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Psychopathology
Exam Prep
Chapter 7 – Somatic Symptoms Disorders and
Dissociative Disorders
Main Topics
•
Somatic Symptoms Disorders: Mind → Body
Theory and Therapy
•
originates in the mind, something psychological is causing the body to
have something wrong
•
Hypochondriasis-
can have feelings that they’re having ulcer or something, there is nothing
wrong organically, it is in the mind (currently referred to as illness anxiety
disorder)
•
Need
to show them that there’s nothing wrong
•
They
are not “faking” – but at the same time, there is not a physical cause and
nothing is actually “happening” to their body
•
The
individual complains of boldily symptoms that suggest a physical defect or
dysfunction – but for which no phsyciological basis can be found
•
Dissociative Disorders: Holistic →Components
Theory and Therapy
·
The
individual experiences disruptions of consciousness, memory and identity
•
a
whole person becomes split into different personalities
•
they
become
compartmentalized and different parts of yourself become dissociated
•
This
is NOT schizophrenia
•
Here
there are multiple personalities, minimum 2 could be 8 or more
•
Schizophrenia
is one personality but perceptions split – personality intact, (often misinterpreted)
Somatic Symptoms Disorders
•
Psychological
states that take on a somatic, or physical form and cause distress
•
sometimes
no stress as it is serving a purpose- it is a defense mechanism
•
Way
of distancing themselves from having to combat etc for soliders
•
Not
under voluntary control
•
Thought
to be linked to psychological factors, presumably anxiety, and psychologically
caused
•
Causes the person to seek medical treatment, but
cannot be explained organically
•
so
if you claim you cannot see, all the neurons are firing still ( if you were physically
blind this would not happen)
•
Difference
between sensation and perception
•
Most
of your vision is actually in the brain ( it is awareness)
•
You
must actually become aware of what you’re looking at
•
You
may able to see (sensation)- but you are unaware that you can see ( n
perception) – this can occur from certain brain pathways inhibiting your
conscious awareness of vision etc.
•
It
sometimes occurs with certain individuals who can see something but not know
what it is that they’re seeing (ex: recognize that they saw a word on a screen
but claim they are unable to see)
•
This
neurosis is affecting higher levels of vision ( or other sense )
•
When
they’re calm ( not experiencing the psychological issues), the sense comes back
•
Psychogenic
cause – not a physical one
Body Dysmorphic Disorder (BDD)
•
DSM-5
includes BDD as an OCD condition
•
A
preoccupation with an
imagined or exaggerated defect in appearance, frequently in the face
•
perception
that there is something wrong with you
-
Examples: facial wrinkles, excess facial hair, or the shape or size of
the nose.
•
Women
tend to focus on the skin, hips, breasts, and legs
•
Men
tend to focus on height, penis size, and body hair
•
people
that usually suffer from this are quite attractive
•
people
with this disorder will often spend hours each day checking themselves in the
mirrors
•
others
take unusual steps to avoid seeing their reflection
•
lead
to frequent consultations with plastic surgeons – they will never be fully
satisfied with the work of a cosmetic surgeon
•
occurs
mostly among women, typically begins in late adolescence and is frequently
comorbid with depression and social phobia, eating disorders , thoughts of
suicide and personality disorders
•
linked
to eating disorders, hair pulling
•
half
of all victims of BDD try to commit suicide
•
mothers
that are high control/low emotion can trigger this
•
cognitive
therapy (thoughts) is the only way to treat this – usually it is about CONTROL
•
usually
a chronic disorder only 1 in 5 experience fll remission and even so they have a
high possibility of relapse
•
people
were less likely to achieve remission if they had more severe symptoms, a
longer lifetime with the disorder and were adults when there were diagnosed
Somatic
Symptom Disorder (formerly Somatoform Disorder)
•
Recurrent,
multiple somatic complaints, with no apparent physical cause, for which medical
attention is sought
•
begins
in early adulthood and has a chronic course
•
when
bodily concerns are present, diagnosed in DSM-5 as: somatic symptom
disorder (formerly somatization)
•
DSM has criteria for how many symptoms are needed
•
Continuous
physical complaints with no physical cause
•
Complaining
of dizziness, stomach issues, gastrointestinal issues
Illness Anxiety Disorder (formerly hypochondriasis)
•
When
bodily symptoms are not present but person is preoccupied with
persistent fears of having a serious medical disease, then diagnosed as: illness
anxiety disorder
•
the
term “hypochondriac” is pejorative (derogatory) , no longer used
•
Illness
(Health) Anxiety
•
Preoccupied
with having a disease
•
Doctor
for a second opinion – the first opinion is already their own
•
They
think they have a disease- cancer, ebola, etc
•
They
find one symptom and think they have it
•
Cognitive
issue – The cognitive factors are considered central
•
“catastrophic” misinterpretations of bodily
sensations
•
Pain
in stomach- stomach cancer, rash- skin cancer
•
Think
the worst case scenario
•
Headache-
tumor ?!
