risk of depression greatly rises in

adolescence and gender ration 2:1

Depression in Adolescence

cognitive diathesis-stress models

Beck: negative schema

Seligman: negative attributions

Cognitive style + negative events = < Depression

Predict depression from 12-14 years (abela, 2001)

Mid adolescence: critical time for MD

Negative cognitive styles are consolidated

(habits)

increased stress during adolescence

Depression in Adolescence - Why MD increase especially in females?

◦ Reporting differences?

◦ Self-medication in males?

◦ hormonal

differences?

Higher stress exposure in females ◦

Sexual victimization (16-19 peak age for

rape) ◦

Body image concerns (80% girls) ◦

Interpersonal negative events ; HSC,

peer groups etc.

‘Vicarious stress’ in social network; bitchy girls

Higher negative cognitive style in females

Different coping responses to stress ◦

Rumination vs. distraction/problem solving

(Nolen-Hoeksema)

Causes of depression in preadolescents?

Do children possess negative cognitive

styles?

Negative events => cognitive style

=> depression

Role of depressed parent (Shih et al.,

2009)

Emotional abuse, neglect (Gibb &

Abela, 2008)

Depression Treatment

Medication

◦ SSRIs:

Zoloft, Prozac, Paxil, Luvox etc. SNRIs (Effexor)

◦ None

of the SSRIs, and indeed no antidepressant, is currently approved in Australia

for the treatment of MDD in children and adolescents (persons aged less than 18

years)

Fluoxetine, but none of the other SSRIs is approved in

the US for MDD in young people without a specified lower age limit

Two of the SSRIs fluvoxamine and sertraline, are

approved in Australia for child and adolescents with obsessive compulsive

disorder (OCD)

CBT derived from adult approaches

Prevention (e.g., Gillham, Reivich,

Jaycox, & Seligman, 1995)

◦ aimed

at children/adolescents with high scores

◦ universal

prevention programs

Uses CBT techniques

◦ aimed

at parents of young children/toddlers

Depressed or overprotective parents are

treated

Child Abnormal Psychology part II

DSM-IV Anxiety Disorders

· Same diagnostic categories as in adults

◦ Specific Phobia, Social Phobia, Panic Disorder, Generalized Anxiety

Disorder, OCD, PTSD

· Diagnostic issues:

◦ limited validity of differentiation among the anxiety disorders

(Schniering, Hudson & Rapee, 2000)

· One category specific to childhood onset

◦ Separation

Anxiety Disorder

Diagnostic

criteria for separation anxiety disorder

Separation Anxiety Disorder

From age 6-7 months:

◦ Strong separation fears are normative

◦ Increases chances of survival

School-age:

◦ interferes with normal developmental milestones

◦ BUT:

these are culturally sanctioned

Often develops in response to stress

esp.

in vulnerable children

genetic

component neuroticism

behavioural

inhibition

overprotective

parents

anxiety

is associated with parents response

GAD

Very little is known about GAD and worry

in children and adolescents (Vasey & Daleiden, 1994; Cartwright-Hatton,

2006)

Only development analysis: Vasey (1993) nothing published since.

Children need to be able to:

imagine chains of catastrophic outcomes

switch to verbal thinking from imagery

develops by age 7-8 years

Cognitive avoidance theory of worry (Borkovec, 1994)

Relevance of other theories of worry/GAD?

cognitive avoidance theory of GAD

does not acknowledge all the other theories of GAD applied to adults…

Generalised Anxiety Disorder – is this the case in

children as well? ) Or just adults?

Developmental differences:

Problem solving and other worry control

strategies?

Role of intolerance of uncertainty?

Meta-worry?

Emotion regulation

Differences between fear, anxiety, worry?

Tension vs. autonomic arousal symptoms?

Content/focus of worries?

Role of cost and likelihood estimates?

Do kids have kid style worries or

completely different

Adults worry about things that are likely

Kids worry about things that are not very

likely like monsters etc.

They also know that it is not likely to

happen this is different in adults

Very different triggers, likelihood etc.

We don’t know if worrying is the same for

adults and children

Adults can problem solve

Resolve by thinking of yoghurt

More like fear than adult worry

Anxiety Disorders: Treatment

Biological treatments:

SSRIs: Zoloft, Prozac, Paxil, Efexor,

Luvox (effective for OCD, used also for other disorders)

Psychological Treatments:

CBT derived from adult approaches

Psychoeducation, relaxation,

Cognitive restructuring (e.g., detective

game), depends on age of child. Made into games.

