PSY 240S

Aaron Clarke

16/01/01

Jan 30, 4-6pm is new office hours for Michelle Keightley. Her e-mail address should be spelt in lower case letters.

Clinical Assessment and diagnosis

Diagnosis:

Classification of psychological Disorder

Diagnostic and Statistical Manual (DSM)

Semi-structured Clinical Interviews (SCIC)

Clinical Assessment:

Aspects of assessment

Clinical Interview

Behavioural Assessment

Neuropsychological and Neuroimaging

Psychological testing

Aspects of assessment

Psychologists have become known for their assessments. Assessment is the gathering of information about a person, and trying to identify the causal factors in the person’s diagnosis. This includes information about the persons current symptoms, are there any current major life events that have occurred in this persons life. Do they have physical conditions, drug and alcohol abuse, personal family disorders. How is their cognitive functioning? Collecting information across these areas helps psychologists to make the diagnosis. Assessment helps us to know what forms of treatment to offer.

Concepts that determine the value of clinical assessments

Value of assessment depends on:

Reliability - the degree to which a measurement is consistent (between psychologists or psychiatrists). Reliability can be broken down into three categories.

1. Test-Retest Reliability – Similar results with same patient at two points in time.

2. Internal Reliability – Different parts of a test produce similar results.

3. Inter-rater Reliability – Two or more raters come to similar conclusions about patients diagnosis.

Validity – the degree to which a technique measures what it is designed to measure.

Validity can be divided into the following categories:

1. Face Validity – Appears to measure what it should measure.

2. Content Validity – Assesses all-important aspects of phenomenon (even though it might not test all aspects of the phenomenon).

3. Concurrent Validity – Test yields the same results as other similar measures (e.g. two different I.Q. tests should yield similar results with the same individual).

4. Predictive Validity – Test predicts behavior it is supposed to measure.

5. Construct Validity – Test measures what it is supposed to measure.

Standardization – Application of certain standards to ensure consistency across different measurements. E.g. the test should always be administered in exactly the same way.

Clinical Assessments

The first thing that is often done in a clinical assessment is a clinical interview. This interview examines what the person’s current behaviours are, what they are doing in their daily life, what are their attitudes about others and themselves, what sort of problems are they describing about themselves and their lives outside of the interview. A framework that guides the interview is called the mental status exam.

Mental Status Exam

1. What is the person’s appearance and behaviour – clothing, well-groomed, have they bathed in the last 6 days, how is their posture, what is their behaviour like (tense, upset?), how slow is their speech (in depression it’s slow).

2. Thought Processes – What are their thought processes like, what is the nature of their thinking. What is the style of their speaking, what is their flow of speech like, is there continuity of thoughts. Do they speak rapidly (mania?) or normally. What is the content of their speech?

3. Mood and Affect – Mood is the person’s predominant feeling state from day to day. Affect refers to the feeling state at a given time. Interviewer looks at the appropriateness of the person’s affect (inappropriate would be a sad story with a laughing storyteller). Another type of affect the interviewer examines for is blunted affect, where the person is completely flat in their emotional state, and they just sit there.

4. Intellectual Functioning – A person’s vocabulary is currently our best measure of a person’s intelligence. Do they speak in abstractions and metaphors, or in terms of physical descriptions? What are their memories like?

5. Sensorium – Does the subject have an awareness of their surroundings (date, time, and location)? If they know their date time and surroundings, they are “sensorium 3.”

Mental status exam is a general assessment that allows the assessor to tell where the patient is in their mental health, and allows the assessor to form hypotheses about the person’s pathologies.

Behavioural Assessment

The ABC’s of observation

Involves someone’s thinking behaving and behaviours in specific situations and contexts.

Observational assessment focuses on:

1. Antecedents – what factors or triggers were there when the problem started. Where and when does the problem occur, with who does the problem occur, and when does the problem not occur. Many children only have behavioural problems either at home or at school.

2. Behaviour – what does the person do in that context. You could go to the person’s home and see them in a debate in their living room, and see what they do (withdraw or lash out at each other?).

3. Consequences – how are the subjects being rewarded or punished for their behaviours. What are the emotional consequences, how do they end up feeling. What are the life consequences of the person’s behaviour?

Involves identifying specific behaviours for observation. Clinition or subject may monitor the behaviour.

Psychological Assessment

This is what the majority of psychologists do. Psychologists are particularly good at interpreting and administering psychological tests. They are used to determine cognitive, emotional or behavioural responses that might be associated with specific disorders. There are two general classes of tests, personality tests, and neuropsychological tests.

Projective tests – Personality tests started with projective tests. These tests started with psychoanalytic theory, and are based partially on the idea that people are not always aware of their feelings. In these tests, ambiguous things are presented to the subject, and the people are asked to describe what they see. In these tests, people project their thoughts and feelings onto other things, and do so without realizing it.

-Rorschach inkblot test. This test was invented by Hermon Rorschach 80 years ago to study basic perception, and was later used to study psychological disorders. The problems with this test are the following. It has limited reliability and validity. Two clinicians are unlikely to agree upon and come to the same conclusions with an inkblot test on the same patient. The test does not distinguish between two diagnostic groups. There are also standardization problems with this test. The Exner comprehensive system has helped to standardize the test, but there are still some problems. The Exner system guides what questions the clinition is allowed to ask.

-Thematic Apperception Test (TAT). This test is similar to the Rorschach test. Morgan and Murray at Harvard developed it in the 1950s. It shows the patient 20 cards with people in different contexts. “I want you to tell a dramatic story about the picture, I want your imagination to have it’s way and tell a tale as in a myth or allegory.” The TAT has low reliability, questionable validity, and standardization problems.

These tests lack ability to predict psychopathology.

Personality Inventories

As early as the 1930s it was already common for patients to have clinical interviews and receive psychological tests. It was hoped that paper and pencil tests would eventually help us to better standardize personality tests.

MMPI-1 was published in 1943. This test was said to come from the empirical tradition. There were 567 questions that were included in the test, which were imperically found to distinguish between different groups. There is no theory behind the MMPI as there were in the behavioural tests. The are some interesting questions in the MMPI that appear to have no face validity but do distinguish between groups. There 10 main categories:

1. Hyperchondrialysis

2. Depression

3. Hysteria

4. Psychopathy

5. Masculinity - Femininity

6. Paranoia

7. Pryasthenia

8. Schizophrenia

9. Myohypathemia

10. Social Inversion

This test helps to distinguish between people who are faking and who really have disorders. People cannot fake and get passed the testers. The examiner looks at the subject’s personality configuration, which tells the experimenter what to expect about the subject’s personality. The original MMPI was criticized for its sexist wording, its cultural insensitivity and its poor sample selection for its initial standardization. As a result, the MMPI-2 was made in the 1980s, as a revision to the original MMPI. The test had modernized language, and it has excellent reliability and validity.

Neuropsychological Tests (continued)

Has become a very active development in psychological testing. Assess:

-Receptive and Expressive Language

-Attention

-Concentration

-Memory

-Motor Skills

-Perceptual Abilities

-Learning and Abstraction

There are 3 main neuropsychological batteries.

1. Bender visual-motor gestalt test.

2. Luria-Nebraska neuropsychological Battery.

3. Halstead-Reitan Neuropsychological Battery.

These tests are administered as a general way to try to find and identify brain damage. The Halstead-Reitan is about 80-95% accurate in their ability to identify brain damage. These tests are used as a screening device. There are, however, false positives with these tests, in addition to missed cases of people who actually have brain damage. These tests are now used in conjunction with brain imaging tests if there are indications of brain damage. These imaging tests include CT scans, MRI scans, and PET scans. Computerized tomography is an enhancement of x-rays, where a narrow x-ray beam is passed through a person’s head, and the amount of radiation absorbed is measured. The image can get different slices of the brain, and can show the brain in three different dimensions. With a CT scan you try to identify brain injury or tumors, it allows you to assess for structural abnormalities. It does, however, expose the person to high levels of radiation.

The PET scan looks at the activity of the brain. In this scan, a harmless radioactive isotope is passed into the brain, and a substance passed into the brain tells us which areas of the brain are the most active. A PET machine costs about $6 million dollars, and costs $500 000 over the year to maintain, so only big hospitals have it.

MRI involves no radiation, and provides finely detailed pictures of the brain at any angle. It can examine structure and process simultaneously.

Diagnosis

There are 2 different core strategies in arriving at a diagnosis. The first is an ideographic strategy. This strategy tries to find what is unique about this person’s personality, cultural background, and circumstances. The most common test for this strategy is a behavioural test. An alternative strategy is the nomothetic strategy. In this strategy information is collected to find a general class of problems to which the presenting problem belongs (e.g. the MMPI). The official system in Canada in the US is the DSM (diagnostic and statistical manual). The DSM classiffies a persons emotional and cognitive problems. It has all the criterial to classify all psychological disorders. The DSM tries to classify disorders according to the prototypical approach. It identifies certain essential essential characteristics of a disorder that have to be met for a diagnosis. It also allows for certain non-essential variations. For instance, in the classification of depression, 5 symptoms have to be present, but there are 9 symptoms that may be present all together. The DSM has emerged from a psychiatric association. The DSM – I was first published in 1952, and outlined all psychiatric disorders available at the time, and was accepted by psychologists and psychiatrists. It was originally very psychoanalytic and was couched in psychoanalytic terminology. In 1968, the DSM – II was published. It included different disorders, but was essentially the same as the DSM – I. The descriptions were too abstract and full of psychoanalytic terms. The DSM – I and II had low construct validity and low reliability. 154 clinitions agreed on the diagnosis only 54% of the time. The DSM – III was published in 1980 with broad sweeping changes. All of the psychoanalytic stuff was dropped, and the focus was brought to description of the presence or absence of symptoms rather than the presence or absence of certain unconscious problems. The content validity of the DSM was increased as well. There was now a description of the essential features for the disorder, and a description of the potential accompanying features. There was also a description of the onset, course, prevalence and sex ration of the disorders. There was also clear algorithms about how to differentiate between different disorders. For example, in the DSM – II, phobias were said to occur if the person was under psychic defense mechanisms. Now, the DSM – III gives a detailed account of the person’s fears and behavioural manifestations if they have a phobia. Also introduced with the DSM – III, was that it directed the clinition to consider a wide range of dimensions in forming their assessment. This is referred to as a “multiaxial assessment.”

Multiaxial Assessment

-Axis 1 – Clinical disorders (all disorders except for personality disorders and mental retardation). The clinition notes whether the disorders are chronic or acute. The disorders are usually episodic.

-Axis 2 – Personality disorders. Makes sure that the clinition takes into account the long term factors of the person’s difficulties. The person’s difficulties are usually life long.

* Axes 3-5 are not required to make a clinical diagnosis, but give the clinition useful things to consider along with their diagnosis.

-Axis 3 – General Medical Conditions (e.g. brain tumors may look like a psychological disorder, but are actually a medical condition). A person who has lung cancer may require a different coping strategy.

-Axis 4 – Psychosocial and Environmental Problems. Aimed at determining psychosocial and environmental problems that may be contributing to the disorder. For example, the lack of a supportive family may make it difficult for a depressed person to stop feeling depressed. This axis assures that we are considering psychological factors when making a diagnosis.

-Axis 5 – Global Assessment of Functioning. The clinition rates where their patient fits within the categories of psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. Does not include impairment in functioning due to physical or environmental limitations.

Problems with the DSM: Some of the reliability of some of the disorders are low, and this is problematic for Axis 2 personality disorders (personality disorders). This axis is a mess, and may be scrapped in the next DSM. There is also a problem in constructing categories for the different disorders. The diagnoses were decided by a committee, and are somewhat arbitrary. For example, to have a panic disorder, you have to have had 4 panic attacks in 4 weeks. We don’t know weather or not these cut-offs are the best cut offs. The current DSM – IV was introduced in 1994. The DSM – IV TR (“text revision”) came out a couple of months ago, without any changes in the actual diagnostic categories but with some better descriptions. There is increasing standardization between psychiatrists and psychologists in the diagnoses that they are making.

Structured clinical interviews called “structured clinical interview for clinical disorders” (SCID) have been developed from the DSM which ask the patient questions that would probe every possible disorder. If the person is not experiencing significant stress or impairment with the person’s life, a diagnosis is not made.

In research now, a paper will not be accepted without a SCID.

Often disorders are co-morbid. This can be a problem for which disorder to start with.

There are still the possibilities of cultural and gender biases in the diagnostic system. In the 1960’s Thomas Szazd postulated that the psychiatric community was manufacturing diagnoses and disorders for their own profligation.

Aaron Clarke

23/01/01

Components of a Research Study

a. Hypotheses

b. Independent and Dependent Variables

c. Internal and External Validity

Research Methods

a. The Case Study

b. Epidemiological Research

c. The Correlational Method

d. The Experiment

Repeated Measurements

Withdrawal Designs

Multiple Baselines

e. Studying Behaviour Over Time

Cross-sectional Designs

Longitudinal Designs

Problems Associated with Researching Abnormal Psychology

· Thoughts and feelings are hard to measure. Researchers often have to rely on self – reports. For some people this is very hard because they man not be aware of their internal states, and they man not be very good at reporting their thoughts and feelings.

· People change. What does it mean when people are depressed today, and normal tomorrow?

· Abnormality has multiple causes. We often need research that looks at the interaction of different causes (biology, psychology, etc.). The politics of group research often pulls researchers apart.

· Hard to manipulate variables. If you wanted to know if stress caused depression, it would be difficult to control the variables that cause depression in order to study it.

If we really trust the science that underlies the disorders we can feel more confident in treating and approaching them.

Aspects of Research

Hypothesis: An educated guess or statement to be supported by data. The scientific approach requires that ideas be defined in a specific way. The clearer the statement, the more open it is to scientific testing.

Null Hypothesis: The alternative to the stated hypothesis.

Statistical Significance: The likelihood that the results of an investigation are not the due to chance. The cut off point for statistical significance is a p of less than 0.05, which means that 95 times out of 100 the obtained results would occur and only 5% of the time would the obtained results occur as a result of chance.

Reliability: Is the result reproducible under the exact circumstances under which the original study was conducted.

Dependent Variable: Some aspect of the phenomenon that is measured and is expected to be changed or influenced by the independent variable. The variable that were trying to see if the independent variable influences.

Independent Variable: The aspect that is manipulated or that is thought to influence the change in the dependent variable. The thing that we are measuring to see if it has an effect on the dependent variable.

Internal Validity: The extent to which the results of the study can be attributed to the independent variable.

Confound: The variable that gets in the way of interpreting your results.

External Validity: The extent to which the results of the study can be generalized or applied outside the immediate study. How well the results of the experiment can be applied to the rest of the population.

Methods to Ensure Internal Validity:

· Use control groups – the two groups are the same in every way, except that the control group does not get exposed to the independent variable.

· Randomization – the process of assigning people to different research groups. Each person has an equal probability of ending up in the control group or the experimental group. This helps to eliminate systematic bias in both groups.