•
strong
beliefs that unexplained bodily changes are always a sign of serious illness
•
go
from doctor to doctor to get tests etc
•
Lots
of money can be wasted as they do not need the test
•
When
told it is in their head they get upset- as this is so hard to determine , some
biological cases may go undiagnosed because it is hard to tell
•
Usually
we know if something is physically wrong due to the multitude of tests
•
Cognitive
Model of Health Anxiety
•
Four contributing
factors:
Critical precipitating incident (Need precipitating incident – ex: parent
had illness ->you could get illness)
Previous experience of illness and related
medical factors (making you look for signs and factors that you have the
given illness)
Presence of inflexible or negative
cognitive assumptions (may have a diathesis for thinking the worst)
Severity of anxiety ( when bodily changes
occur, may obsess over them)
Pain Disorder (DSM-IV-TR)
•
No
longer diagnosed in DSM-5
•
Psychological
factors are viewed as playing an important role in the onset, maintenance, and
severity of the pain
•
Most
likely now diagnosed with somatic symptom disorder with predominant pain
•
differs
from organic pain disorder – can’t describe the pain
•
describe
in psychological terms- “it’s around here and it bothers me “
•
talk
about it in emotional terms over physical terms
Conversion Disorder
Rare disorder in which, physically healthy people experience
sensory or motor symptoms suggesting a neurological illness (although the
body organs and nervous system are found to be normal).
sufferers may experience paralysis of the arms or legs; seizures
and coordination disturbances; a sensation of prickling, tingling, or
creeping on the skin; insensitivity to pain;
·
vision
may become seriously impaired and the person may become partially or completely
blind or have tunnel vision
•
Actual
disability without organic pathology that would explain the disability
•
disability
here
•
are
actually blind, deaf, can’t speak, paralyzed etc. – no neurological evidence as
to why
•
psychogenic
cause
EXAMPLES:
•
Sudden
loss of vision
•
Paralysis
of arms or legs
•
Seizures
and coordination disturbances
•
Sensation
of prickling, tingling, or creeping on the skin
•
Insensitivity
to pain
o
Anesthesias-
the loss or impairment of sensations, called anaesthesias
•
Aphonia
– reduction in voice
•
Anosmia
– smell disrupted
•
Tends
to appear suddenly in stressful situations
•
Can
happen in PTSD
•
Serving
a purpose – not deliberate – person suffers from this but brain is controlling
this
•
Signs
of Conversion Disorder:
•
Rapid
appearance of symptoms, especially after psychological trauma
•
“La
belle Indifference”- Aids diagnostic of conversion disorder not
malingering (malingering = faking)- not that upset about it – don’t seem to
care that much that this is happening – this is because this is serving a
psychological defence
•
Neurological
nonsense: differing from organic symptoms
of physical illness ( impossible symptoms- can’t happen)
Hysteria
•
Term
originally used to describe what are now known as conversion disorders
·
Originates
back to ancient Greece when Hippocrates thought it was a disease of women
caused by a wandering uterus
·
This
presumably symbolized the longing to produce a child
·
Usually
develop in adolescane or early adulthood, typically after undergoing life
stress
·
And
episode may end abruptly, but sooner or later the disorder is likely to return
·
Frequently
comorbid with other disorders like depression, substance abuse, anxiety, and
dissociative disorders
·
Usually
a history of physical or sexual abuse
Conversion Disorders: actual nerve pathways vs. glove anesthesia
Often carpal tunnel !
It is impossible for the
hand to freeze just at the wrist due to the nerve pathways, it would have to continue
up onto the wrist (Carpal tunnel is an exception **)
Somatic Symptoms Disorders: Theory and Therapy
Psychodynamic
Perspective:
•
Somatizing
as conflict resolution (displacement)
•
If
displacing my emotional pain onto the body, what is emotionally bothering me is
now a physical thing
•
It
may be that it is a sign of weakness in culture to talk about emotions
•
Could
be a way to get that attention in a more acceptable way, physical –nothing you
can do about it, mental/emotional- oh snap out of it
•
Use
psychodynamic theory to uncover it (uncovering conflict through psychotherapy
Behavioral &
Sociocultural Perspectives
•
The
sick role
•
Treatment
by non-reinforcement- Similar to malingering
in that the person adopts the symptom for some additional benefit (secondary
gain)
•
You
learned if you had a sore stomach you could stay home
•
Being
reinforced
•
Treatment
is non-reinforcement
The Cognitive
Perspective
•
Over-attention
to the body – google-itis
•
Treatment:
challenging faulty beliefs
The Neurological
Perspective
Evidence is weak
•
Brain
dysfunction (suppression: hypoxia, low glucose, RH)
•
Over
active right hemisphere (panicky people)
•
Drug
treatment- no drug treatment for this specifically but they can treat the
anxiety or depression
Therapies for Somatic Symptoms Disorders
•
Little
controlled research on psychological treatments because somatoform disorders
are less commonly seen in psychological practices than other conditions
•
Comorbid
with anxiety and depression ( treatment
would be targeted at the anxiety and depression )- see treatment sections for these disorders
•
Cognitive-behavioural
approaches
Dissociative Disorders – DSM-5
Characterized by
disruptions of consciousness, memory, and identity
Dissociative Amnesia – memory loss following a
stressful experience
Depersonalization/derealization disorder – altered experience of the
self
Dissociative Identity Disorder (DID) – at least two different
(alternative) ego states (alters)
•
brain
states – when you look at the different personalities under the PET scans and
other scans, there brain looks completely different (functionally)
1. Dissociative Amnesia
·
Unable
to recall important personal information, usually after some stressful episode.