Exposure must face it slowly

Increased

behavioural component

Positive reinforcement of coping

behaviours; like blackmailing,

Importance of parent involvement must

involve the parents otherwise they can exacerbate it when at home. Parents can

undue all good work

Parents need to be taught new styles of

parenting

Both parents and students learn new

techniques

Cool

kids CBT changed into child language. Macquarie uni. (R. Rapee, M. Dadds, P. Barrett, S. Spence, P. Kendall)

what is the evidence, what are the facts,

has it happened before = new realistic perspective

Child

Abnormal Psychology part III

- ‘Internalising’ Disorders ◦ Mood disorders ◦ Anxiety

disorders,

- ‘Externalising’

Disorders ◦ Attention

Deficit Hyperactivity Disorder (ADHD) ◦ Oppositional Defiant Disorder (ODD), ◦ Conduct Disorder (CD),

Attention Deficit-Hyperactivity Disorder (ADHD; DSM-IV)

Inattention

◦ Inability

to sustain attention, particularly for repetitive, structured, and less

enjoyable tasks

Hyperactivity-Impulsivity

◦ excessively energetic, not goal-directed

◦ hyperactivity-impulsivity

is a specific marker for ADHD (inattention is not)

ADHD: Associated Characteristics

· Cognitive deficits

· Speech and language impairments

· Medical and physical characteristics

· Interpersonal difficulties

· Associated with ODD, CD, anxiety, depression, and tic disorders

ADHD: Developmental Course

· Hyperactivity-impulsivity appears first

· Onset often in preschool years, by school age

· In early school years oppositional and socially aggressive behaviors

develop in 40%-70%

· Most problems continue into adulthood

· Prognosis poorer for children with co-morbid behavioral problems

· Mainly boys conduct section

· Girls more in neurotic spectrum

Main Theories of ADHD

· Motivation Deficits (e g., Crowell et al., 2006) ◦ Diminished sensitivity to rewards / punishment

· Low Arousal Level (e.g., Luman et al., 2005) ◦ Low arousal => needs stimulation

· Deficits in Executive Functions (Nigg, 2005) ◦ Goal

setting, planning, monitoring behaviour

· Deficits in Self-regulation (e.g., Brown, 2006)

· Inability to use thought/language to regulate behaviour, switching on

and off functions. Can’t stop themselves like if they see fire.

ADHD: Possible Distal Causes

· Biological ◦ Genetics, Neurobiological Factors

(prefrontal cortex), runs in families .8 or higher through twin studies.

Adoptions studies suggest .5

· Pregnancy, Birth, and Early Development ◦ Not

be specific to ADHD can include it but also a range of other disorders as well.

Are associated to ADHD. Substance abuse, low birth weight, early problems

associated with development of ADHD.

· Diet, Allergy, and Lead ◦ No

consistent evidence (Bateman et al., 2004) ◦ Importance of parents’ beliefs. Red cordial etc. But more what the

parent thought played into it because parent treats them differently. Parents

look for evidence consistent with belief.

· Family Influences ◦ Direction

of causality not clear. Associated with ADHD but direction difficult to

determine. Child born with tendency and then parent’s responses make it worse.

ADHD: Treatment

· Medication ◦ Dextroamphetamine,Methylphenidate

(Ritalin). Usually frontline with treatment. Central nervous system stimulants.

More stimulation somehow works. Over diagnosed over medicated.

· Parent management training ◦ Operant

conditioning principles ◦ Clarity

of consequences contingent on behaviour ◦ Begin by reinforcing positive Behaviours ◦ Prepare for ‘high-risk’ situations. They are difficult to parent but

they require different treatment. They need operant conditioning, behaviour

with reward increases, without reward the behaviour decreases. Specific

consistent response is required. Don’t

kick teacher, you get rewarded. Very specific and what will follow. Start with

positive behaviours. Many negative reactions already. Focus on the positive.

Look for something that child does right. And then reinforce it. Changes

atmosphere. Initially ignore the negatives. Very clear instruction.