· Analog models – Where we try and create the controlled conditions of the laboratory so that they are very comparable to the phenomenon under study. It tries to reproduce the outside world and bring it into the lab and make it as real as possible. For example, you can do a mood induction experiment, where the person listens to sad music, and records their thoughts and emotional states before and after listening to the music. This model is a contentious one because a lot of psychological research is conducted on undergraduate psychology students, who are not representative of the general population.

Research Methods

The Case Study

This is the most familiar method in psychology. Here, one person at a time is studies, and detailed information is collected on the individual. The clinition collects historical and biographical information on the individual. What is that person family history. What is that person’s medical history. What is their education level. What employment have they had (what sort of jobs have they held or not held). Are they married or single or divorced. What is their developmental history, how have they adjusted to stressors over time. You would want to say something about their personality, and what kind of treatment they had before they had this treatment.

Case studies provide a detailed description of rare or unusual phenomenon. In 1954, Eve White was described, who had three different personalities. A case study was done with her. In the 1970s, however, it was found that Eve continued to worsen over time and fragment into 21 different personalities.

Case studies provide novel methods of diagnosis and treatment. For instance, the focus on Anna O in the literature led to the technique of free association, which was the beginning of psychoanalysis. Aaron Beck, as early as 1952 described cognitive therapy, and it is only now that his treatments are being looked at and used.

Case studies can be used to disconfirm aspects of a theory. You can show how a person fails to fit into the framework of a prevalent theory.

Case studies allow us to generate hypotheses for testing. Kanner, in his work with children failing to develop language, wrote case studies that led other researchers to submit similar reports and lead to the identification of autism.

Case studies are not generalizable, because they don’t use the scientific method (has low internal validity because they don’t have independent variables).

Epidemiological Research

Epidemiology is the study of the frequency and distribution of a disorder in the population. It may tell us about the rates of the disorder are, as well as the factors that are associated with the disorder. It also helps us get a better picture of the disorder in the general population. It can help us know if the disorders are more common in men or women, or whether or not the disorders are specific to social or cultural factors. It can tell us what might be the expectancy for a given disorder, and when to diagnose it.

Prevalence is the rate of the disorder in the population at large, and is given by epidemiology.

Incidence the number of cases of the disorder at a given time.

Epidemiology also tells us what the risk factors are for a given disorder.

The advantages of doing an epidemiological study are that they tell us the rates of disorders, and they help to identify the potential causes of disorders/illnesses. John Snow discovered that cholera was transmitted from contaminated water through an epidemiological study in London, England. Also, it has been found that people who are economically disadvantaged are more likely to suffer from schizophrenia than are those who are economically well off. This provides correlational information, but does not provide information about causality.

**A good exam question would be: Which of these two variables is the independent and which is the independent variable in the following experiment?**

Correlational Method

· Are variable X and Y associated in some way so that they vary together? This approach differs from an experimental approach because the variables are studies as they occur in nature. In this method you are not talking about manipulations controlled by the researcher.

· Steps:

Collect pairs of observations. (E.g. height and weight).

Compute the correlation coefficient

r=-1.00 to 1.00

This tells us the strength and direction of the association.

Determine statistical significance (p<0.05)

· In a perfectly correlated relationship the plot of the levels of the variables falls in a straight line. In a 0 correlation relationship, the points on the plot are scattered.

· Correlation does not imply causation.

· Causation does imply correlation.

Research By Experiment

The experiment is considered the most powerful tool for determining the causal relations between events. In an experiment there is some manipulation of an independent variable, and there is clear measurement of a dependent variable and there should be random assignment of subjects to the manipulation being studied.

Single Case Experimental Design

Experiments don’t have to be done using groups of people. In this type of study, subjects are studied one at a time, and are exposed to the independent variable. The problem with this type of study is that there is no control group. Only one measurement is made before the subject’s exposure to the independent variable, and only one measurement is made after the subject’s exposure to the independent variable.

Repeated Measures Design

In this type of experiment, behaviour is measured several times, instead of once before you changed the independent variable. Here you measure the person’s functioning on a number of periods in time, and then you expose them to the independent variable and measure them again on their functioning. This is a pre-study post-study measurement experimental design. This kind of experiment allow us to talk about the degree of change associated with the introduction of the independent variable, and it allows us to talk about the direction of change with the introduction of the independent variable.

Withdrawal or Reversal Experimental Design

Measures the subject’s basal level of performance, exposes them to a treatment and measures the subject’s level of performance during treatment, and then removes the subject from treatment and measures the subject’s performance in the absence of treatment, and then does a final measurement of the subject’s performance in the presence of the treatment. If the subject’s performance is different only when they are under treatment, then you can have a powerful demonstration of treatment effects. This design can pose ethical problems for researchers if they are researching behaviours like suicidal tendencies, where the person may kill himself or herself if they are removed from treatment. Also called the A B A B design.

Treatment Treatment

Multiple Baseline Experimental Design

This is where the experimenter exposes different subjects to the intervention at different points in the progress of the subject’s disorder. Here there is no removal of the subjects from treatment. This is better than the A B A B design, because if the subject is suicidal, they will stay in treatment.

Studying Behavior Over Time

1. Cross-sectional Design: Where the researcher takes a cross-section of the population across different age groups and compares them on some characteristic. The problem with this kind of design is that it doesn’t tell us how the problem developed in the first place.

2. Longitudinal Design: where you identify one group of people and follow them across time and assess different variables. E.g. the 7 up 32 up study on following peoples lives. There are dropouts in the study, and people die while in the study too.

Aaron Clarke

30/01/01

The exam next week is 2 hours. It is a knowledge based test. Try to have a ball park idea about the names associated with studies. The test will be aimed at a conceptual understanding. There will be 60 multiple choice questions.

Mood Disorders

In depression, one is sad all of the time. In clinical depression, the level of sadness takes over the person’s life. It takes over the whole person, taking over their emotional states, and it affects their body and their behaviours an thoughts. Clinical depression is characterized by severe sadness from day to day, a loss of interest in day to day things. When things are engaged in there isn’t really much pleasure in them. Behaviorally, there is withdrawal from others. The person’s sense of themselves are deeply affected, there is a sense of worthlessness, and a sense of what they didn’t do that they should have done in the past. Sleep and appetite are often affected. For many people ther is a loss of interest in sex. In general, depression is a huge societal problem costing 40 million dollars annually in treatment and lost labor. Fortunatley, we have great teatments for depression and mania now. Depression includes poor concentration. Even keeping up a conversation may be difficult for the depressed person. There is slowing of speech, and a sense of agitation (even great agitation). If the person is really agitated, they are said to have agitated depression. The person’s cognitive style is characterized by self reriminations. The person focuses on their weaknesses, and finds fault with the decisions they have made in their life. For the depressed person, there is no point in even getting out of bed. In children, depression is reflected as withdrawal, and somatization (headeaches, stomach aches, and soreness).

Mania is the opposite of depression. The person has great feelings of euphoria, hyperengagement with other people, rapid speech. A manic state is characterized y loud remarks, incessant joking with puns and rhyming, high distractability (sentence ends on a different topic than what it started on) the person is annoyingly social, when they are interrupted the person often responds with great rage. These symptoms often onset very abruptly (within a day or two).

The DSM-IV defines criterion for major depression (unipolar depression) and bipolar disorder.

Criteria for major depressive episode (the first two must be present, plus any 3 other symptoms in order for a diagnosis to be made):

· Depressed mood most of the day.

· Diminished interest or pleasure in almost all activities.

· Significant weight loss or weight gain (defined by a 5% change). Depending on the person, there can be great weight loss or gain.

· Insomnia or hypersomnia. Depressed people often wake up early in the morning and can’t get back to sleep. (In contrast, in anxiety insomnia, the person can’t get to sleep).

· Psychomotor agitation or retardation nearly every day.

· Fatigue or loss of energy nearly every day. The person tires easily.

· Feelings of worthlessness or inappropriate guilt.

· Recurrent thoughts of death. (Suicidal thoughts). The person might have a specific plan for how they will kill themselves. As a therapist, one listens for the presence of a plan, and the means to execute the plan.

Major Depressive Disorder

· Is the most common disorder (prevalence is 19%).

· Twice as common in women as in men (this finding is replicated across cultures).

· Recurrent nature: 80% will have another episode within the year.

· Chronic condition >2 years in15% of patients.

· Median lifetime number of episodes = 4 for those who have an episode. The average duration for those episodes is 5 months.

Clinical Descriptors of Major Depressive Disorder:

Look at whether or not it is a single episode or a recurrent episode.

Establish the absence of mania and hypermania.

The depressive episodes are said to be recurrent if the person has had two different episodes separated by at least 2 months.

Most people get labled major depressive disorder – recurrent.

Diagnostic criteria for 300.4 Dysthymic Disorder

A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

1. poor appetite or overeating

2. insomnia or hypersomnia

3. low energy or fatigue

4. low self-esteem

5. poor concentration of difficulty making decisions

6. feelings of hopelessness

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.

D. No Major Depressive episodes.

In Double Depression someone is initially dysthymic, and then goes on to develop a full blown depressive episode. In double depression, dysthymia usually comes first, and then the depression comes.

If dysthymia is not treated it is known to lead to another depressive episode.

The average onset for a depressive episode is 25. Among people who seek treatment for depression, the average onset is 29. There is an increasingly early onset of age of first depressive episode across all countries. A one-month incident study showed that those who are 15-24 have the highest rates of depression. The lowest rates of depression are in those who are between 45 and 54.

Klien in 1988 found that if dysthymia onsets before the age of 21 it’s associated with greater chronicity, a comparatively poorer prognosis, it’s associated more with family transmission, and it tends to be associated with the presence of personality disorders.

Kovacks in 1984 found that if dysthymia was present in childhood, 76% of the sample went on to develop major depression in adulthood.

There are also cultural differences in the age of onset of depression. Hispanics have the highest rates of depression regardless of age group. For whites, rates of depression are highest when they are younger, and rates of depression are hither in the African Americans when they are older.

Bipolar Disorder:

Involves the alternating of manic episodes with depressive episodes. Many patients talk about as tantamount to an emotional rollercoaster ride. There are two types of bipolar disorder, the first of which is called Bipolar 1.

Bipolar 1: Involves episodes of mania or mixed episodes that include symptoms of both mania and depression.

Manic Episode:

Presence of elevated or irritable mood, plus three additional syptoms. The symptoms must be severe enough to impair social and occupational functioning.

· Abnormally and persistently elevated, expansive or irritable mood.

· Grandiosity.

· Decreased need for sleep.

· Talkativeness.

· Flight of ideas or racing thoughts.

· High distractibility

· Psychomotor agitation

· Buying sprees, sexual indiscretions, and foolish investments.

Bipolar disorder occurs less often than major depression, and its prelalence is only 1%. The average for onset is in the 20s. It occurs equally in men and women. It also tends to be recurring, where 50% of patients have more than one episode. The episodes could be manic, or alternating between mania and depression.

Bipolar 2: Depressive episodes alternate with hypomanic episodes (rather than full manic episodes). Hypomanic episodes are often less severe than manic episodes. They lack the expansive mood, and haven’t gotten themselves in trouble. Where mania often results in an admission to a hospital, hypomania is never severe enough to necessitate admission into a hospital. Average age of onset is 21.

Cyclothymic disorder:

There is an alternating between manic and depressed states, but in both states the mood swings don’t reach a severity where they could be classified as depressive or manic episodes. They have subthreshold depressive and manic states. Like dysthymia, the pattern of ups and downs in cyclothymia has to last for 2 years. Cyclothymia is a risk factor for the development of full-fledged bipolar disorder.

In the bipolar disorders, if you get the disorder when you are younger, you tend to get a more acute onset. 1/3 of the disorders are diagnosed in adolescents. 10-13% of those with bipolar 2 will go on to get bipolar 1.

There is a great risk of suicide in bipolar disorder. 1/5 cases of bipolar disorder result in suicide.

Mood disorders and specifiers for the most recent episode of the disorder (fig. 7.2)

Specifiers: Atypical Melancholic Chronic Catatonic Psychotic With

postpartum onset

Depressive episode

Mood disorders: Dysthymia Major depressive disorder, single episode

Major depressive disorder, recurrent Major depressive disorder, rucurrent

Double depression

Differences between unipolar and bipolar depression

Variable Unipolar Bipolar

Motor activity Typically agitated typically retarded when depressed

Sleep Difficulty sleeping Sleeps more than usual when depressed

Age of onset Late 30s to early 40s 30

Family history First-degree relatives First degree relatives at high risk for both

At high risk for unipolar and bipolar depression

unipolar depression

Gender Much more frequent About equal in each gender

among women

Biological treatment Some response to Best response to lithium

Lithium but better to

Tricyclics

The difference between bipolar disorder and schizophrenia is that in bipolar disorder there is only psychotic behaviour during the manic or depressive episodes, whereas, in schizophrenia, the psychoses are always present.

Biological Theories of Depression

There may be 4 aspects of depression that point to biological underpinnings:

Depression and mania tend to be episodic like physical illnesses.

Symptoms of depression and mania represent disruptions in vital bodily functions.

Depression and mania run in families.

Depression and mania respond to biological treatments.

There are 2 classes of biological depression.

One strain suggests disorders in genetics, the othere suggests disorders in neurobilogical disorders.

Genetic Etiology of Depression.

Family Studies. Have looked at the relatives of the person who have had the disorder (the probands). The rates of depression are 2 –3 times higher in people with first degree relatives who have depression. Bipolar disorder increases the probability of having another personality disorder. Bipolar increases the probability of another family member having a unipolar depression. Having a person with unipolar depression in the family doesn’t increase the probability of having a realtive with bipolar disorder. About 10% of people who have a family member with bipolar disorder go on to have a relative with a depressive disorder.

Adoption studies. If there is a genetic contribution, it should be the case that a person with depression should be more likely to have a biological first degree relative with depression, than in cases where there is no depression. The evidence from the adoption study approach as revealed very little evidence to support the theory that depression is genetic.

Twin studies. This metholodology has provided the strongest evidence for a genetic contributor to depression. If the disorder was genetic, you would expect to find higher disorders in identical twins than in fraternal twins. It has been found that identical twins are 3 times more likely to share a mood disorder than are fraternal twins. For bipolar disorder, the concordance rate is 80% for identical twins, but only 16% for fraternal twins. Severe depression shows a 59% concordance between identical twins, but only 30% between fraternal twins. Depression shows a concordance rate of 36% in identical twins and 17% in fraternal twins.

Neurotransmitter theories

See the textbook…but focus on:

· Monoamines

· Endocrine System

· Sleep and circadian Rhythms

Biological Treatments

Mecications:

Lithium is the treatment of choice for mania and bipolar disorder.

Tricyclic Antidepressants

Monoamine Oxidase Inhibitors (MOI)

Selective Serotinin Reuptake Inhibitors (SSRI’s)

Electroconvulsive therapy.