The information is not permanently lost, but it cannot be retrieved during the
episode of the amnesia
·
The
holes in memory are too extensive to be explained by ordinary forgetfulness
•
Selective
amnesia (traumatic event)
•
after horrendous experience – lose memory of
maybe the whole event or parts of it
•
Everything
else is remembered fine ( retains the ability to talk, read, and reasons and
also retains talents and previously acquired knowledge of the world and how to
function in it)
•
Indifference
to condition
•
You
are maybe not upset that you cannot remember because it is serving a purpose –
why would you want to remember
•
Brain
protects you from reliving this
•
Amnesia
is a protective psych defense
•
You
know who you are and what year it is etc.
•
Oriented
and able to learn
•
You
are able to learn new things – you wouldn’t be able to if this was an organic
amnesia
•
Ability
to recover memories
•
-amnesia
can happen due to brain damage
•
How
do you know its not due to an organic pathology - MRI will show it
•
In
psychogenic amnesia – you can get these memories back through psychoanalytic
theory
•
reserved
for psychiatrist – using psychoanalytic types of therapies
•
Psychogenic
amnesia – your brain is intact – there is no problem with learning or
remembering other things
•
Because
no brain damage you will be able to recover the memories in time
•
Amathol
– drug used to bring back memories
•
Hypnosis
– problems with validity
•
Source
amnesia – is the inability to remember where,
when or how previously learned information has been acquired, while retaining
the factual knowledge.
•
Leading
questions can cause the patient to answer how they think they’re supposed to,
it may not have happened but after the hypnosis they will think that this is an
actual memory because they can’t remember when they learned it
•
Iatrogenic
– created in the clinical setting
•
Hypnosis
cannot be used in a court of law
•
the
brain has ways of developing full stories even if they are inaccurate – you may
not know it’s not real
•
power
of suggestion
•
the mind having seen things on tv or reading –
works with scenario and creates story
•
Ability
to recover memories shows that it is not a pathological problem
•
Brain
injuries will not be able to be recovered by hypnosis
•
Person
unable to recall important personal information, usually after some stressful
episode.
•
Information not permanently lost, but cannot
be explicitly retrieved during the
episode of amnesia
•
Most
often memory loss involves events during a limited period of time
•
Total
amnesia: Patient does not recognize relatives and friends, but retains the
ability to talk, read, and reason
•
Amnestic
episode may last several hours or as long as several years.
•
-period
of time
•
-total
amnesia – don’t recognize friends, relatives, but retain ability to read, to
talk, to have skills, autobiographical/personal memories have been lost,
procedural or semantic memory is intact
•
-May
last several hours or several years
•
-cyclic
type of recovery
•
-Onset
is not very quick
•
Total
amnesia is very rare
Dissociative Fugue
•
Memory
loss more extensive in dissociative fugue than in dissociative amnesia.
•
Person
becomes totally amnesic and suddenly leaves home and work and assumes a new
identity. (Here you actually take a trip away from home)
•
Fugues
typically occur after a person has experienced some severe stress
•
Come
back to their former life and end up
wandering off with new identity
•
Whole
new life
•
Unconscious
of this
•
Don’t
know who they were
Dissociative Amnesia
Patterns of Memory Loss
*
•
Localized amnesia- all the events are wiped out
relating to a specific event
•
Selective amnesia- only certain events are wiped out,
its sketchy , spotty
•
Generalized amnesia- entire life
•
Continuous amnesia- you don’t remember who you are,
friends etc., any events after a traumatic event and any events after (can’t
build new memories)
•
Systematized amnesia- only certain categorical
information is remembered, forget everything about a relationship, your
workplace, etc. , everything else is fine
•
Fugue- take intentional trip away from home assume a
different identity , hours or years,
•
Dissociative
Disorders
2.
Depersonalization/Derealization Disorder
·
Person’s
perception of experiences of the self/situation
·
Is
disruptively altered (stress triggered)
·
Only
one where you don’t have memory loss
·
Very
scary
·
Perception
of yourself/experiences is altered – triggered by stress
o
Depersonalization- a sense of strangeness or
unreality in the self
o
Derealization- a feeling of detachment from
the world/situation
•
Dissociative
Disorders
3. Dissociative
identity disorder (DID)
Personality breaks up into 2 or more
distinct identities or personality states ( have at least 2 personality states)
•
Host: the personality corresponding to who the
person was before onset of the disorder ( the core- it is the person that you
were before the onset of the disorder)
•
Alters: later-developing
personalities (these happen after onset)
•
There will be more alters depending on how early you
developed the disorder
•
Most of these people have been sexually abused
(often incestuously)
•
This causes them to go off into an imaginary world
to deal with this
•
They develop a personality to deal with rage or fear
etc.