· Educational intervention ◦ Operant

conditioning principles

Disruptive Behaviour Disorders

Oppositional Defiant Disorder (ODD) ◦ Age-inappropriate stubborn, irritable, and defiant behavior. Deliberate resentful.

Unpleasant and disagreeable.

Conduct Disorder (CD) ◦ A repetitive and persistent pattern of violating basic rights of others

and/or age- appropriate societal norms or rules ◦ Importance

of age of onset. Aggression, animals persons, bullying, fighting, cruelty ,

truancy.

1-10% diagnosed with these disorders

differences between the two are just in degree of severity one not

destructive.

Disruptive Behaviours: Associated Characteristics

varied

· Cognitive and verbal deficits

· IQ in normal range but inability to apply themselves

· School and learning problems

· Peer problems; physically aggressive, bullies, rejected, form aggressive

antisocial group, more and more aggressive

· Family Problems; instability, highly conflicted difficulty coping

· Health-Related Problems; risk taking Behaviours, sexual activity more

risk, STIs, personal illness etc. rates of death higher because they are risky

drug taking etc.

Co-morbid Disorders; ADHD, depression, ODD

Disruptive Behaviours: Developmental Course (Age of

onset important)

· Two Pathways (Moffitt, 1993) longitudinal

studies

◦ Adolescence-limited (AL) – during adolescents, low level rule breaking, shoplifting, skip school

etc., most students during A break rules 94%, well adjusted adolescent does try

to break rules, they stop Behaviours when they are 20.

◦ Life-course-persistent (LCP) – starts symptoms before age 10, more likely to be boys, don’t do it

because of peer pressure, torture kittens, they are more likely to remain on

this path. Account for a large amount of criminal behaviour as adults. End up

in goal, diagnosed after 18 years with APD. 40% of kids with conduct disorder

will be diagnosed with APD

· Often negative adult outcomes, especially

for those on the LCP path

◦ Antisocial

Personality Disorder

Disruptive Behaviours: Possible Causes

Biological ◦ Genetic, Neurobiological. Some genetic

connection with aggression. Birth related trauma.

Social-Cognitive

(Crick & Dodge, 1994) ◦ Encoding,

◦ Interpretation ◦ Response search ◦ Response

decision ◦ Enactment.

When they encode they interpret information they pick up fewer cues before they

interpret and assume its hostile. Laughter is about me. Both aggressive and

anxious children will do this. Anxious hide, aggressive will conflict.

Family ◦ Family instability and stress ◦ Parental criminality, psychopathology ◦ Coercion Theory (Patterson et al, 1992) Coercive family communication

patterns. Parent child communication is strained. Parent wants child to do

something child does something provocative leading to negative reactions. Child

does not have to comply. I am going to

bash my sister instead of doing homework. Parents are less likely to enforce

demands because child has provoked.

Societal or Cultural ◦ Criminal subcultures ◦ Media

violence?

Disruptive Behaviours: Treatment; not very successful

Medication

(Lithium, Stimulants, Neuroleptics) mood stabilizers, anti couvulsants. Tying

to calm these kids down.

Parent Management Training

(Barkley, 1997) can work if the child is young enough can work if parent can

carry through. Many mental health problems.

◦ Operant conditioning principles

◦ High drop-out rate

Cognitive Problem Solving Skills (Kazdin,1996)

· Stop and think, Consider alternative

explanations, Generate/ implement non-aggressive responses

· Perspective taking; maybe I see it that way but others see it another

way

Problem solving

Multi-systemic

treatment

many forms of treatment but not very successful.

Bipolar Disorder

Mood disorder

characterised

by disturbance to mood

DSM-IV

breakdown; major depressive episode, manic episode hypomanic episode, mixed

episode

Diagnosis

relies on the presence/absence of episodes. Constellation of episodes that give

diagnosis the presence or absence of these episodes will dictate diagnosis.