Lights (for seasonal affective disorder)

Lithium

Was discovered by Cade in the 1940’s who gave his pig lithium to treat gout, and noticed that his pigs became lethargic and unresponsive. Early studies suggested that 80-90% of people responded to lithium. Newer studies, however, have shown that there is only a 30-50% response in subjects, and it is mostly effective in treating the manic episodes. There are side effects: abdominal pain, nausia vomiting, treamours, and toxic levels of lithium can result in diabetes, kidney dysfunction, and birth defects if taken by pregnant women if taken by pregnant women in their first trimester. Most clinitions believe that people with bipolar disorder need to be treated with lithium, an antidepressant, and psychosocial treatments. Lithium in combination with family therapy resulted in 55% recovery, where lithium without family therapy resulted in 21% recovery.

Tricyclic Antidepressants

Work on depression by preventing the re-uptake of norepinephrine in the synapse. It changes the number of neurotransmitters. 60-85% of patients can get some relief with the use of these meds. Common trycyclics are ammiprimene anatrypaline and …aline. Side effects: dry mouth, excessive perspiration, blurring of vision, sexual dysfunction (desire is affected). May take 4-8 weeks to show its effects. May be fatal if overdosed. Overdose with a tricyclic is very easy, it only takes 3-4x the normal dose to overdose.

Monoamine Oxidase Inhibitors

They work like the trycylics by inhibiting re-uptake. Some studies suggest that the MAOIs are more effective than the tricyclics. They can’t however, be mixed with rich foods, like ripened cheeses, red wine, beer, chocolate. May lead to liver damage over time, leads to significant weight gain, leads to a gradual lowering of blood pressure.

Selective Serotonin Reuptake Inhibitors (SSRI’s)

Acts specifically on serotonin. The benefits of using this drug are usually seen in 2 weeks. Side effects are less, but may include gitteryness, nervousness, anger, hostility. Prozac is prescribed 1 million times each month (even for people not manifesting the clinical symptoms of depression).

Electro Convulsive Therapy (ECT)

Very contraversial. Originally used for schizophrenia, but found to be more effective for depression. It is referred to as the treatment of last resort. It is not currently done so that it is painful. The long term effects on the brain are not well known.

Psychosocial Theories

65% of people with depression report some kind of negative live event in the 6 months prior to the development of depression. A life stressor can pre-dispose one to depresssion, but so also may a small daily life stressor. The behavioural theory states that negative life events cause depression because they reduce the person’s ability to find positive re-enforcers. The depressed person often withdraws from society, preventing others from raising their mood. People who are depressed are cutting other people off. When people are depressed, people don’t want to spend time with them.

Cognitive Theories

Aaron T. Beck

Biases in Processing Information

People could experience horrific life stressors, but not become depressed. The way people make sense of life and experience affects weather or not they will become depressed. Depressed people think that they are lousy as individuals, that the world is unfair, and that the future is hopeless.

Beck wrote this in the mid 1960s.

Cognitive factors associated with depression

Negative cognitive triad (self, world, future)

Cognitive Distortions

All or non thinking

Catastrophizing

Disqualifying or discounting the positive

Emotional reasoning

Labeling

Magnification/ minimization

Mental filter (selective abstraction)

Mind reading (you believe you know what others are thinking)

Categories of core beliefs

Helpless Unlovable

Inadequate unattractive

Powerless undesireable

Trapped rejected

Inferior alone

Ineffective unwanted

Incompetent uncared for

Weak Bad

Vulnerable worthless

Failure different

Defective Not good enough

(doesn’t measure up) (To be loved by others)

Not good enough Defective

(doesn’t measure up) (so can’t be loved)

loser Nerd

(achievement wise)

Needy Loser

(in relationships)

Out of control

70-80% of subjects receiving cognitive therapy don’t relapse in the following 2 years, whereas, only 20% of people receiving clinical medical therapy don’t relapse.

Aaron Clarke

13/02/01

Anxiety Disorders

What is “frontalis EMG?”

There is a difference between normal anxiety and pathological anxiety. Anxiety can really fluxuate between mild uneasyness, and complete terror. We can distinguish between intense periods of anxiety, and more moderate periods of anxiety that is with the person from day to day.

Anxiety: a response to danger or threat with a focus on the future. The person doesn’t expect the future to go well, and they don’t feel prepared for the future. The purpose of anxiety is to protect the person or the organism. In our evolutionary past, anxiety served to motivate adaptive functions inducing the flight or fight response. The outlook in anxiety is that something is about to go wrong. Anxiety affects the body causing dizzyness, sweating, heart palpatations, chest pain, and difficulty breathing. Anxiety affects behaviour by inducing a desire to escape and get away from the situation. If possible, anxiety also makes you want to avoid the anxiety provoking situation. The systems of anxiety vary across people and across situations. For some people, the impulse to avoid or escape is the strongest; in other people the physical symptoms predominate. The manifestations of anxiety may be over or under activated depending upon the situation.

Emotional State

Anxiety: Negative affect

Somatic symptoms of tension

Future-oriented

Feelings that one cannot predict or control upcoming events

Fear: negative affect

Strong sympathetic nervous system arousal

Immediate alarm reaction characterized by strong escapist tendencies in response to danger for life-threatening emergencies

Panic Attack: Fear occurring at an imappropriate time

Three Types: situatinally bound

Unexpected

… (See fig. 5.1)

Three Separate Systems of Anxiety

Physical – Nervous System (sympathetic nervous sympathetic nervous system, and parasympathetic nervous system). Sympathetic nervous system releases adrenaline and noradrenaline when activated. These are released from the kidney and increase the activity of the body making it ready to meet danger. The parasympathetic nervous system regulates the sympathetic nervous system to ensure that you don’t stay anxious forever.

Cardiovascular – Anxiety causes an increase in heart rate and an increase in the force of the heartbeat. Blood is drawn away from the extremeties to the large muscles to facilitate the rapid flight or fight response.

Respiratory Effects – There is an increase in the speed and depth of breathing when anxiety is present. This causes people to think that they are choking because they can’t get enough air, but this effect serves to deliver more oxygen to the body. There may be slight dizzyness due to lower blood pressure in the head.

You also sweat more allowing you to cool down, and make you more slippery.

The pupils open up and let in more light.

Salivation decreases, resulting in a dry mouth.

Digestion stops, and people may experience nausia or diarrhea.

Most people also experience muscle tension.

Most people feel exhausted after a flight or fight response.

Mental

Perception of danger: there is an immediate and automatic shift to recognize danger. People who are anxious often talk about being distracted easily, and often report problems with memory.

Behavioural

Escape

Avoidance

Anxiety Disorders

Agoraphobia

Panic Disorder with /without Agoraphobia

Specific Phobia

Social Phobia

Obsessive-CompulsiveDisorder

Posttraumatic Stress Disorder

Acute Stress Disorder

Generalized Anxiety Disorder

Disorder	ECA Study	NCS Study	Edmonton Study
Panic Disorder	0.9	3.5	1.2
Agoraphobia	4.2	5.3	2.9
Any Anxiety Disorder	10.4-25.1	24.9	11.2

Epidemiology Research

Lifetime Prevalence: ranges from 10-25%

Gender Differences: one year prevalence – 9% men, 16% women.

Age of onset: varies but on average in the 20s.

Causes of Anxiety

Biological:

· Genetic risk for anxiety is supported

· There is a tendency for panic to run in families.

· Anxiety is associated with GABA-Benzodiazepine system. Deep levels of this neurotransmitter are associated with high levels of anxiety.

· Noradrenic and Serotenergic systems involved.

Psychological:

· Freud – When an unconscious wish or fantasy was brought closer to consciousness, the person becomes aware of them and becomes anxious.

· Perception of control

· Interoceptive conditioning (we can become conditioned to our own bodily events).

Social:

· Stressful life events cause anxiety.

Generalized Anxiety Disorder (GAD)

Excessive worry most days regarding a number of different domains (e.g. work, relationships, health) causing distress or functional impairment. People with this disorder describe their worry as follows:

Undesirable

Troublesome

Umproductive

Disturbing

Obsessive

Etc.

Worry Domain Questionnaire

Relationships:

That I will lose a close friend.

Lack of Confidence:

That others will not approve of me.

Aimless Future:

That I’ll never achieve my ambitions.

Work competence:

That I will not keep my workload up to date.

Financial:

That my money will run out.

Socio-Political:

That the health service is declining.

*Most people score highest on the relationships aspect of the questionnaire.

Why Do People Worry?

1) Superstitious avoidance of an event. “If I worry about it enough it won’t happen.”

2) Practical avoidance of an event. “If I worry about it enough, I will come up with a solution to prevent it from happening.”

3) Avoidance of an emotion. “If I worry enough about money, I won’t have to think about my relationship.”

4) Motivation for action. “If I worry enough, I’ll do something to change the situation.”

Difficult to control, plus 3 of the following 6:

1) Restlessness

2) Fatigue

3) Impaired concentration

4) Irritability

5) Muscle tension

6) Impaired sleep

These symptoms are reflective of chronic autonomic nervous system arousal. Most people who are anxious (90%) report that they feel physically up tight all of the time.

In GAD, the people fear worry, physically feel sore muscles, and are often figity and restless.

The DSM-IV says that the criteria for GAD must be present for at least 6 months, and the person must not be able to control their worry, and they go from one crises to the next.
Children worry most about academic and athletic performance. Adults tend to worry more about health concerns.

GAD – Statistics

Is a common anxiety disorder (1 in 4 have the disorder).

Incidence: 4% of the population in a 6-month period are diagnosed with GAD.

Sex ratio: 55-65% are female.

Onset: early and gradual onset.

Course: chronic.

Causal factors that create GAD

Probably is some genetic component, however, there is not a lot of twin data on the disorder. The prevaling hypothesis is that GAD results from some problem with the
GABA system so that anxiety is not brought under control.

Psychologically, the cognitive behavioural view has been prevalent. Here the focus is on the role of conscious cognitions and the nature of the thinking of the people with this disorder. Studies have found that individuals with this disorder are hypersensitive to threat in their environment, particularly when there is something of a personal threat that is outside of their control. They also fear that they are going to lose their control. They fear relaxing, because they think they will lose control. They constantly are on the go so that they don’t have to relax and lose control. The Stroop effect has been used to test distractability. The test is modified so that the subjects are presented with words that are associated with threat, and the subject is measured on how much they are distracted by the words. People with GAD are more distracted by words associated with threat than are non-GAD people.

Treatment of Generalized Anxiety Disorder

Cognitive Behavioural Therapy (CBT):

· Confront issues they worry most about.

· Challenge negative, catastrophic thoughts.

· Develop coping strategies.

· Intensive relaxation.

Benzodiazepine therapy, Placebos, Supportive Psychotherapy

Many people are using SSRI’s

Effectiveness of CBT for GAD

· Results of five studies

· CBT more effective than waiting list or placebo at post-test.

· Treatment effects maintained or increased at 6-12 month follow-up.

A few studies have shown up showing that CBT may be most effective for children experiencing GAD.

An integrative model of generalized anxiety disorder

Biological vulnerability to experience anxiety

Stress due to negative life events

Anxious apprehension Psychological vulnerability

Worry process focused on a variety of minor life circumstances.

Avoidance of imagery Intense cognitive processing

Restricted autonomic response

Modified by lack of problem-solving skills

Generalized Anxiety Disorder

Panic Disorder

Criteria for panic attack:

A discrete period of intense fear of discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

· Pounding hear or palpitations

· Sweating

· Trembling

· Shortness of breath

· Feeling of choking

· Chest pain

· Nausea

· Feeling dizzy

· Depersonalization (being detached from oneself)

· Fear of going crazy

· Fear of dying

· Numbness

· Chills or hot flashes

Panic Disorder is when there is an experience of severe unexpected panic attacks. The person thinks that they are dying, or that some other catestrophic event is likely. People start to worry that a panic attack could happen at any time, and they develop agoraphobia, where they fear an avoid any situation where it might be dangerous for them to have a panic attack, or where they wouldn’t be able to be helped in the event of a panic attack.

The person has to be worrying that another attack is going to occur. They are vary concerned and worried that an attack is going to happen again. Or the person has demonstrated behaviour to avoid having a panic attack.

Panic in the Normal Population: 1/3 of the population has a panic attack in a year according to their own reports. Only 3-5% of the population, however, develop panic disorder.

For most people, their first panic attack happens under a period of intense stress. For most of these people, this panic attack will not change their life, they will go back to normal afterwords.

Life Events Occurring Prior to Onset of Agoraphobia

Precipitating events Frequency (N=58) %

Interpersonal conflict situations

Marital familial 20 34.5%

Death/illness of significant other 9 15.5%

Situations Avoided by Agoraphobics

· Shopping malls

· Cars

· Buses

· Trains

· Subways

· Wide streets

· Tunnels

· Restaurants

· Theaters

· Being far from home

· Staying at home alone

· Waiting in line

· Supermarkets

· Stores

· Crowds

· Planes

Panic Disorder Statistics

· Prevalence of panic disorder: 3.5% of population get panic disorder

· 2/3 are women

· 60% of those who have panic attacks also have panic attacks at night (nocturnal panic attacks).

Agoraphobia Statistics

· Prevalence of Agoraphobia: 5.3% of people are agorophobic (this is probably an overestimate, however, as the number of agoraphobics shouldn’t be greater than the number of people with panic disorder).

· 75% of agoraphobics are women

CBT and Panic Attacks

Panic attacks symptoms can be broken down into 3 components”

1) Cognitive component:

Sense of impending doom

Worry about present and future

2) Physiological component:

Difficulty breathing, sweating, rapid pulse etc.

Could last a short period of time or hours/day.

3) Behavioral component:

Escaping or avoiding places or events that produce anxiety.

Cognitive Model of Panic

Internal/External Trigger

Perceived threat

Anxiety

Misinterpretation Physical/Cognitive Symptoms

Myths and Misinterpretations of Panic Attacks

· Going Crazy

· Losing Control

· Nervous Collapse

· Heart Attacks

*In panic disorder, the patient has learned to fear the symptoms of their body’s panic attacks.

In treatment you would want to familiarize the patient with the cognitive model of panic. Then you would want to get the person to record their physical experiences when they have a panic attack. Another approach might be to induce a panic attack in a person and show them that there is nothing to fear.

To induce a panic attack you can:

1) Get them to hyperventilate.

2) Get them to do Physical Exercise Tasks

3) Get them to do Chest Pain Exercises (holding breath for a long time).

4) Inducing Visual Disturbances

*Identifying Catastrophic Misinterpretations.

In treatment, you would next get the client to fill out modifying self-statements. Here you would get the person to list their overestimation errors, and propose alternative evidence and the probabilities that their overestimates will actually happen.

An average course of treatment for this disorder is 10-12 sessions. The suicide rate for this disorder is 10-20%. An average course of treatment for this disorder is 10-12 sessions. The suicide rate for this disorder is 10-20%.