•
It is a brain state- levels of glucose shown
differently on a PET scan depending on the personality brain state
•
While in the other brain states, often have amnesia
for the other person
•
It happens more often in women than men because of
the sex abuse link
•
Comorbid with depression
•
Takes a very imaginative person
•
Have to be able to escape into their imagination and identify with characters well
•
These
people are highly hypnotizable (open to suggestion – believe in hypnotism )
•
Presumably
begins in childhood, but rarely diagnosed until adulthood
•
More
common in women than in men
•
Comorbid
with depression, borderline personality disorder, and somatization disorder
•
In
one study 90% had a history of suicidal tendencies, depression, recurring
headaches, and sexual abuse
•
Another
study is suspecting poor attachment due to exposure of frightening or chaotic
behaviour from caregiver
•
Diagnosis
of DID is a very controversial
•
Some
people think it’s a way of getting out
of things (ex: crime)
•
No
way to tell if malingering
·
Brain
activity is different in the different brain state
Etiology of Dissociative Disorders
Psychoanalytic:
Dissociation as a defense that protects the person from memories of traumatic
experiences
·
Different
forms of amnesia are distinct disorders (not all just DID)
Dissociative Disorders: Theory
and Therapy
Behavioral &
Sociocultural Perspectives:
•
Learning
to dissociate
•
Nonreinforcement
•
helps
you to get rewarded
•
helpful
to ignore the other personalities, don’t reinforce that
The Cognitive
Perspective:
•
Memory
dysfunction- normally much better to remember things when you’re in the same
emotional state that you’re in when you experiences it
•
Retrieval
failure- brain state takes over, inability to retrieve when not in that
particular state
The
Neurological Perspective:
•
Brain
dysfunction (epilepsy, hippocampus)
•
Stress
can cause the hippocampus to shrink and have atrophy. For uniting the memory,
if atrophy, there will be gaps
•
Drug
treatment
•
SSRIs
– treat the comorbid issues (depression/anxiety), can’t treat DID specifically
•
Migraines
linked to low levels of serotonin
•
Derealisation
and depersonalization different from the other disorders because they do not
have any amnesia
Chapter 8 : Mood Disorders
Symptoms of Major
Depression (MDD)
·
Sadness
·
Anhedonia - lack of pleasure-
not pleasure seeking
·
Sadness and Anhedonia MUST be present for diagnosis
·
Disturbance
of appetite- some overeat, others don’t eat at all
·
Sleep
disturbance – over/undersleep
·
Psychomotor
retardation or agitation- slow and sluggish or very agitated
·
Loss
of energy
·
Feelings
of worthlessness or guilt- don’t love themselves, feel everyone would be better
off without them (recurrent thoughts of suicide)
·
Reduced
ability to think or concentrate
·
Recurrent
thoughts of death
o
Men
are more likely to be “successful” in suicide as they se more defininitive
methods (shotgun, hanging etc.)
o
Women
use more drugs and alcohol
·
Can’t
think of concentrate
Depression (MDD)
About 80% having MDD experience another
episode
Average
is 4-5 episodes lasting for 3 to 5 months
kindling hypothesis: once a depression
has already been experienced, it takes less stress to induce a subsequent
recurrence ( if you’ve had a bout one time, it might not take much for it
to come back )
2x more common in women than in men
Difference appears in adolescence and is
maintained across the lifespan
Men are more reluctant to go talk to someone
Violence higher in men
Men become outwardly aggressive when
depressed, women become more emotional
o
These
differences could be due to the sociocultural treatment of boys and girls (
boys don’t cry, girls its ok to cry etc.)
Gender, Age, & Depression
Women are about twice as likely as men to be diagnosed with
depression.
True around the world
After age 65, rates of depression drops
sharply in both sexes.
In the graph the categories are a bit
skewed since the age category is so large (unequal)
Women are way more prone
Dimensions of Mood Disorders
Psychotic versus Neurotic:
Continuity Hypothesis: Look at depression
as an exaggerated form of normal sadness (extreme)
Depression an exaggerated form of
§
“normal”
sadness
quantitative vs. qualitative
This id quantitative- theres a level
being measured, normal distribution with st.dev units
If you fall above or below then it
could be a clinical situation
Ex: mania would be an exaggerated form
of happiness
§ Qualitative – based on a dichotomy:
either you are or you’re not
§ It is much better to look at it as a
continuum
Endogenous versus Reactive
Endogenous means coming from within,
biological (coming from your genes, a diathesis)
Reactive means an environmental
stressor triggers it, it has the best prognosis over time it will heal
Early versus Late Onset
Early onset- you hve had a disposition to
be sad early on
Late onset – develops later on
* endogenous causes probably started the
behaviour earlier
Bipolar Disorder
Bipolar I disorder– involves episodes of mania or mixed episodes that include symptoms of both
mania and depression
Diagnosis of a manic episode requires the
presence of elevated or irritable mood + 3 additional symptoms
have to have manic –overactive mood
irritable because people don’t want to do
the stuff you want to do
Manic Episodes
Manic Episode:
Elevated, expansive, or irritable mood
Inflated self-esteem- think youre the
best at something, you can do anything, like youre on cocaine
Sleeplessness- might only sleep a couple
hours a night
Talkativeness – does not shut up, not in
coherent stream of thought (flight of ideas)
Flight of ideas
Distractibility- cant pay attention
Hyperactivity- not thinking about
consequences , spending all kinds of money , excessive over the top , no
thought to consequenes AT ALL
Reckless behavior
Heterogeneity (diversity)
Examples:
Bipolar I Disorder with mixed episodes
Could occur early in childhood or later
on
There is no known demographic
In this course we are typically referring
to this type of bipolar disorder
Manic, depressive, manic depressive OR
manic, depressive, normalcy, etc.