Manic Episode

Criterion A

At least one

week of abnormally & persistently elevated, or irritable mood

distinct period lasting at least one week or any amount of time if hospitalised

episodes

move quickly from an elated mood to an irritable mood or can fluctuate between

elation and irritability

Criterion B

At least 3 of

the following symptoms need to be present to a significant degree

grandiose

inflated

self esteem

rapid

pressured speech

decrease

need for sleep

flight

of ideas or racing thoughts

distractibility

increase

in goal-orientated behaviour or psychomor agitation

excessive

involvement in activities that have a high potential for negative consequence (buying

sprees)

Criterion C

Do not meet

criteria for a mixed episode

Criterion D

Mood disturbance

is sufficiently severe to cause marked impairment in occupation of functioning

in normal social activities etc., or hospitalisation

Criterion E

Symptoms are not

due to direct physiological effects of a substance (e.g. drug) or a general

medical condition

HYPOMANIC EPISODE

A – at least 4 days of abnormally and persistently elevated or

irritable mood.

B – 3 or more of the following:

inflated

self esteem or grandiosity

deceased

need for sleep

talkative, pressured speech

flight

of ideas/racing thoughts

distractibility

increased

goal directed activity or psychomotor agitation

excessive

involvement in pleasurable activities which have a potential for negative

consequences

C – change that is uncharacteristic of the individual; a stark

change in person

D – disturbance and changes are observable by others

E – not severe enough to cause marked impairment or

hospitalisation

F- not due to substance abuse or a medical condition

HYPOMANIC EPISODE different to manic

episode…less intense

A hypomanic episode is similar to a manic

episode except that:

has a shorter duration

is less intense

does

not cause the same degree of impairment in functioning

does

not necessitate hospitalisation

there

are no psychotic features

MIXED EPISODE = manic and major

depressive episode (MDE)

A – criteria of both Manic and MDE are met (except duration) nearly

everyday during at least one week (highs and lows)

B – the mood disturbance is severe to cause marked impairment

etc. Or to necessitate harm to self and others and cause hospitalisation or

there are psychotic features (delusions or hallucinations)

C – not due to the direct physiological effects of a substance

or general medical condition

Bipolar Disorders:

Characterised by

a distinct pattern of manic, hypomanic and depressive episodes: diagnosis of

Bipolar I or II is determined by the most recent episode.

Bipolar I

Disorder; A )AT LEAST ONE MANIC/MIXED EPISODE, B) presence of MDE is not

necessary but common.

Bipolar II; A

)AT LEAST ONE MDE, B) at least one hypomanic episode.

Both are not

better accounted for by different diagnoses.

Diagnostic Differences

Episode

Bipolar I

Bipolar II

Depressive

episode

Can be present

but not necessary for diagnosis

yes

Manic episode

yes

Hypomanic

episode

Can be present

but not necessary for diagnosis

Yes

Mixed episode

Instead of

manic episode

Cyclothymic Disorder

cyclothymic

disorder is a less severe form of bipolar disorder

characterised

by numerous cylces of hypomania symptoms and depression symptoms

but

these mood cycles are not severe enough to meet criteria a manic/mixed/MDE

symptoms

must be present for at least two years with no more than two months without

symptoms

patients

with CD may experience euphoric highs, boosts of energy and require less sleep

in one phases, but then experience severe mood swing into depression with

feelings of negativity and sadness for no particular reason

Bipolar

Disorders DSM-V

Mood disorders

working group have porposed few changes for Bipolar Disorder

Manic and

Hypomanic Epsiode:

Criterion A to include

increased energy/activity as core symptom

at least one week of abnormally and persistently elevated or irritable mood

at least 4 days of abnormally and persistently elevated or irratble mood

Consider

removing “mixed episode” and including as a diagnostic specifier only

Consider

introducing temper dysregulation disorder to better account for over diagnosis

in pediatric populations

longer in mood disorders: instead a separate category “Bipolar and related

disorders”

Bipolar

Bibolar

Cyclothymic

disorder

Substance/medication

induced bipolar and related disorder

Other

specified bipolar and related disorder

Unspecified

bipolar and related disorder

Diagnostic

Issues

Bipolar

disorders are often:

-undiagnosed

- over diagnosed

(i.e borderline personality disorder)

mis diagnosed

as: phsychosis and unipolar depression

-diagnositic

problems are important and hve implications for pharmacological and

psychological interventions

Prevalence

bipolar

I has a lifetime prevalence of ).4% to 1.6%

together,

B I and II have a lifetime prevalence of 3.9%

comparison the life time preveleance for MD is 16/6%

mth prevalence is 1.3% of Australians

bipolar

disorder is equally distributed between men and women

unlike

unipolar depression

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