Coping Styles

New Learned Positive Cycle

Feared situation allow and accept symptoms challenge imagined worst thoughts stay watch symptoms reduce gradually Memory “I did it.” Increased courage Reduced anticipatory anxiety Intentionally enter and repeat the task

Effectiveness of CBT for Panic Disorder

-Within 3 months, not one person who received treatment had another panic attack.

-A new Oxford study has found that the disorder can be treated in 5 days if the patient is an inpatient undergoing intensive therapy.

-Drugs also help, but relapse rates are high (25%)

-Only 4% of CBT treated patients relapse.

-There are no additive effects of combining CBT with medication.

27/02/01

Aaron Clarke

Chapter 5 part II

The Anxiety Disorders

Social phobia

Panic Disorder with (PDA) or without (PD) Agoraphobia

Posttraumatic Stress disorder (PTSD)

Obsessive Compulsive Disorder (OCD)

Generalized Anxiety Disorder (GAD)

Specific Phobia

Spectrum of anxiety disorders:

Depression, Social anxiety disorder, … Obsessive compulsive disorder.

Diagnostic Criteria for specific phobias

1. Individual must have an excessive or unrealistic fear that is triggered by a specific object or situation, e.g., flying , heights, animals, receiving an injection, seeing blood.
2. Exposure to the feared object or situation almost always triggers an immediate anxiety response, which may be in the form of a panic attack, i.e., a sudden rush of fear accompanied by intense symptoms of arousal, such as palpitation and dizziness.
3. The individual recognized that the fear is excessive or unreasonable (in children this may not be the case).
4. The individual either avoids the feared object or situation or endures the situation despite intense discomfort.
5. The fear or avoidance leads to significant interference with the individual’s normal routine, functioning or relationships, or the individual is distressed about having the phobia.
6. In the individual is under 18 years old, the fear has been present for at least 6 months
7. The fear, anxiety or avoidance related to the specific object or situation is not due to another psychological disorder.

How Do Fear/Phobias Develop?

Information transmission

Traumatic Conditioning

Observational Learning

e.g., child observing mother being afraid.

Types of Phobias

1. Animal phobias: e.g., fears of animals, birds, insects, bugs, spiders.
2. Natural environment phobias: e.g., fears of the dark, storms, water, heights.
3. Situational phobias: e.g., fears of planes, trains, cars, closed-in spaces such as elevators or closed rooms.
4. Blood, injection, injury phobias: e.g., fears of medical procedures or hospitals.

Prevalence of intense fears and phobia

1. Snakes (253/1000 population)
2. Heights (120/1000 population)
3. Flying (109/1000)
4. Enclosures (50/1000)
5. Illness (33/1000)
6. Death (33/1000)
7. Injury (23/1000)
8. Storms (31/1000)
9. Dentists (24/1000)
10. Journeys alone (16/1000)
11. Being alone (10/1000)

The best treatment for these phobias is exposure therapy. Here you expose the person to their fears, and allow them to test their beliefs about their fears, and improving their ability to cope with their fears. 90% of people are helped by exposure therapy in 8-10 sessions and most are cured after that treatment, and there is very little relapse with exposure therapy.

Social Phobia

Social phobia was grouped with all of the other phobias until 1980, when it was found that people with social phobia have a very chronic condition, and it seemed like that the clinical characteristics of social phobia suffered great problems as a result of this phobia in their lives. It was introduced and described in the DSM-III, and is still in the DSM – IV.

DSM-IV Diagnostic Criteria for Social Phobia

Marked or persistent fear of social or performance situations

Fear of scrutiny

Fear of humiliation or embarrassment.

Exposure almost invariably provokes anxiety

May result in panic attack

Person recognized that the fear is excessive or unreasonable.

Feared situations are avoided or endures with intense distress

Avoidance, anxious anticipation or distress interfere with normal functioning

Symptoms >= 6 months. Average duration is 15 – 25 years before the person seeks help.

Signs and symptoms of Social Phobia

• Cognitive symptoms
• Physical symptoms
• Avoidant behavior

Physical Symptoms

• Blushing
• Stammering
• Sweating
• Gastrointestinal symptoms (embarrassing)
• Dry mouth
• Palpitations
• Trembling
• Urgency of micturition
• Panic attacks

Cognitive Symptoms

• Fear of negative evaluation or disapproval
• Negative evaluation of one’s own performance
• Perfectionist standards
• Expectations that others will be critical
• Expectations that social situations will go badly

Avoidant Behavior

• Avoidance of difficult social situations
• Being in situations but not participating (speaking)
• Use of alcohol in social situations
• Non-verbal behavior – eye contact, shaking hands, interpersonal distance
• Relying on family and friends to do things so that they can continue to avoid situations

Social phobics often fear:

Speaking in public or in front of others

Talking to people in authority

Talking to strangers

Being embarrassed or humiliated

Being criticized etc.

Prevalence and Onset

• 1-month prevelaence: 5-7%
• Lifetime prevalence: 10 – 16%
• Most prevalent anxiety disorder

Higher lifetimeprevalence in women than in men (16% vs 11%)

• Social anxiety disorder has a much earlier onset than other anxiety disorders (90% of people experience onset of the disorder before they reach 20).

Problem of Comorbidity

• 20% of social anxiety disorder cases occur without comorbidities at presentation
• 70-80% of cases have comorbidity at presentation:

45% - agoraphobia

17% - major depression

19% - alcohol abuse

13% - drug abuse

Social and Occupational Impariments

Variable	Pure Social Anxiety Disorder (N=65)%	Control Subjects (N = 65)%
Never Married	48	32
Divorced	17	8
Unemployed	11	3
Impairment Mild Medium Severe	23 25 52	2 3 95

Etiology

predisposition

temperment

Developmental Factors

• Buss (1986)

Fearful shyness -> early developing (first year of life)

Genetic component

Somatic anxiety & behavioral inhibition

Self-conscious shyness -> Late developing (age 4 or 5)

Peaks at age 14-17

Cognitive symptoms (self-consciousness/preoccupation)

The Neo Test Examines 5 Major Personality Traits

• Neuroticism
• Introvertedness/Extrovertedness
• Conscientiousness
• Openness
• Agreeableness

In Social Phobics there is clear evidence of behavioral inhibition, introversion and neuroticism.

Developmental Factors (continued)

Sex-Role Socialization and Gender Differences

· Boys more likely to receive negative feedback for shy behavior than girls.

Peer Relations

· Shy children more likely to have negative peer relations

· Vernberg et al. (1992) lower levels of intimacy related to increased fer of negative self-evaluation

Disturbances in Self-Esteem

• Early developing shyness -> before self-concept
• Late developing shyness -> while self-concept emerges (4-5 y.o.) and at height (14-17 y.o.)

Etiology

Behavioural

• Early exposure to traumatic events (reported by half of the social phobia sufferers).

Twin Studies

• 24.4% concordance between identical twins
• 15.3% concordance for fraternal twins.

Family Studies

There is 3 times the rate of developing social phobia if a first degree relative has a social phobia.

Fears in Social Phobia

Fear of Negative Evaluation Scale (Watson and Friend, 1969).

• Looking foolish
• Making Bad Impression
• Being Thought of Badly

Hartman (1984) – FA 21 –items of Social Evaluation

• Concerns about Social Inadequacy
• Others’ Awareness of Distress
• Fear of Negative Evaluation

· Autonomic Arousal

Self-Schema In social Phobia

1. Excessively high standards for social performance.

“I must get everyon’s approval”

“I must not show any sighs of weakness”

“I must appear intelligent and witty all of the time”

2. Conditional beliefs concerning social evaluation

“If I show feelings (or make mistakes) others will reject me”

“If others really get to known me, they won’t like me”

“What people think about me must be the truth about me”

3. Unconditional beliefs about the self

“I’m odd”

“I’m different”

“I’m stupid”

A Cognitive Model Of Social Phobia

The Most effective treatment of social phobia is group cognitive therapy. It is even effective 5 years after treatment. Beta blockers are also effective, as are SSRIs. Two thirds of people on the SSRI “paxil” benefit from the drug. There is, however, no data on the long term benefits of using paxil.

Follow-up Studies in CT for Social Phobia

Fava (1989) Gains maintained at 1yr.

Mersch et al. (1992) Gains maintained at 18 months.

Mersch et al. (1991) Gains maintained at 14 months for both SST and CT

Wlazlo et al. (1990) Gains maintained at 2-5 years. Many continue to improve

Heimberg et al. (1993) Gains maintained at 5.5 years. 88% successful in CT, 44% successful in Placebo.

Obsessive Compulsive Disorder

This is the most severe of the anxiety oisorders, and looks like a chronic illness in terms of persistence. OCD in an anxiety disorder characterized by a flooding of persistent and uncontrollable thoughts. The person is compelled to repeat acts over and over again. The repetition of acts leads to impairment and stress in the affected person’s life. The person spends at least 1 hour a day engaging in some compulsive ritual. The person fears having some thought, image, or impulse.

Obsessive-Compulsive Disorder (OCD)

· Obsessions: recurrent and intrusive thoughts, images or urges causing marked anxiety.

e.g. contamination fears, doubting, disturbing sexual thoughts.

· Compulsions: repetitive behaviors or mental acts to reduce anxiety.

e.g. washing, checking, and ordering

Common Obsessional Experiences:

1. Doubting (e.g. locks, turning appliances off, completion/accuracy of tasks)
2. Contamination (e.g., contracting germs from doorknobs, toilets, money, etc.)
3. Nonsensical impulses (e.g., shouting or undressing in public)
4. Aggressive impulses (e.g., hurting self or others intentionally, destroying objects)
5. Sexual obsessions (e.g., obscene thoughts or images)
6. Religious/satanic thoughts (e.g., blasphemous impulses)

The most common of this list are thoughts about contamination, doubting, aggressive obsessions, and then sexual obsessions.

10% of OCD patients don’t recognize the irrationality of their behaviour.

Common Compulsions

1. Counting (e.g., letters, numbers, objects, etc.)
2. Checking (e.g., locks, appliances, driving routes important papers, waste baskets)
3. Washing
4. Hoarding (e.g., newspapers, garbage, trivial items)
5. Internal repetition (e.g., phrases, woreds, prayers)
6. Adhering to certain rules or sequences (e.g., assuring symmetry, ritualistic acts, adhering to a specific routine for daily activies)
7. Other

People with OCD experience the same kinds of thought intrusions as everyone else, but they experience them differently.

Dan Wagner (Wagner – late 80s) found that when people try to fight normal thoughts, it increased the frequency of those thoughts. As time passes people have a harder time fighting those thoughts, and give up, and the frequency of those thoughts increases. This is a rebound effect.

Behavioral Model for OCD

	Traumatic Event
Neutral event
	Media Information

Vicarious Experience

			Negative reinforcement: (strengthens rituals and obsessions)
		Anxiety Decreases

Cognitive Factors in OCD

1) Overimportance of Thoughts, and idea that the thoughts must be controlled.

2) Thought-Action Fusion (belief that “If I think a thought I believe that it is more likely to happen.”, belief that thinking bad thoughts are as bad as doing the bad things that you were thinking of .)

3) Catastrophizing (“Terribly bad things are going to happen unless I do something”).

4) Inflated Responsibility (this is the most important factor responsible for OCD. A person with OCD may believe that they are personally responsible for preventing bad outcomes).

5) Perfectionism (“I can’t take the risk that I’ve made a mistake” – the person goes back and checks over and over again).

Eating Disorders

Aaron Clarke

06/03/01

Majority of woman and 1/3 of men feel that they are overweight. This occurs across cultures.

· 45% of women and 25% of men are on diets (in the U.S.) to control their weights.

· 16% of women are perpetual dieters (between 19 and 39 years old).

· Oprah (yo-yo dieting)

· Diet Industry = 30 billion per year (this is as much as the combined amount spent on education, and work development).

· 70% of American girls have dieted before the age of 10.

Other people have other means of controlling their weight (in 1990, people had their jaws wired to prevent them from eating so much, others use liposuction).

The average percentage of expected weight of Playboy centerfolds and Miss America contestants, from 1959 to 1988 has decreased by about 15%.

Women are aware of societal expectations, and conform their behaviour to match societal expectations. Historically men’s self esteem has not been so strongly attached to their weight. In part, if we look at the societal pressures to be thin, it becomes no surprise to see food becoming linked to feelings of self-worth, and a sense of social accomplishment. In this context it becomes no surprise to see eating behaviours becoming social disorders.

Prior to 1980, there were no recognized eating disorders in the DSM. In the DSM – IV, there is a division of eating disorders into bulimia and anorexia.

In bulimia there are binges of eating which are followed by attempts to purge the food.

In anorexia, the person eats very little and tries to maintain a low weight. In both of these disorders, there is an overwhelming drive to be thin.

Anorexia Nervosa

• Anorexia = loss of appetite
• Nervosa = for emotional reasons.
• Anorexia Nervosa represents the refusal to maintain normal, healthy body weight.
• Anorexics don’t really lose their appetite, they actually may really want to eat food, but they refrain.
• For a person to be anorexic, they must be 15% of their ideal weight. Most anorexics weigh 25-30% below their ideal weight.

In girls and women who have begun menstruating, the weight loss causes them to stop having their periods (i.e. they get amenorrhea - missing 3 normal periods in a row). This is an indication that their weight is too low, and they may have anorexia.

Also, anorexics have an intense fear of gaining weight. Irrespective of continued weight loss, they have a fear that they are overweight, and will gain weight.

Thirdly, anorexics have a distorted sense of their body shape, despite being very thin. They often believe that they are fat and still need to lose more weight. Anorexics typically weigh themselves frequently throughout the day, and look at particular body parts, and spend more time gazing at themselves more critically.

They often exercise to the point that it is punishing.

• DSM – IV Criteria:

Patient must be 15% below normal weight (average patient with AN is 25-30% below normal weight)

Intense fear of gaining weight

Distorted sense of body shape

• DSM-IV Subtypes:

Restricting type – tries to prevent food intake to prevent gaining weight, but eats enough to appease family and friends. They seem to be described as having deep feelings of mistrust of others, and a tendency to cope with their problems through denial.

Binge/purge type – they have small binges that leads to purging behaviours. This type is generally more pathological, they exhibit more personality disorders, have more impulsive behaviour, have more drug and alcohol abuse, and have more suicide attempts than the restricting type. Their course is more chronic than is the restricting type’s.

Epidemiology of Anorexia Nervosa

90-95% of diagnosed with AN are female

Onset begins in the early to middle teenage years. The onset usually follows after a period of dieting and the co-occurrence of a life stressor (usually an interpersonal life event like parental divorce or separation).

50% recover in 4 years – 30% still have AN after 4 years and beyond, and are still 30% under weight.

The death rate is 15%.

Medical consequences: (you don’t need to memorize all of these)

Cardiovascular Complications

Slowness of heart rate

Irregular heart beat

Fluid in the sac enclosing the heart

Heart Failure

Metabolic Complications

Yellowing of the skin

Impaired taste

Hypoglycemia

Fluid and Electrolyte Complications

Dehydration

Weakness

Tetanus

Hematological Complications

Susceptibility to bleeding

Anemia

Dental Problems

Decalcification

Tooth decay

Endocrine complications

Amenorrhea (missing 3 normal periods in a row).