Bipolar II Disorder (no ‘full-blown mania)
episodes of major depression accompanied
by hypomania (less extreme than Bipolar I mania)
MDD with psychotic features
Bipolar and unipolar disorders can be also sub-diagnosed as
seasonal
Seasonal affective disorder (SAD) – lack
of sunlight
Highest rates of SAD can be found among
people who live in the Canadian Arctic (up to 18% of population)
Mood Disorders-Bipolar
PET scans show that brain energy consumption rises and falls with
emotional switches
Depressed phase – barely functioning
Manic phase – high functioning, frontal lobe high activation
Depressed phase – its worse when you go back…each time gets lower
and lower
Lithium is the most common drug for bipolar
The manic phase usually shorter than the depressive phase
Usually have insight into their illness
Neurotransmitter based we think
Psychological Theories and Therapy
The Psychodynamic Perspective:
Oral fixation (dependence diathesis –
dependent on other people for other people, looking to other people for
affirmation)
The time during psychosexual phases when
you need to ween from the breast or bottle and if you don’t you will
become defendant on the caregiver
Reactive loss ( anger turned in, ambivalent about the people in our
lives)
Repairing the loss ( insight ( pin point
the trauma ); IPT( interpersonal therapy – how to deal with the people
around you in a social realm))- reaction to a loss in life and later
reopens the wound , focus on the here and now
The Behavioral Perspective:
Extinction – lack of positive reinforcers
BA – Behavioural Activation – getting out
and going for a walk, getting out of your own head, more of an
opportunity to build more positive reinforcement
Aversive social behavior- looking for affirmation from
other people, or irritable because they’re so short tempered, makes
people avoid them which can make the depression so much worse
Increasing reinforcement & social
skills
The therapy would be to deal with how you
are handling your social situations
Cognitive Perspective
based on the assumption that thoughts intervene between events and
our emotional reactions
teaches more adaptive ways of thinking and acting
Beck’s Theory of Depression
Thinking is biased toward
negative interpretations
Everything is bad
Negative triad
Negative views of the self, the world,
and the future (schemas)
This forms a schema, and you interpret
everything through that lens
This negative triad can be a diathesis
for the things that lead to depression
Assumption that you have to be perfect,
can never make a mistake
·
Principle
Cognitive Biases
Arbitrary inference - absolutely no evidence, for
your conclusion – ex: random event and blaming yourself for it
Selective abstraction- hold on to one negative thing
Overgeneralization- fail at everything because you
failed one test..
Magnification and minimization-
magnify your
weaknesses and minimize your strengths
Helplessness/Hopelessness Theories
Learned Helplessness
Passivity and sense of being unable to act and control own
life
Revised theory is the concept of
attribution
Attribution – what is the
reason something happened (causations), we do this all the time – what
is the reason for the things that happen in these peoples live
Internal - External
Stable - Dynamic
Global - Specific
Hopelessness Theory
Advantage of theory is that it can
explain the comorbidity of depression and anxiety disorders
Helplessness – we learn to be helpless,
by not having control over our environment, no control over the
consequences of my behaviour
Dog experiment ( escapable shock,
inescapable shock, no shock – then in the test condition could jump out,
the group that learned they couldn’t escape the shock didn’t even try)
Internal- it’s me
External – its something else
Stable – its never going to change
Dynamic- its changing
Global – its everything
Specific- its just this
Recipe for depression is an attributional
style of internal, stable, global for negative things
When good things happen: something
wonderful has happened, its external , dynamic, specific
Hopelessness Theory – its not gonna get
better, I don’t see the future as ever changing, can explain the
comorbidity of anxiety and depression, anticipating not being able to do
something makes you anxious
Cognitive Perspective
A cognitive perspective on psychological
disorders
Changes due to how you perceive your cognitions
Cognitive Habits
Cognitive explanations emphasize
particular habits of thinking and ways of interpreting events.
Depressed people believe their situation
is permanent, and uncontrollable.
Rumination involves brooding about
negative aspects of one’s life.