Lack of sexual interest

Impotence

Gastrointestinal Complications

Salivary gland swelling

Acute expansion of the stomach

Constipation

General Complications

Weakness

Hypothermia

The most serious medical complications of anorexia nervosa are:

Heart failure

Acute expansion of the stomach to the point of rupturing

Kidney damage

Bulimia Nervosa

Bulimia = “ox hunger”

Includes rapid binging

Eating is seen (by the patient) to be out of control.

Engaging in purging techniques

Subtypes:

Purging type

Evidence more psychopathology than non-purging bulimics.

They have more frequent binging.

They have more co-morbid anxiety and depression than the non-purgers.

They have more entrenched negative attitudes towards eating.

Are distinguishable from binge-purge anorexia because the anorexics must be 15% below their normal body weight, where the bulimics don’t have to be 15% below their normal body weight.

Non-purging type

They fast or exercise excessively after binging.

Involves rapid consumption of enormous amounts of food, often upwards of 2000-4000 calories (twice that required for the normal person in one day). Some people consume 15000 to 20000 calories in one episode. The DSM says that binging has to be eating an excessive amount of food within 2 hours. The binging is usually concealed by the person. The binging usually continues until the person is uncomfortably full. After the binge is over, there are feelings of disgust and discomfort and there is a fear of weight gain. These feelings and fears together lead to purging behaviours. The purging techniques include self-induced vomiting, or using laxatives. Alternativelly, the people exercise excessively (57% of bulimics). About 57% of college students have binges. Bulimics must have at least 2 binges per week for 3 months to meet the DSM-IV criteria. Bulimia nervosa patients are afraid of gaining weight, and their self-esteem is dependent on regulating their weight. They also have a distorted view of their body image – they see themselves as fat, even when their weight is normal.

Epidemiology of Bulimia Nervosa

Prevalence Rates = 1% women

Among women, 30% of 2000 reported binging at least once per month, but only 3% felt that the binges were out of control, and only 1% actually purged.

<1% men

The full syndrome for bulimia is fairly uncommon.

Onset – during adolescence

Many patients with BN are overweight

Medical complications:

Renal complications

Dehydration

Kidney disease

Gastrointestinal Complications

Electrolyte Abnormalities

Dental Problems

Laxative Abuse complications

Other Abnormalities

Binge-Eating Disorder

BED is currently in the Appendix of DSM-IV

The patient doesn’t regularly engage in fasting, excessive exercise or purging to control the weight.

The patient may eat continuously throughout the day without properly scheduled meal times.

Other patients may have binges in response to stress or anxiety.

Patients with BED are significantly overweight. They say that they are disgusted with their bodies.

Usually found in weight control programs. In “overeaters anonymous” 70% of the members are diagnosable with this disorder.

The disorder is more common in women, but the ratio of women to men with this disorder is 3:1.

The disorder often leads to impairment in functioning in work.

The disorder is often co-morbid with depression.

Etiology of Eating Disorders

Biological factors:

Genetics – Both anorexia and bulimia run in families. Female relatives of women with an eating disorder are 5 times more likely to develop an eating disorder themselves. Concordance rates among monozygotic twins were 20% and 10% in dizygotic twins.

Hypothalamus – this is the key brain center in regulating hunger and eating. Lesions of the hypothalamus lead to weight loss and loss of appetite. The pattern of weight loss in animals doesn’t match that of hypothalamically lesioned animals. The anorexics are still hungry, they just don’t eat. They hypothalamus model fails to help us understand why people are still hungry, why they have a distorted body image, and why the fear becoming fat.

Endogenous Opiods – these are substances produced by the body that reduce pain sensations, and are released during periods of binging. Binging in anorexia is accompanied by release of opiods, which condition starving behaviour. Bulimia may also cause the release of opiods.

Serotonin – the serotonin system is currently being researched extensively. This may relate to greater impulsivity which could lead to binge eating. High levels of serotonin have been associated with the absence of craving and the presence of satiety.

Sociocultural Views:

A recent study of girls in grade 10 found that 1/3 felt that they were over weight, even though they were not overweight.

24% of men and 74% of women said that they were actively dieting in 1984.

Between 1950 to 1970, the rate of fear of getting fat quadroupled.

Overweight men are 2-5 times more common on television than are overweight women.

There is a significant correlation between watching TV and body dissatisfaction.

The risk for groups considered to be at particular risk for an eating disorder are particularly high.

Aesthetic sports (figure skating, hmnastics) – 35 % have an eating disorder

Judo, wrestling – 29%

Endurance sports - 20%

Technical sports - 14%

Ball Game sports – 14%

Etiology of Eating Disorders (continued)

Family Factors:

Family conflict – high levels of conflict within the family with parental denial.

Families are socially isolated and have very little social support.

The mothers of anorexics have perfectionistic mothers, who set perfectionist standards.

There is guilt and frustration, and fear and hurt, and the person with the disorder becomes part of the family dynamic.

Expression of emotion becomes discouraged in these families.

The role of childhood sexual abuse remains uncertain (some researchers show high rates of physical and verbal abuse, but this literature is still not fully substantiated).

Psychological Factors:

Low self-esteem (at least in terms of their physical appearance); low perceived control .

Pre-occupation with how others feel about them. Early social anxiety may be related to later eating disorder incidence. Purging behaviors in these cases may be used to relieve social anxiety.

See figure 8.6 – An integrative causal model of eating disorders.

Treatments

Medications:

Drug treatments have not been found to be effective in treating anorexia. When medication is prescribed, it is usually an SSRI. Co-morbid depression may be helped by the SSRI’s. There have been some reports of SSRI’s (antidepressants) being helpful in treating bulimia. Prozac (an SSRI) leads to a 60% reduction in binging. As soon as the patient is off of the SSRI, the patient returns to binging.

Tricyclics reduced binging 47%

Prozac reduces bingeing 65%

Behavioural:

Cognitive Behavioural Therapy – Therapist focuses on what bingeing does to the person’s body. Looks at the benefits of continuing to purge and use laxatives (doesn’t actually help reduce weight). Therapist schedules 5-6meal times throughout the day, and tries to schedule small meals throught the day to prevent cravings. Helps people develop coping strategies. This method results in 75% having a significant reduction in purging, and 57% had an elimination in purging altogether. CBT remains the preferred treatment for bulimia.

Treatment of Anorexia:

First goal is to restore the person’s weight (may require inpatient admission). 80% of patients do have their weight improved in the immediate treatment.

Second phase is to try to work on the patients distorted body image and their fear of getting fat. Psychotherapy may help, but may take several years. Even CBT is not very positive for treating anorexia.

Aaron Clarke

13/03/01

Sexual and Gender Identity Disorders

When fantasies or desires begin to affect us in a harmful or destructive way, that is when they qualify as disorders.

Sexual and Gender Identity Disorders:

1. Gender identity disorders – Psychological dissatisfaction with one’s biological sex.
2. Paraphilias – Where sexual arousal occurs primarily to inappropriate objects or to inappropriate individuals.
1. Fetishism
2. Transvestic fetishism
3. Pedophilia
4. Exhibitionism
5. Voyeurism
6. Sexual masochism
7. Sexual sadism
8. Frotteurism
9. Paraphilias not otherwise specified (e.g., coprophilia, necrophilia).
3. Sexual Dysfunctions – Where there are difficulties in functioning adequately when having sex.
1. Sexual desire disorders

a. Hypoactive sexual desire disorder

b. Sexual aversion disorder

2. Sexual arousal disorders

Sexual Disorders

• Gender Identity Disorder
• Paraphilias
• Sexual Dysfunction

Gender Identity Disorder

Are you a man or are you a woman? This question is usually answered in childhood and is engrained by the age of 3. Some people, however, feel very deep within themselves from their early childhood that they are of the opposite sex. The evidence of their anatomy doesn’t persuade them that they are the gender that they seem to be.

Varies in degree from mild wistful desires to total consumption with wanting to be the opposite sex, resulting in the inability to reach goals and dreams. Cross-gender identification has been recognized as early as age 3.

In the other extreme, there people who haven’t presented in the clinic until the age of 60.

This gender dysphoria occurs in females and males and in both heterosexuals and in homosexuals. The DSM – IV category includes those who are just discontented with their own sex, and who whish to be recognized as a member of the opposite sex.

Diagnosing Gender Identity Disorder

• Strong, persistent cross-gender identification (not just a desire for the perceived cultural advantages of being the opposite sex)
• Persistent discomfort about one’s assigned sex
• Presence of clinically significant distress
• Not Schizophrenia, Not Hermaphrodites
• Not Transvestitism

• Specifiers:
• Sexually attracted to males
• Sexually attracted to females
• Sexually attracted to both males and females
• Sexually attracted to neither

A. Prefer male partners, think they are heterosexual inside, reject lovers who are attracted to their genitals, he thinks that man is homosexual.

People with GID often feel socially isolated.

GID in Childhood

Most people with GID report a strong history of GID in childhood.

For boys, they often dislike rough and tumble play, associate with girls, insist that they will grow up to be a girl, feel that the penis is disgusting. Parents usually detect cross-gendered behavior in their children at age 3.

Causes

There is some evidence for the role of hormones. If the mother had taken sex hormones during pregnancy there is often GID in the offspring. Mothers who took progestins (precursors to male hormones) the little girls showed tomboy behavior during adolescence. Males whose mothers had high levels of female hormones were less athletic and showed female behaviors in adolescence.

In adults, there is no significant difference in adult male hormone levels between GID males and heterosexual males.

In GID homes, often cross gendered behavior is encouraged in the child. Cross-gendered behavior is often encouraged especially in boys. A longitudinal study done in 1993, it was found that young tomboyish girls saw their dad as their primary role model, and their mothers also saw themselves as tomboys and accepted that behavior. GID is far less common than the number of boys who play with dolls and the number of girls who are tomboys.

Treatment:

• Only a few institutes offer treatment. The first is Johns Hopkins University, and the second is the Clarke institute.
• Reassignment surgery – the existing genitalia are removed and replaced by the genitalia from the opposite sex.
• Men undergoing reassignment surgery, they have to take hormones and have vaginoplasty. They take female hormones to develop breasts. They undergo electrolysis, training to raise the voice, and plastic surgery if needed. In a lot of cases the person is terrified that other people will find out that they were once a male.
• For women an artificial penis is constructed.
• To be eligible for gender reassignment surgery you would have had to have lived in the opposite role for at least 2 years.
• Sex reassignment surgery presents no advantage to the individual in terms of social rehabilitation. Johns Hopkins University now no longer does this surgery.
• Between 1979 and 1989, 97% males and 87% of females undergoing reassignment surgeries reported satisfaction with the surgery.
• Only 20% of people with GID would even receive gender reassignment surgery. There were only 11 cases of gender reassignment surgery in Ontario last year.
• The surgery was expensive ($120,000 for all 11), and is now no longer covered by OHIP (on the grounds that it was an elective surgery).
• There have been early successes with other treatments (e.g. behavioral treatments designed to change patterns of arousal)
• With behavioral intervention there was greater identification with masculine identity. Sexual identity is then possibly amenable to change. The individuals in this study, however, were subjects who volunteered.

Paraphilias

People with paraphilias often exhibit more than one paraphilia.

They are almost always males.

Masochism occurs in a ratio of 20 males to 1 female.

Paraphilic behavior usually declines after the age of 25.

Fetishism – a person is sexually attracted to an inanimate object. Has recurrent and intenst sexual interests in such things as women’s shoes, stockings, undergarments etc. The fetishes are usually associated with two different classes of stimuli. The fetishes could be for inanimate objects or for tactile stimulation. An unusual case of a fetish was reported where a man was turned on by peoples sneezes. This attraction felt by the fetishes toward the object is involuntary and irresistible. Usually the fetish begins in adolescence, but often has roots in childhood.

Transvestic Fetishism – when a man is sexually aroused by dressing in women’s clothing. The term is transvestism. Unless the cross dressing is associated with sexual arousal, the cross dressing is not considered to be transvestic fetishism. Tranvestites are always male. The cross dressing is usually episodic rather than on a usual basis. Transvestites are otherwise masculine in appearance and demeanor. 60% of transvestites are married. Cross dressing occurs in private and is only know to a few family members. The wives tend to be supportive. It usually begins with partial cross dressing in childhood an adolescence.

Voyeurism – the practice of observing an unsuspecting individual undressing or naked in order to become aroused. A true voyeur doesn’t find it particularly exciting to find a woman undressing for his benefit. The element of risk is often important. There is oftenthe element of the question of “how would she react if she knew that I was watching?” The frequency of this disorder is not easy to assess, because it is illegal. The voyeurs tend to be young, submissive and fearful of sexual contacts.

Exhibitionism – sexual arousal and gratification by exposing one’s genitals to unsuspecting strangers. Sexual arousal comes from exposing others to one’s genitals, and there is a desire to shock or embarasse the observer. Exhibitonists are so strongly driven, that at the time of the act they are often oblivious to the legal andsocial consequences of they are doing. Typically these people have difficulty ininterpersonal relationships. 50% are married, but report unsatisfactory sexual relationships with their partners. They are not aroused by scenes depicting violence or violet images, and are less aroused by violence than are not exhibitionist individuals. Voyeurs and exhibitionists account for most sexual offences.

Pedophilia and Incest – men who derive sexual gratification through physical, often sexual contact with pre-pubertal children who are unrelated to them. The offender must be at least 16, and must be older than the child molested, and may be heterosexual or homosexual. If the person involved is a relative, then it is incest. In some cases, the pedophile is content to stroke the child’s hair, but also may attempt intromission, and often continues the act for several years. Taboo against incest is universal (this has evolutionary significance in terms of adaptability). Incest is limited as a subtype of pedophilia. It is most common between brother and sister, and second most common between a father and a daughter. A quarter of men drawn randomly from the community reported arousal to pedophilic stimuli. The difference is that most men don’t act on these arousals. The pedophilic men tend to be religious, low in maturity, low on self-esteem, low on impulse control and low on social skills.

Causes:

An inability to develop adequate social relations.

Early inappropriate sexual associations or experiences (some accidental and some vicarious)

Possible inadequate development of consensual adult arousal patterns

Possivle inadequate development of approproate social skills for relating to adults.

Often patients have very high sexual arousal (masturbates 3-5 times a day).

Classical conditioning often operates where fetish or child is included in the fantasies in masturbation.

Assessment and treatment:

Sophisticated assessment techniques are required. They focus on the presence of deviate arousal, and compare appropriate arousals. Look at the individual’s social skills – their ability to form relationships. Look at procedures for reducing unwanted arousal. Behavioral therapy tries to change the associations between the inappropriate arousing stimuli to a different stimuli. Also, in covert sensitization, arousal images are paired with the consequences of such actions to decrease the arousal in those situations. In that case the therapist would help the client to build up scenes that eth client would rehearse that have horrific outcomes. Also, the therapist helps the client to recognize the early signs of temptation.