Differences between men and women
Men more productive
Women want to talk
Vulnerability-Stress
Model
·
More
of a diathesis
·
Left
hand side + right hands side is a recipe for severe depression
·
Snapping
out of it not that easy- you cant always, maybe you were born with a gene that
predisposes you to this
·
Excercise
increases serotonin
Mood Disorders:
Theory and Therapy
The Cognitive Perspective:
Negative self-schema
Cognitive (reattribution) training
Changing your attributions, diary, keeping track of maladaptive
thinking , ema, writing down , watching yourself on video etc etc
Changing your schemas which could be very difficult
Other Theories of
Depression
Interpersonal Theory
of Depression
Sparse social networks that provide
little support
â an
individual’s ability to handle negative life events
á
vulnerability to depression
negative reactions
reassurance of others
Psychological Theories of Bipolar
Disorder
Largely neglected by scholars and
clinicians
Nobody around (sparse social
networks )
o
small
towns gives you feeling of support
cities – individual
maybe we are too focused on money/jobs
than family/support/friends
Decrease your ability to handle negative life events
Increase your vulnerability to depression
Needy people – feel like theyre draining us
Biological part treated by meds
Psychological treated with support, awareness, how to cope
Mood Disorders: The
Biological Perspective
Genetic Research
First-
degree relatives
Major depression (3X more likely if first degree relative )
Bipolar (10X – as likely)
Twin
Studies (Bipolar concordance: 85 (MZ) vs. 15% (DZ))
Adoption
Studies (biological > adoptive)
Biological Theories
Genetic Data
Bipolar
Concordance rates high as 85%
Adoption studies studies support a strong
heritable component
11th chromosome – may be linked to a
dominant gene on this chromosome
BDNF (Brain-derived neurotrophic factor )
gene also implicated
Sometimes when people have
these polymorphisms – something goes awry in the migration
MDD
Heritability estimate = 35%
Relatives of unipolar probands á risk
for unipolar depression
(5-HTTLPR) is being considered (short vs. long form)
Unipolar relatives at higher
risk for unipoler
5 HTT – certain individuals have short versions of this gene, if
you have at least one short version youre at risk, two versions, high risk
5HTT is a gene that is present in either a long or short form
17% of individals with the long form become depressed
43% of individuals with 2 copies of the short form become depressed
Genetics may also influence levels of serotonin and other neurotransmitters
Postulated that â levels of norepinephrine, serotonin and
dopamine lead to depression á
norepinephrine to mania.
Clues for drugs
Tricyclic drugs- drugs work on
all three, serotonin, norepinephrine and dopamine (called tricyclic
because three rings)
Monoamine oxidase - degrades
neurotransmitters
Selective serotonin reuptake inhibitors -
blocks the reuptake of serotonin inhibitor * DRAW PICTURE *
Drug actions suggest that depression and
mania are related to serotonin, norepinephrine, and dopamine.
BUT mechanism not straightforward : G-protein regulators
Biological Theories (cont.)
Drug actions suggest that depression and
mania are related to serotonin, norepinephrine, and dopamine
your levels of neurotransmitters will be altered within 48 hrs, but
at the postsynaptic neuron there may be less receptors which is the same
as having low serotonin neurotransmitters.
G protein regulators work on the receptors – both dopamine and
norepinephrine
BUT the biological mechanisms of the
disorders are not straightforward and perhaps not just related to
levels of neurotransmitters
Anti-depressants and mood stabilizer
(anti-manic) medications may work by changing the responsiveness of
receptors (which may be too insensitive in people with depression) and too
sensitive in people with mania) for these neurotransmitters
Neuroendocrine System
HPA axis may play a role in depression
Hormone Imbalance (cortisol)
- dexamethasone suppression test (DST)
thyroid dysfunction often seen in bipolar
patients
Pituitary gland **
HPA axis – hypothalamis, pituitary adrenal axis
Stress – cortisol pumping through body
More t cells and more cortisol indicates more stress
DST- dexamethasone is a drug that will suppress cortisol within 24
hrs, however people who have a problem with hpa axis, over secreting
cortisol and even with the dexamethasone it does not decrease, it wont
wont have an effect, indicating an adrenal depression
Thyroid hormones can induce mania
Beck’s Developmental Model of Depression
·
******
IMPORTANT *********
·
Diathesis
is the 5HTT gene
·
So
the amygdala is going to be hyperactive – threat perception is high , may be
due to have two short forms or the long form of the 5HTT
·
So
activates the cognitive biases ( ex: overgeneralization)
·
Thinking
the worst through this area , the amygdala has many connections to the frontal
lobe, but less to the amygdala (thinking with your emotions) – cant use logic
·
Deficients,
negative cognitions,depressive symptoms
Summary of Biological
Theories
Treatment: The Biological Perspective
Antimanic Medication:
Lithium
Carbonate (natural mineral salt)
highly effective but fatal
when taken in high doses, it has to be taken regularly, must be
regulated by doctor, reduces the symptoms of cycling back and forth
Electroconvulsive therapy
(ECT)
Unilateral vs.
Bilateral ECT (one hemisphere vs two)
Frontal vs.
Temporal (lobe)
Therapies for Mood
Disorders
·
*category,
generic name and how each one works *
·
MAO
inhibitors – inhibit the enzyme reuptake of neurotransmitters
·
SSRSIs
– selectively inhibit the reuptake of serotonin ( picture of this )
Chapter 11 – Schizophrenia
Schizophrenia : Main Points
·
Schizophrenia
o
Symptoms
o
Subtypes
o Dimensions-
includes the severity of the hallucinations etc
o Each of
these symtpoms ranked on 5 point scale
What is
Schizophrenia?
·
from Schiz (divide) and phren (mind)
·
A diagnostic label for psychoses marked by severe
distortion of thought/language, perception, mood, and
bizarre behavior
·
Affects
your thought and language, disordered, nonsense, no one can makes sense of what
youre saying, thoughts are bizarre, hallucinations, catotonia
·
DSM
requires 2 or more each present for at least one month with continuous signs
for at least 6 months
Diagnosing
Schizophrenia
·
No essential symptom must be present for a diagnosis
of schizophrenia.
·
People with schizophrenia can differ from each other
more than do people with other disorders.
·
There is heterogeneity at the empirical and
conceptual levels.
·
People
with schizophrenia are so different – more than any other disorder
·
No
one fits neatly into one category
·
Positive
and negative symptoms
·
Positive
– adding things that shouldn’t be there ( hallucinations )
·
Negative-
nothing where it should be (no emotion )
Symptoms of
Schizophrenia: Disorders of Thought
·
Delusions: beliefs that
have no basis in reality
·
Resilient to contradiction (Contradict in the
face of evidence)
Schizophrenia: 7 Patterns of
Delusions
·
Persecution
o
most
common in paranoid schizophrenia (
paranoid schizophrenia can be treated with medication, reactive, life
trigger)
o
- believes that someone is tracking them,
spying , something like a CIA chip in their brain
o
Very
elaborate schemes against them, plots against them at a high level
·
Reference
o things
refer to you ( things you hear on radio and see on tv are directed to you )
ideas of reference
·
Grandeur
o
dilusions
that you are someone who you are not ex: jesus or a high ceo
·
Sin & Guilt
o
think
you’ve committed the ultimate shame and crime when none exists
·
Hypochondriacal
o
believe
they have an illness like cancer or a tumor or an ulcer something that is
rooted in reality but unfounded in reality, when it has no basis in reality it
means like mold in the brain or something that cant happen *check this,…*
·
Nihilistic Delusions
o
maybe
nothing is real we are all spirits
·
Control (influence)
o
people
trying to control you or influence you
Symptoms of
Schizophrenia: Delusions of Control
·
Delusions of control may involve:
·
Thought broadcasting
o
Thoughts
are broadcasted to the world they can see or hear my thoughts
·
Thought insertion
o
An
external source is putting thoughts into my head
·
Thought withdrawal (may be STM problems)
o
something
is taking away my thoughts
Symptoms of
Schizophrenia: Disorders of Language
·
Loosening of Associations
·
(loose verbal/semantic associations):
·
Ideas jump from one to another, with the result that
the person wanders further and further away from the topic
·
in
non paranoid schizophrenia ( worse kind )
·
Ideas
jump from one to another – branch out further and further with no coherency
·
Poor
attention to track what was said before
·
Poverty of Content:
o
Poor communication despite correct grammar and
adequate vocabulary
o
speaking
a lot but not really saying anything
·
Neologisms:
o
The use of new words and phrases, often formed by
combining parts of two or more regular words that have little if any
translation
o
making
up new words because you cant retrieve the word you were looking for, new words
used to conform the same meaning
·
Lack
of communication = negative symptoms
·
Clanging (clang association):
·
The pairing of words that have no relation to one
another beyond the fact that they rhyme or sound alike (word
pairs, speech is inchorent because word use based on rhyme that’s all )
·
Word Salad:
·
Words and phrases are combined in what appears to be
a completely disorganized fashion (mishmash)
·
Symptoms of Schizophrenia: Disorders of Perception
·
Hallucinations:Perceptions that
occur in the absence of any appropriate external stimuli
·
Auditory
o
–
usually auditory (visual rare except when taking medication )
o
These
are in the absence in external stimuli,
o
Sometimes
mistake internal info for external voices
·
Badly’s
loop *
·
Visual
Symptoms of
Schizophrenia: Disorders of Mood
·
Blunted Affect: Patient shows
little emotion
·
Flat Affect: Patient shows no
emotion
·
Inappropriate Affect: The
expression of emotions unsuitable to the situation
The Course of Schizophrenia
·
The Prodromal Phase:
o
The gradual deterioration of functioning before any
clearly psychotic symptoms appear
o
Can happen overnight or over longer period of time
o
Withdraw into yourself
·
The Active Phase:
o
Patient begins showing prominent psychotic symptoms
o
Prominent- distortions of perception
·
The Residual Phase:
o
Gradual recovery
o
Most of the time its not back to normal functioning
o
Might go back to prodromal phase
o
Some may go back right to the active phase
o
Its not really go back to …normal…
·
Rare full remission (30% roughly)
·
Typically paranoid is most responsive to treatment
·
Behavior is similar to that of the prodromal phase
The Subtypes of
Schizophrenia
Disorganized Schizophrenia:
·
Pronounced incoherence of speech- word salad,
poverty of content, loosening of associations, clanging etc.
·
Sometimes these people don’t respond to neuroleptic
drugs
·
So much heterogeneity some drugs work and some don’t
·
Because of its earlier onset, pathology of the brain
this may have been there their whole life
·
Mood disturbance
·
Showing
little emotion or no emotion or the wrong emotion, inappropriate
·
Disorganized behavior, lack of goal orientation
·
May show disheveled lack of hygiene, lack of
motivation, no goal setting
Catatonic
Schizophrenia:
·
Marked disturbance in motor behavior
·
Catatonic stupor
·
complete immobility, usually accompanied by mutism
·
can be complete immobility
·
stay in one position for hours
·
waxy behaviours
Paranoid Schizophrenia:
·
Delusions and/or hallucinations of a relatively
consistent nature, often related to the themes of persecution and grandeur
·
Coherent hallucinations
·
Organized plot , everything is strategic
·
Organized
Dimensions of
Schizophrenia
·
Positive - Negative Symptoms
Positive Symptoms:
·
The presence of something that is normally absent
(hallucinations, delusions)
Negative Symptoms:
·
The absence of something that is normally present
(flat affect, poverty of speech, social withdrawal, attentional impairment)
·
Paranoid
schizophrenics have positive symptoms
·
Non
paranoid – have lots of negative symptoms
·
Behavioural deficits
·
Avolition -Lack of energy, motivational issues
·
Alogia- Poverty of speech, amount of speech, poverty
of content of speech etc.