Treatment outcome for paraphilias (N=7,186)

Treatment is highly successful (between 78-95%)

Treatment is less successful if the person has had multiple victims, or is in denial.

There are also chemical treatments – Chemical castration: siproderone acetate (reduces testosterone levels). Depropreverra also reduces testosterone.

For psychosocial intervention, the success rates range from 7% to 100% (with good follow up data), however, treatments are offered only in specialized clinics (not widely available).

Sexual Dysfunction

The human sexual response cycle

Desire phase – sexual urges occur in response to the sexual cues or fantasies.

Arousal stage

Plateau phase

Orgasm phase

Resolution phase

Desire phase…

Sexual dysfunctions can be lifelong or can be acquired.

It can be generalized or situational. Situationally, it can be in specific situations. For other people it can be generalized, where with different partners they have the same problems.

Sexual dysfunction can be due to psychological factors, or can be due to psychological factors interacting with biological problems.

Sexual Dysfunctions

Sexual Desire Disorders:

Hypoactive sexual desire disorders (little or no interest in sexual activity). About 50% of people who come to sex clinics do so because they have hypoactive sexual desire disorder. This is the most frequent complaint of women. The average rates of activity in this group: 1/3 to ½ of women presenting report that they never masturbate, and report intercourse at frequencies of less than once a month on average.

Sexual Aversion Disorder – the thought of sex or a brief touch can evoke panic in the individual. Sometimes this represents the fear of sex evoking a panic attack. 20% of people with sexual aversion disorder meet the criteria for panic disorder.

Causes are still widely unknown.

Sexual Arousal Disorders:

Male erectile disorder – the problem is not with the desire, but with the arousal. Males are not able to achieve or maintain an errection.

Female sexual arousal disorder – Females are unable to achieve or maintain sufficient lubrication.

These difficulties are very common. In a community sample, 40% of men reported having occational erectile dysfunctions. 40% of men in their 40s and 70% of men in their 70s have erectile dysfunction.

For women, the average is 20% having sexual arousal disorder.

Orgasmic Disorders:

Inhibited orgasm – where the person is unable to achieve an orgasm. This is rarely seen in men, and mostly occurs in women.

Premature Ejaculation – 36-38% of men in community samples have premature ejaculation. This is ejaculation in 1 to 2 minutes. The average time is 7 to 10 minutes. An important aspect is that the man reports having a lack of control of the orgasm. It occurs primarily in young or inexperienced men, and decreases with age.

Sexual Pain Disorders:

Dyspareunia – persistent or recurrent pain before, during or after intercourse

Vaginismus – involuntary spasms within the outer third of the vagina that makes intercourse impossible.

The prevalence rates are 8-15% for women, and less than 1% for men (almost 0).

Causes:

May be fear of pregnancy, negative attitudes towards sex. One study found vaginismus occurred frequently after the female’s partner had gotten erectile dysfunction.

Biological:

Neurophysiological Diseases – causes loss of sensitivity in the genitals

Vascular disease – not enough blood makes it to the penis

Chronic Illness – e.g. heart disease, or congestive diseases

Prescription Medication – esp. SSRIs for depression

Alcoholism

Psychological:

Fear of inadequacy – distracts the individual from natural responsivity (performance anxiety). There may be arousal, but then cognitive processes kick in, and then there is the fear that the person will not be able to perform.

Assessment and Treatment:

Some brief direct successful day programs provide education and increse communication. The primary goal is often to eliminate performance anxiety. They teach sensate focus – non-demanding sexual pleasure. The couple engages in sexual activity throughout the day without engaging in intercourse. There is 100% successful therapy with this treatment. There is usually a single therapist with weekly appointments. Also, the squeeze technique benefits men. Using the squeeze technique, 60-90% of men are treated (squeeze the tip of the penis just before premature ejaculation).

Treatment of female are 60-90% effective. Here the female is instructed on how to pleasure herself, and on how to communicate to their partner what they want effectively.

For vaginismus, the female is treated with dialators which widen the vagina and reduce the pain. This is effective 80-90% of the time.

Low desire is treated by exposure to erotic material and is associated with 50-70% success rates. Viagra is 50-80% successful. Other options include injections of vasoactive substances directly into the penis. Surgically, penile prosthetics could be used.

Associated Features of Sexual Desire Disorder

• Religious orthodoxy
• Having sex with partner of non-preferred sex
• Fear of losing control
• Fear of pregnancy
• Depression
• Interpersonal tensions
• Lack of attraction to partner
• Sexual Trauma
• Fear of AIDS
• **Anger

A model of functional and dysfunctional sexual arousal

See figure 10.6

Aaron Clarke

27/03/01

Substance Disorders

Prior to 1980, the discussion of alcoholism and substance abuse was considered part of the discussion of personality disorders. Canada is a drug culture: we wake up to coffee and tea, we take alcohol to relax, and we take asprine to relieve pain. Drug use has been used historically for a long time. Cocoa was originally chewed by natives to enhance endurance, and cocaine was originally the main addictive substance in Coca-Cola. The piyoti cactus has been used by the Aztec for centuries to produce hallucinations in religious ceremonies.

Percentage of U.S. Population Reporting Drug Use in the Past Month (1995)

Substance Percentage Reporting Use

Alcohol 52.2

Cigarettes 28.8

Marijuana 4.7

Cocaine 0.7

Hallucinogens 0.7

Inhalants 0.4

Crack 0.2

Heroin 0.1

The current trend is toward declining drug use. Costs are over $200 000 000 due to accidents that are drug related. Alcohol is the cause of over half of all deaths related to homicide, and half of all deaths that are suicides.

Substance-Related Conditions Recognized by the DSM-IV

• Substance Intoxication
• Substance Abuse
• Substance Dependence
• Substance Withdrawal

Substance Intoxication

“Behavioural and psychological changes that occur as a direct result of the physiological effects of a substance on the CNS”

When intoxicated perceptions change, attention is diminished, one is easily distracted, judgement is affected, as is balance.

The specific symptoms of intoxication depend on what substance is taken, how much is taken, how long the substance has been ingested, as well as the user’s tolerance levels. Short term or acute intoxication can produce very different symptoms than long term intoxication. For example, people who initially take cocaine are friendly, but chronically, they become despondent.

People’s expectations about a substance’s effects influence the symptoms shown.

The environment or setting where the substance is taken can influence the types of symptoms people develop. A few drinks at a party lead to gregariousness, whereas a few drinks at home leads to tiredness and sadness.

The diagnosis of substance intoxication is only given when the behavioural and psychological changes cause significant disruptions in the person’s social and family relationships, occupational or financial problems, or place the person at risk for adverse effects e.g., accidents, medical ailments, legal problems.

Substance Abuse

• The diagnosis of substance abuse (SA) is given when the person’s recurrent use of a substance results in significant harmful consequences.
• There are four categories of harmful consequences that suggest SA in SSM-IV

Fails to fulfill important obligations at work, school, home.

Repeatedly uses the substance in situations in which it is physically hazardous to do so.

Repeatedly has legal problems as a result of substance use.

Continues to use the substance even tough he/she repeatedly had social or legal problems as a result of the use.

• A person has to show repeated problems in at least one of these categories within a 12-month period.

How much of a substance is ingested is difficult to determine, so the DSM has used how interfering the substance is as a diagnostic criteria instead.

Substance Dependence

• The diagnosis of substance dependence preempts the diagnosis of substance abuse, since dependence is considered a more advanced condition than abuse. This is what we are talking about when we colloquially talk about an addiction.
• A person is physiologically dependent on a substance when he/she shows either tolerance or withdrawal from the substance.

· Tolerance: requires greater and greater amounts of the drug to experience the same effect.

• Withdrawal: occurs when negative physical symptoms develop when the substance in no longer ingested.
• Physiological dependence, however, is not required for a diagnosis of Substance dependence. The diagnosis can be given when a person compulsively uses a substance.

With dependence, the person is often in a constant state of craving for the substance, and will often do anything to get it.

Symptoms of Substance Dependence

• Tolerance to the substance, indicated by a need fort increased amounts of the substance to achieve intoxication and or by a diminished effect of the same amount of substance with continued use, is experienced.
• Symptoms of withdrawal from the substance and the use of the substance to relieve or avoid withdrawal symptoms are experiences.
• The substance is used over a longer period of time or in larger amounts than was intended.
• The person has a persistent desire to cut down on substance use or stop using altogether.
• The person spends a great deal of time acquiring or using the substance or recovering from its effects.
• The person gives up or reduces important social or job-related activities as a result of substance use.
• The person continues to use the substance despite recurrent physical or psychological problems that result from substance use.

Substance Withdrawal

• Involves a set of maladaptive physiological and behavioural symptoms that result when people who have been using substances heavily for prolonged periods stop. Symptoms of withdrawal can begin after just a few hours of stopping consuming the substance (esp., heroin and alcohol).
• More intense symptoms of withdrawal usually end within a few days to a few weeks.
• Some withdrawal symptoms, including seizures, may develop from the elimination of high doses of substances such as the reduction of anxiolytics (e.g. zanex). Other symptoms include chills, fevers, diarrhea, vomiting, etc.

Easy to get hooked on, hard to get off (ranked in order of addictiveness)

Nicotine

Ice, glass (methamphetamine smoked)

Crack

Crystal meth (methamphetamine injected)

Valium (diazepam)

Quaalude (methaqualone)

Seconal (secobarbital)

Alcohol

Heroin

Crank (amphetamine taken nasally)

Cocaine

Caffeine

PCP (phenycylidine)

Marijuana

Ecstacy (MDMA)

Psilocybin mushrooms (magic mushrooms)

LSD

Mescaline

The different substances can be divided into 4 categories:

Depressants

Stimulants

Opiates

Hallucinogens

Alcohol

• Alcohol is a depressant – it decreases central nervous system activity.
• For the average person:
• 1 drink leads to a slight change in feelings
• 2 drinks (2 beers) leads to feelings of euphoria, warmth, loss of inhibitions and motor coordination, very friendly, taking liberties
• 3 drinks leads to exaggerated emotion and behavior, talkative, noisy, or dull and depressed; legally drink in may states
• 4 drinks leads to clumsiness, unsteadiness in standing or walking; legally drunk in most states
• 5 drinks leads to being very drunk; legally drunk in all states.
• Beyond 5 drinks you get fatigue, lethargy, reduced motivation, sleep disturbances, and psychological confusion. The average person is able to metabolize one drink per hour.
• In terms of alcohol intoxication, one thing that influences the intoxication is whether or not the stomach is full. When the stomach is empty, alcohol is quickly absorbed from the stomach. In France, where alcohol is usually consumed with the meal, alcoholism rates are lower, than in the US where alcohol is consumed on an empty stomach. Movement is labile, when one is intoxicated. With severe intoxication, the person may fall into a stupor or a coma. Large amounts of alcohol can lead to death.
• One third of deaths due to alcohol intoxication occur due to respiratory paralysis. Most alcohol related deaths are accident related resulting from car accidents, boating accidents etc.
• Half of all car accidents are alcohol related. More than half of all murderers are intoxicated at the time of their murders. Many people who commit suicide do so under the influence of alcohol. Alcohol has effects of disinhibition and impairs our ability to judge consequences.

Alcohol Use And Dependence

• Alcohol Abuse is the diagnosis given to someone who uses alcohol in dangerous situations, fails t meet obligations at work or at home due to alcohol use, and has recurrent legal or social problems
• Alcohol dependence is the diagnosis given to someone who has a physiological tolerance to alcohol, spends a lot of time intoxicated or in withdrawal, or continues to drink despite significant legal, social, medical, or occupational problems that result form the alcohol.
• There appears to be three distinct patterns of alcohol abuse:
• One is that the alcoholic drinks large amounts of alcohol every single day.
• The second type of drinking pattern of alcoholics is the showing of abstinence for a certain period of time, but then goes on binges for days of weeks.
• The third drinking pattern of alcoholics, is that they are sober during the week days, but drink heavily during the evenings or weekends.
• People who begin drinking early in life develop their alcoholic withdrawal symptoms during their early 30s and 40s.
• Three stages of withdrawal symptoms:
• Stage 1: Usually begins a few hours after drinking has stopped. Symptoms may include tremors, weakness, and heavy perspiration. At moderate levels of dependence the person may experience these symptoms for a few days and then they disappear all together.
• Stage 2: The person experiences convulsive seizures that usually occur between the second and third day.
• Stage 3: Characterized by delerium tremmons (a.k.a. the DTT’s) where the person has auditory, visual, and tactile hallucinations, and the person often experiences delusions. The person often experiences agitation, disorientation, and is stuck in a fever. In 10% of cases, this level of withdrawal will lead to death. Fortunately, only 11% of individuals with alcoholism will experience DTTs or stage 2 symptoms.

Dementia, Wernicke’s Disease & Koraskoff’s Resulting From Alcoholism

Dementia: may occur as a result of neurotoxicity of the brain by excessive amounts of alcohol – resulting in a loss of intellectual abilities including memory, abstract thinking, judgement, problem-solving, often accompanied by personality changes. Dementia occurs in about 9% of those diagnosed with substance dependence (alcoholism) and is the second greatest cause of adult dementia.

Wernickes Encephalopathy: involves mental confusion and disorientation – leads to permanent cognitive impairment

Korsakoff’s: alcohol induced permanent cognitive disorder involving deficiencies in memory functioning.

The effect of alcohol use extend beyond the well being of the drinker. The effects of alcohol can extend to the children born to mothers who are alcoholics. This effect is termed Fetal Alcohol Syndrome. The child may be born with fetal growth retardation, cognitive deficits, behavioural problems, and learning difficulties. The development of fetal alcohol syndrome is dependent on high alcohol use and a genetic risk factor. Alcohol use has diminished over the past 20 years.

In terms of gender differences, males seem to be most vulnerable to drinking problems. The age of particular risk is between the ages of 18 and 29. In this age group, 14% of males report symptoms of dependence on alcohol. The rates of actual alcohol dependence seem to be about 5%, and this figure doesn’t really change across the life span. At greatest risk are single males. About 20% of people with severe alcohol dependence have a spontaneous remission.

Jellinek, 1952

Mailed out 1600 study packages, and was returned 98 of them for his research in which he found the following:

Pre-alcohol stage – occasional drinking, no consequences

Prodromal stage – drinking heavily, no problems

Crucial stage – loss of control, occasional binges

Chronic stage – daily activities revolve around drinking

A fair amount of research has not supported this model.

Schuckit et al., 1993

In their 20s, about ¾ of those who are heavy drinkers will begin to show difficulties at work, including demotions.

In their 30s the person begins to experience blackouts.

In their 40s the person experiences long term difficulties including seizures and perhaps hepatitis.

Other depressants include:

The benzodiazephines

The barbiturates

Inhallents

The Benzodiazephines include:

Zannex

Valium

Helcium

Safer than Barbituates

Barbituates (Qualudes)

Are legally manufactures and sold for the treatment of anxiety and insomnia.