·
Anhedonia- Lack of interest in recreational
activities, relationships with others and sex
·
Flat affect ( outward emotional expression- it
doesn’t mean you aren’t feeling an emotion, but it physically looks like you
aren’t)
·
Asociality
·
Few friends, poor social skills, and little interest
in being with others
Dimensions of Schizophrenia
·
Process-reactive Dimension
·
Variation in onset of schizophrenia
·
Andogenous because it may have been there for your
whole life
·
In particular due to
·
The frontal cortex is for : planning, attention,
concentration, motivation (all of the thing people with negative symptoms have
a problem with)
·
Processual thing- brain problm
·
May not occur until later with an enviro event ( reactive)
·
Good-poor Premorbid Dimension
·
How well the patient was functioning before the
onset of the active phase
·
How were you doing before the onset?
·
In process there probably wasn’t a premodal phase
·
Process-Poor, Reactive- Good
·
Paranoid - Nonparanoid
·
The criterion of classification is the presence
(paranoid) or absence (nonparanoid) of delusions of persecution and/or grandeur
·
Process – Poor – non- Paranoid
·
Reactive- Good – paranoid
·
Type I
·
Reactive
·
Good Pre-morbid
·
Positive
·
Paranoid
·
Type II
·
Process (endogenous)
·
Bad Pre-morbid
·
Negative
·
Non-Paranoid
o
Hallucinations but all over the place
o
Incoherent
Schizophrenia: Neurological Theory and Therapy
·
Neurological
disorder – this is psychotic
·
Genetic studies:
·
Family studies (relatives)
o
Risk increases if you have a family member that has
schizophrenia
o
Postulated that there are 40 genes that are related
to it
·
Twin studies (concordance rates)
o
The chance that one twin has it if the other twin
has it is roughly 78% (MZ)
o
17% (DZ)
o
Keep in mind enviro factors are more similar for MZ
too (placenta sharing, socio reasons etc.)
·
Adoption studies (nature vs. nurture)
o
Bio parent vs adoptive parent
Family Studies
Etiology of
Schizphrenia
·
Concordance for identical twins ( 44.30%) although
greater than that for fraternal twins (12.08%), is less than 100%
·
Common deviant could be environmental ( eg MZ more likely to have shared blood
supply)
·
Consistent with a genetic interpretation of these
data, concordance among MZ twins does increase when the proband is more
severely ill
·
Even if they don’t have schizophrenia- the other
twin may have scizo-type personality disorder
·
When the proband is severly affected the other twin
may have something else wrong
Schizophrenia: Theory
and Therapy
·
The Neurological Perspective:
·
Brain imaging studies
o
Enlarged ventricles
§ Non
paranoid
§ Brain
pathology
§ The
ventricles aren’t actually larger
§ They
appear larger because of the decrease in neural tissue in the brain
o
Deterioration
of cortical brain tissue
§ Parts of frontal lobe ( languge,
motivation, attention ) and temporal lobe ( Primary auditory cortex)
§ BDNF Gene- if migration doesn’t
occur properly, synaptic connections aren’t strengthened
§ Occurs in type 2, cant fix this with
a drug
·
Prenatal brain injury (2nd trimester)
o
This is when the brain has pretty much formed
o
Twins who are discorded may show differences in
their fingerprints
o
One thing that nature has differentiated
o
Twins who are discorded for schizophrenia, their
fingerprints are even more different than normal
o
Fingerprints are created at this time ( 2nd
trimester)
o
Gliosis is a brain repair process – happens when
there is an insult or trauma to the brain
o
Only occurs when the damage happens after the second
trimester
o
Twins that are discordant for schizophrenia, there
is no gliosis in the affected twin
o
Must have happened prior to the 3rd
trimester
·
Biochemical Research: *******
important for midterm ****
·
The Dopamine Hypothesis:
·
schizophrenia is associated with excess activity in
the parts of the brain that use dopamine as a neurotransmitter (mesolimbic
pathway)
·
have to lower the levels below what would be normal
·
when you give the person an antipsychotic drug, you
have to use enough to drop the dopamine below what is normal
o
if you give them enough of these drugs, they can
develop parkinsons disease/symptoms
·
PD symptoms support hypothesis
·
Other clues provided by amphetamine psychosis ( you
would be diagnosed with schizophrenia but its due to taking too many
amphetamines- eventually your brain will stop producing dopamine ) – this can
become permanent –even once clean
·
Amphetamines…make the negative symptoms better tho
·
Problems with hypothesis (drugs & - symptoms)
·
Other neurotransmitters
o
Sometimes too many dopamine receptors
o
If one neurotransmitter is affected, others are
affected
·
Frontal
lobe gives rise to negative symptoms
·
Dopamine
neurons may be underactive
·
Amphetamine
can increase the activity of these dopamine neurons
·
If
you have positive symptoms tho, you have too much dopamine in the mesolimbic
area, taking an amphetamine is going to increase the activity and cause you to
hallucinates
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