3 billion doses of barbiturates are consumed each year.

Benzo and Barbituate use tends to:

Be done by teenagers or young adults at parties to produce a feeling a sense of well being. This escalates to chronic use and physiological dependence.

The second pattern is seen by people who use sedatives under their physician’s care. They abuse the prescription.

The result is decreased blood pressure, respiratory arrest, or cardiovascular collapse.

Inhallents:

Solvents such as glue, paint thinners, and spray paints. The person using these often soaks rags with these solvents and holds these rags to their noses. These are fast acting, and are often used by boys who are 15 years old. At greatest risk are Native American teenagers. These inhallents can cause permanent damage to the CNS and can lesion the brain. They can also cause hepatitis. The prevalence of inhallent use is 20% in US high schools.

Unfortunately, from the video, it can be seen that the person doesn’t have a rich emotionally descriptive language, and he doesn’t have any other coping strategies for dealing with problems (other than alcohol abuse).

Stimulants

These include caffeine, nicotine, amphetamines, and cocaine.

Stimulants make you more alert and energetic

Amphetamine Use Disorder:

DSM-IV diagnostic criteria fo ramphetamine intoxication include significant behavioural symptoms including euphoria, anxiety, tension, and anger. Amphetamine tolerance builds up quickly, and withdrawal is associated with long periods of sleep. Ecstasy is a very popular form of amphetamine, used often by high school students. It was introduced in 1912, marketed as an appetite suppressant. It has been readily available in the last 10-15 years here in North America. New York Times has reported that the use of Ecstasy in no longer being used just in clubs, but is being used in the larger population. In 1996, 8 pounds of Ecstasy, were picked up crossing the border. By 1999, this number had increased to 800 pounds. In 2000, 8 000 000 doses of Ecstasy were found crossing the boarder. Chronic use is associated with depression, suggestion of effects on memory (memory loss), and potential brain damage. In over-dose, it can lead to high blood pressue, fainting, and panic attacks. The amphetamines stimulate the nervous system by enhancing the actgivity of norepinephrine and dopamine. Over-activity in this area can lead to hallucinations.

Cocaine Use Disorders:

Cocaine became popular in the 1970s. In small amounts, cocaine leads to feelings of euphoria, alertness, feelings of self confidence, and creativity. This comes as cocaine activated the areas of the brain associated with reward and pleasure. These effects are often short lived (around 1 hour), and so the user must take frequent doses. Tolerance can develop very easily with cocaine. At high doses, or even when taken chronically, cocaine can lead to hypersexuality, agitation, and increased anxiety and paranoia. In fact, 2/3 of cocaine users report paranoia.

Many cocaine users started with chronic alcohol or marijuana use, and then moved on to cocaine. Cocaine makes the heart beat more rapidly and more irregularly, potentially leading to heart failure. Babies may also be affected by mothers using cocaine. These babies are known as Crack babies, are more irritable, and have a high pitched squeeling cry. The effects may be due to the cocaine, or to other substances (such as alcohol or nicotine).

Stimulants

Opiods

Includes substances such as morphine and heroin

The word opiod refers to the natural chemicals present in the poppy, which have a narcotic effect (i.e. they relieve pain and induce sleep).

Our bodies produce natural opiods such as endorphins to relieve pain. Herion and opium induce our natural endorphins to relieve pain and induce sleep.

When used illegally, opiods are usually injected directly into the veins, snorted or smoked.

Opiods tend to create a sensation of euphoria, and may elicit a sensation a kin to sexual orgasm.

After this high, the person falls into a state of lethargy, and are clouded (“they are in the nodd”)

Severe intoxication on opiods canlead to comas, seizures and respiratory failure.

In conjunction with depressants, opiods produce a very high risk of respiratory failure.

Anxiety, withdrawal and agitation follows withdrawal from opiods.

There is a great risk of contraction HIV from using used needles if you are a heroin addict. 66% of heroin addicts are HIV positive.

Amongst 500 addicts, 28% died on follow up, due to overdose, with a mean age of 40.

Additionally, 11% were incarcerated.

Hallucinogens

Hallucinogens are very different from stimulants and depressants. They are taken for their ability to alter perception.

Hallucinogens, phenylcyclidine (PCP), and cannabis differ in their mechanisms of action on the body but produce similar psychological effects - will consider them together.

Hallucinogens = LSD, ecstasy, and peyote.

LSD is the most common hallucinogenic drug (with E in close competitin).

PCP can be ingested, or smoked, and produces at low doses, euphoria, at moderate doses it leads to distortion of thinking and distortion of body image, and at high doses can lead to seizures and respiratory arrest.

The effects of Hallucinogens are immediate, and may last for days.

Only 1% of teenagers had tried PCP in 1984.

Marajuana causes feelings of well-being, relaxation and tranquility. Cannabis is a mood enhancer, moving the person in the direction that they are inclined to feel. Everything seems funny when you are high on cannabis.

Theories of Substance Use Abuse and Dependence

Most of the theories we can discuss have been used to explain the develooment of use and dependency on a whole range of addictins to different substances, but primarily focus on alcoholism. Alcoholism was originally regarded as a moral deficiency, were the person was weak and could not control themselves. This model has been replaced by the disease model of alcoholism. Now, alcoholism is looked at as an incurable disease like epilepsy.

Theories of Etiology

Biological Models

Family history, adoption, and twin studies all suggest that genetics may play a substantial role. The sons of alcoholic fathers are 4 –5 times more likely to develop alcoholism than are sons of non-alcoholic sons. Mucuge found that the concordance rate for alcoholism was 0.76 for monozygotic twins, and 0.53 for dizogotic male twins. For female twins, it was 0.38 for monozygotic twins, and 0.42 for dizogotic twins (NS). The strongest genetic factor was found to be for early onset alcoholism. What is inherited in this risk, is that people with this genetic risk factor report less intoxication with small doses of alcohol than do people without this genetic risk factor. There seems to be lower reactivity to moderate doses of alcohol in this genetic predisposition, leading to the requirement for more alcohol to achieve intoxication, and faster build up of tolerance. Long term studies of men with lower reactivity to moderate doses of alcohol show that they are significantly more likely to become alcoholics than are men with out this low reactivity.

Neurobiological Models

All of the studies we have talked about so far have effects on the brain. The mesolimbic dopamine system in particular seems to be widely implicated. It is activated by natural rewareds of many kinds (e.g. good food, sexual pleasure). The mesolimbic dopamine system is more intensely activated by drugs than by natural pleasure. One hit of cocaine feels so good that you keep wanting to come back to it. When the mesolimbic system is activated the brain may try to counter the effects by releasing factors that have the opposite effects of the drugs. This is known as the opponent processes. The opponent processes may remain active after the substance use has been stopped, and it may be that it is these opponent processes that produce withdrawal symptoms.

Chronic use may permanently affect the mesolimbic dopamine system causing craving for the abused substances even after the drug use has stopped. There is increased sensitivity in the mesolimbic dopamine system after drug use, leading to a strong craving for the used substance.

Psychological Models

Reinforcement Models

All of the psychoactive drugs are pleasurable in some way. From a psychological perspective, these reinforcing effects may be particularly attractive to people under great stress. Higher rates of abuse and dependence among people facing severe chronic stress. This includes people living in impovrishment, amongst women in abusive relationships, and amongst adolescents living in families experiencing conflicts. About 20% of Vietnamese people used Heroin during the war, and 50% continued using even after the war. Drugs also help people escape from pain. Opiods help people escape pain, alcohol helps people escape stress.

Cognitive Factors

Cognitive theories have focused on people’s expectations about the use of the drug. Peoples expectation will determine weather or not people will g o on to use the drug, and the beliefs about the appropriatnes of using the drug might also predict those who go on to abuse or dependence. People who expect alcohol to reduce their stress and who don’t have other means of coping are more likely to resort to alcoholism.

See Figure 11.11 - An integrative model of substance related disorders.

Treatments

The first step in treatment is getting the person to Detox. They have to get off the drug, and the drug must be allowed to exit the body. Once the drug is out of the body, a variety of treatments are available to prevent relapse. Symptoms of withdrawal may be so severe that other drugs may be prescribed to reduce symptoms. In alcohol dependence, a benzodiazopine may be prescribed to reduce dependence (the dose is really low to prevent addiction). Gradual withdrawal from heroin can be used through the use of a substitute drug known as methodone. Methodone is an opiod itself, but it is less potent, and longer lasting than heroin. Heroin dependents are given drugs that reduce the effects of heroin. Neltraxone and melaxone block the effects of opiods, preventing the effects of heroin. Neltraxone also removes the effects of alcohol. Antabuse makes people vomit if they consume alcohol. Psychosocial treatment is usually done through AA. In this treatment, people completely abstain from drinking. This is done in 12 steps. The people have to accept that they are powerless, and that there is a need for a higher power. These features don’t appeal to everyone. Drop out rates in an AA program tend to be 75%. Yet, AA remains the most common source of treatment with alcoholism. There are 23000 chapters of AA.

Aaron Clarke

03/04/01

Personality Disorders

We have all developed personality traits. These traits probably develop early in life, and hare partially genetically determined. Also, we learn ways of dealing with stress while young, and these shape our personalities. Some traits to talk about might be shyness versus outgoingingness, closedness to experience, openness to experience, sloppyness, neatness, etc.

For a personality disorder to be diagnosed, the personality traits must be distressing to the person, and they must cause disruption in their daily lives. Personality disorders are more disorders characterized by degree and not by kind.

The DSM-IV list 10 distinct personality disorders. There are a few more disorders that arre currently under investigation. In addition to personality disordes are often co-morbid with axis one disorders. What we could say is that personality disorders often serve as a context for understanding an axis one disorder. For instance, a person might be anxious on axis one, and avoidant on axis two. This person would manifest differently on a personality disorde than someone else.

Personality disorders are a heterogeneous set of disorders coded on the axis 2 of the diagnostic system. The personality disorders are long standing, pervasive, and represent an inflexible pattern of behavior and inner experience. Their own internal experiences are considered different from what the average person would experience. The behavior is deviant for the person’s culture, and leads to social and occupational impairment. The personality disorders may also cause emotional disturbance, but this is not a criteria for the disorder. Personality disorders are chronic, they start in childhood, and continue into adulthood. This is a very controversial area. One issue in this area is whether or not personality disorders are extremes of normal personality functioning, or whether there are categorical differences from the traits of normal people.

Neuroticism I am not a worrier(-)

I am not easily frightened (-)

I rarely feel fearful or anxious (-)

I often feel tense or jittery (+)

Extraversion/introversion I really like most people I meet (+)

I don’t get much pleasure form chatting with people (-)

I’m known as a warm and friendly person (+)

Many people think of me as somewhat cold an distant (-)

Openness to experience

Agereeableness/antagonism

Conscientiousness

Widiger (1991)

A dimensional system of diagnosis would retain more information about each individual than would a categorical system.

It would be more flexible because it would permit both categorical and dimensional differentiations among individuals, i.e., cut-off scores.

It would avoid the often arbitrary decisions involved in assigning a person to a diagnostic category - linear associations?

A major problem with diagnosing the personality disorders is diagnosing them reliably. There is doubtful reliability in personality disorder diagnosis, but this has been improved upon a lot in the last 7 or 8 years.

Diagnosis Interrater Reliability Test-Retest Reliability

Paranoid .75 .57

Schizoid .83 --

Borderline .89 .11

Histrionic

Narcissistic

Antisocial

Dependent

Avoidant

Obsessive-compulsive .82 .52

Generally, interrater reliability isn’t bad (above .75) but test-retest reliability is poor.

Diagnostic Overlap of Personality Disorders

Percentage of People Qualifying for Other Personality disorder Diagnoses

Diagnosis	Paranoid	Schizoid	Schizotypal	Antisocial	Borderline	Histrionic	Narcissistic	Avoidant	Dependent	Obsessive compulsive
Paranoid		23.4	25	7.8	48.4	28.1	35.9	48.4	29.7	7.8
Schizoid	46.9		37.5	3.1
Schizotypal

The personality disorders should not be dismissed as they cause impairment and distress in the person’s life.

The personality disorders fall into 3 clusters.

Cluster A: Those who are odd or eccentric.

Cluster B: Dramatic, emotional or erratic.

Cluster C: Anxious or fearful.

Cluster A (Odd and Eccentric)

Paranoid Personality Disorder

These are people who are very suspicious of others, they expect to be mistreated, and expect to be exploited. These people are secretive, and hypervigillant for mistrust. People with this disorder are preoccupied with the loyalty and trustworthiness of others. Even events that have nothing to do with them may be interpreted as personal attacks. They are hypervigillant for criticism. This makes meaningful relationships quite difficult. The person who receives this diagnosis is often hostile and reacts angrily for the insults. These individuals are reluctant to confide in others. They tend to blame others and hold grudges even when they themselves are at fault. Interpersonally, people with this diagnosis tend to be extremely jealous. This person is particularly sensitive to criticism in relationships, and overreact with anger.

Schizoid Personality Disorder

People with this diagnosis are aloof and unemotional. They have no desire to be with other people. This person is usually lacking in close, meaningful relationships and usually reports the complete absence of friends. They are often described as cold, indifferent loners, and in their leisure time they usually persue solitary events. For careers they usually choose occupations that don’t require interpersonal interaction. Thos with a schizoid diagnosis feel that they are observing the world, but that they are not really a part of it. These symptoms overlap with the prodromal phase of schizophrenia (the beginning phases of schizophrenia).

Schizotypal Personality Disorder

People with this disorder are isolated, and often have very high social anxiety. They also experience more severe and odd symptoms as well, they have odd beliefs, and magical thinking. They tend to be superstitious, and hold beliefs that they are clairvoyant or telepathic. They report more recurrent allusions (when you see something in a wrong way). Additionally, the person with this diagnosis tends to have ideas of reference, they are often suspicious, and they tend to be paranoid. There is some support for the idea that schizotypy is a precursor to schizophrenia.

Causes:

The cluster A personality disorders are genetically linked to schizophrenia. Family studies have consistently shown that the relatives of schizophrenia patients are at increased likelihood for receiving a diagnosis of schizotypal personality disorder. This co-occurrence, however, might be the result of depression in the family. There is no clear patter on behaviour genetics in the cluster A disorders.

Common Core Beliefs and Strategies in Personality Disorders (DSM IV)

Personality Type	Self Schemas	Other Schemas	World Schemas	Interpersonal Strategy
Paranoid	Right/Noble	Malicious	Intricate	Suspicion
Schizoid	Self-Sufficient	Intrusive	Unimportant	Isolation
Schizotypal	varies	varies	varies	varies
Antisocial	Strong/Alone	Exploitative	A Jungle	Deceive; Manipulate

Cluster B (Dramatic, Emotional, Erratic)

Antisocial Personality Disorder (a.k.a. psychopathy, sociopathy)

The DSM definition includes two criteria. The first is the presence of a conduct disorder before the age of 15. A conduct disorder includes truancy, running away from home, larson, lying, theft. The second criterion is that there is continuation of this pattern into adulthood. The person with this diagnosis tends to be impulsive and shows regard for neither truth nor remorse. This person is very low in their ability to empathize with others. This person has superficial charm, and a grandiose sense of self-worth. They also have a lack of remorse. 75% to 85% of convicted felons meet the criteria for APD.

Hare

Made a standardized questionairre that breaks down psychopathy into emotional detachment, selfishness, inflates self-esteem, and they enjoy exploiting others. They have a lifestyle that is marked by impulsivity and irresponsibility.

Causes of Antisocial Personality Disorder:

Genetic:

Family, twin, and adoption studies find that there is a genetic influence on having this diagnosis and criminality. Genetic factors may present a vulnerability, but it is fairly clear that the genetic factors require the presence of environmental factors. One key environmental factor may be poor emotional contact with the parents.

Early study by Eysenck and Eysenck (1978) found that concordance for criminality in monizygotic twins was 55%, but was only 13% in dizygotic twins.

Neurobiological Influences:

Underarousal hypothesis. The starting point is that psychopaths have abnormally low levels of cortical arousal. The argument is that this is what leads to risk taking behaviours. They have to engage in risk taking behaviours to increase their arousal. Raine et al., found that future criminals had lower skin conductance in childhood, and had lower resting heart rates and had much lower brain wave activity than did children who were not to become criminals.

Fearlessness hypothesis. This hypothesis suggests that psychopaths have a higher threshold for experiencing fear than other individuals, and that this may give rise to engaging in high risk criminal behaviours. Lykken found that when psychopathic participants were exposed to the potential occurrence of shock, that those with a diagnosis showed a low galvanic skin response. The person can’t anticipate consequences.

Family Factors:

Early literature form the 1960s suggested that psychopaths received little affection from their parents, and severe parental rejection. More recent literature has focused on the importance of inconsistencies in disciplining the child. For example, the coercive family process is where there is harsh and inconsistent parenting, and the parents of these children alternate from being either neglectful, or attentive, but hostile and even violent toward these children. These children learn ways of thinking about the world through their interactions with their parents, and expect others to treat them the same way. Young children who are destined to receive a diagnosis for this disorder have an assumption that other children are going to act that way towards them. They misinterpret normal playful behavour as signs of aggression towards them. That might be why we see a lot of aggressive behaviour in these children – they want to do it first before others get them.

Social Factors:

An early study in Chicago in the 1970s demonstrated that the degree of mutual trust and solidarity in the neighbourhood was tightly correlated with the amount of crime in the neighbourhood.

In summary, there does appear to be a genetic vulnerability in the diagnosis of APD, along with a potential neurobiological influence through either underarousal or fearlessness, and family factors might also influence the occurrence of the disorder.

Borderline Personality Disorder

This disorder is characterized by instability in relationships in mood, and in self image. The person with BPD is unstable in their emotions, and they experience rapid changes in their relationships with friends. They are argumentative, irritable, sarcastic, and quick to take offense. They lack a clear sense of self, not knowing who they are. They can’t bear to be alone. They tend to have one on one relationships that are stormy, intense and unstable. They often have choronic feelings of depression and loniness. About 6-5% of people with this diagnosis will commit suicide?????????

Acounts are about 15% of the population may have BPD. 50% of all personality disorder diagnoses are of BPD. Depression is very co-morbid, as are eating disorders, and eating disorders.

Causes:

Genetic:

Connected to mood disorders. Depression in families increases the probability of diagnosis.

Sexual abuse also has a strong influence, leading to a 90% probability of developing BPD. 20-40% of people with BPD have no history of sexual abuse though.

Histrionic Personality Disorder

The diagnosis of HPD was formerly called hysterical personality disorder. The person is characterized by overdramatic and attention seeking behaviour. They express their emotions as if they are actin all the time. They often use features of their clothes, hair and makeup, to draw attention to themselves. These people are uncomfortable when they aren’t the center of attention. People receiveing this diagnosis are often sexually seductive. Their speech is characterized by very strong opinions with little support for their opinions. The prevalence of HPD is higher among separated and divorced people and is associated with high rates of depression. People with this diagnosis are more likely to be living alone, and to have more health complaints than normal controls. There is very little research on this diagnosis. The psychoanalytic study of this disorder has focused on the sexual relationship between the daughter and the father. HPD and antisocial personality disorder co-occur very often. These disorders are very sex typed, where in men, the disorder becomes APD, and in women, it becomes HPD. 40% of males were APD and 2% HPD, and 2% of females were APD and 40% were HPD.

Narcissistic Personality Disorder

This describes someone who has an exaggerated sense of self-importance and fantasies of great success. This person requires constant attention and admiration to feel good about themselves, and feels that they can only be understood by people of high status. Interpersonal relationships are disturbed by the absence of empathy, and the person appears arrogant and has feelings of entitlement. The person also has feelings of envy, and has extreme reactions to criticism. Persons with this disorder have a grandiose view of their own abilities and of their own personhood. The person who is narcissistic in appearance is really masking a poor sense of self-esteem. They try to attain self-esteem and attention through others. Relationships end in disappointment because people fail to meet their expectations for attention and admirations.

Kohet

Suggested that the failure to develop healthy self-esteem appears when parents fail to respond with approval to their children when they try to show displays of competency. Kohet’s clinical approach was to try to mother and father his patients, increasing their self-esteem. This only helps to a small extent.

Cluster C

Avoidant Personality Disorder

This disorder is characterized by keen sensitiveity to the possibility of criticism, rejection and disapproval. They are reluctant to enter into relationships unless they are certain they will be liked. Even if people demonstrate a liking for the patient, they feel doubt that the person is being sincere, or they fall into a very dependent relationship with the person. APD patients feel incompetent and inferior to others. There is an 80-85% chance that a person with this disorder will also have social phobia. People with this disorder, though, don’t necessarily have the same sense of anxiety in social situations.

Dependent Personality Disorder

Lack self-confidence, and the perceived ability to be self-reliant. They rely on others to make every day, and important life decisions, for them. They are hypervigillant to loosing approval. They have trouble initiating activities and feel uncomfortable when they are alone. This diagnosis may occur as a result of the early loss of a parent and abandonment.

Obsessive Compulsive Personality Disorder

Very preoccupied with rules, and schedules. They often pay so much attention to detail that they never finish projects. As a general outlook, these are people who are work oriented, not pleasure oriented. Their interpersonal relationships are often poor because they tend to be stubborn and demand for things to be done their way. They are stingy and formal. There is a 30% overlap between obsessive compulsive disorder and obsessive compulsive personality disorder. The key risk for developing both disorders are perfectionism. Loss of a parent may pre-dispose one to have one of these diagnoses. Right now we don’t have very well developed research based treatments for OCPD.

10/04/01

AaronClarke

Schizophrenia

The Concept of Schizophrenia

• Affects one in one hundred individuals
• Emil Kraeplein (1898) – Dementia praecox
• DP included paranoia, catatonia, and hebephrenia
• More descriptive than explanatory
• Praecox means early. Kraeplein believed that paranoie, catatonia and hebephrenia onset early in time in the disorder. Kreaplein believed that the disorder was a mental weakness. People would have hallucinations, delusions, negativism (lack of social engagement), attentional difficulties, stereotypical behaviours, and emotional dysfunction according to Kraeplein in the disorder of Dementia praecox. Kraeplein was the first to examine schizophrenia.
• Eugene Blueler (1908) – Schizophrenia
• Wanted to theorize about the core of the disorder and reduce the age of onset and course of the disorder in emphasis.
• Schiz (split) and phren (mind) – “breaking of associative threads”
• Argued that the core feature was the breaking of associative threads (words and thoughts). Disorder, then is characterized by difficulty with language and thinking.

The number of patients diagnosed with this disorder are extensive, but the symptoms between the diagnosed patients are diverse, and the disorder is very heterogeneous. People have subsequently tried to split the symptoms into smaller categories.

Positive Symptoms

Positive symptoms are an excess of what is normally expected (e.g. a hallucination, delusion, and disorganized speech).

Comprise excesses such as hallucinations, delusions, and disorganized speech.

Delusions: are beliefs held contrary to reality. Tends to be fixed and inflexible (not really open to change). E.g., grandiosity, religious, thought broadcasting (receives messages from their radio or television), ideas of reference (“everything in the world has to do with me”).

Delusions are found in more than ½ of the people with this diagnosis. Delusions are also common in manic depressive disorder. Schizophrenics, however tend to have more bizarre delusions.

Hallucinations: distortions of perception. The world seems somehow different or bizarre to the patient. Something in the world exists, and no one else can see it.

Usually auditory but can occur in all senses. Can be one voice offering suggestions about what to do (offering a running commentary), or can be conflictual with ongoing arguments, or the voices may tell the person what to do (command hallucinations). Command hallucinations can be dangerous if they tell the person to be violent or kill someone. The voices tend to be mood congruent. About 5% of the population will report having hallucinations. People under great stress or who are being tortured will hallucinate. Some people are prone to hallucination.

Negative Symptoms

Avolition – apathy and lack of energy and interest in performing routine activities.

Some people with this diagnosis will report having difficulty dong daily activities, like grooming and bathing. These people spend a lot of time just sitting around.

Alogia – relative absence of speech. Poverty of speech v.s. poverty of content. In poverty of speech, the person uses few words. In poverty of content, the person speaks with an average number of words, but there isn’t much meaning in what they say, the information tends to be repetitive.

Anhedonia – inability to experience pleasure. Reflected by a lack of interest in recreational activities, eating being with other people, or having sex.

Affective Flattening – where no stimulus can elicit emotional response. The person is unresponsive to any stimuli, the patient stares vacantly, with an expresisonless face, with flat tone of voice. Here there is marked emotional disfunction. Krink and Neil (1996) had patients with schizophrenia and normals watch emotionally engaging movies and report on their enjoyment of the movies, and their facial expressions were recorded. Schizophrenic faces didn’t show emotional valence, but the subjective emotional reports were the same for both groups. Therefore, schizophrenia might not be an emotional impairment, but an impairment in showing emotion through overt signals (like the face).

Disorganized Speech – problems in the organization of ideas and speech in a way that is understandable to the listener. What the person says is out of context. The person might also display loose associations, where they do a pretty good job of figuring out what is going on in the sentence, but has trouble staying on one idea. Another symptom is inappropriate affect where the person laughs at the wrong or inappropriate time.

DSM – IV Cirteria for schizophrenia

At least 6 months of disturbance, which includes at least one mingh of the active phase

Active phase defined by two or more of:

Delusions

Hallucinations

Disorganized speech

Grossly disorganized or catatonic behaviour

Negative symptoms.

The phase that comes before the active phase is the prodromal period, and incoudes the following problems:

Social withdrawal

Impairments in role functioning

Lack of initiative

Impariment in hygene or grooming

Odd beliefs start to develop

After the acute phase has come to an end, the residual phase occurs:

Withdrawal of symptoms

Person may start loosing the positive symptoms, but maintain the negative ones.

Schizophrenophorm Disorder:

Same as schizophrenia, but doesn’t go beyond a 6 month time frame.

Brief psychotic disorder:

An active hallucination or dellusion lasts between 1 and 30 days, usually brought on by extreme stress or berevemet.

Schizophrenia Subtypes

• Paranoid Type:
• Delusions and hallucinations have a theme focused on being prosecuted.

o No marked disorganized speech or behaviour, or impairment in affect. No negative symptoms.

• Good prognosis.
• Disorganized Type:
• Marked disruption of speech and behavior.
• Grave allosia.
• Flat or inappropriate affect.
• Delusions and hallucinations not organized around a theme.
• Chronic form of illness with poor prognosis.

o Catatonic Type:

o Display odd mannerisms with bodies and faces – such as grimacing.

• Repeating or mimic words of others (echolalia)
• Undifferentiated Type:
• Include major symptoms of Schizophrenia but who do not fit into one of the three previous catgories.
• Residual Type:
• When the patient no longer meets full criteria, but still shows some “leftover” signs of the illness.
• Residual symptoms include social withdrawal, bizarre thoughts, inactivity, and flat affect.

Evaluation of Subtypes

• The usefulness of subtyping is often questioned:
• Diagnosis is difficult
• Moving towards subtyping may reduce reliability in diagnosis.
• The subtypes also have very little predictive validity.
• There is overlap between the subtypes (may be paranoid but also undifferentiated).

Crow (1980)

Introduced type I and type II schizophrenia, where type I is like positive schizophrenia, and type II is very much like the negative symptoms.

Epidemiology

• Age of onset:
• Peak age of onset for men = 18-25, women = 25 – mid 30’s. Women’s later onset may be due to the decreasing levels of estrogen as the woman approaches menopause.
• Early adolescence male to female ratio = 2:1
• Course:
• Most fluctuate between severe and moderate levels of impairment throughout their lives
• ¾ of patients will experience multiple episodes, with various degrees of impairment.

Tardative dyskinesia may result from the antipsychotic medications that are prescribed to schizophrenics. New treatments are being developed that don’t require medication.

The argument for social drift is the migration hypothesis. That is, there are more schizophrenics in the limits of the inner city because they migrate there due to lower living costs.

Julian Left (2001)

The incidence of schizophrenia in the urban centers has been correlated also with living alone. Additionally, having only 3 friends in childhood and adolescence is predictive of schizophrenia. Additionally, parental absence from the home is also predictive of schizophrenia.

50% of people with social anxiety are onsetting before the age of 10, so a person with schizophrenia might develop social anxiety before schizophrenia.

Schizophrenia as a function of degree of relatedness

Across different genetic methodologies, there is strong support for a genetic link in the occurrence of the illness.

If a person has 2 parents with the illness, there is a 46% chance that the person will develop the disorder.

If they have an identical twin with schizophrenia, the chances are 46%

Fraternal (DZ) twin – 14%

Offspring of one patient - 13%

Sibling – 10%

Nephew or niece – 3%

Spouse – 2%

Unrelated person – 2%

There is no evidence to suggest that particular subtypes are inherited, only the general illness. The genetic predisposition is particularly relevant in females and early onset schizophrenics.

Causes of Schizophrenia – Genetic Data

Family studies

Demonstrate a clear genetic relationship

Twin Studies

There is 3x the rate of incidence of the disorder in monozygotic twins over dizygotic twins.

Probands from concordant pairs were higher in negative symptoms, not the positive symptoms. Therefore, negative symptoms are more inheritable.

Adoption studies looked at 155 of offspring of mothers with schizophrenia, compared to 180 controls. There were 16 offspring diagnosed with schizphrenia in the schizophrenia group, but only 1% were diagnoses in the control goup.

Genetics play an important role in the occurrence of the disorder. Genetics doesn’t explain all of the variability in the data, however, and it isn’t certain how many genes contribute to the occurrence of the disorder. Very few genetic linkage analyses are replicated. The nature of the inherited risk is unknown, we don’t know what is inherited. We do know that smooth pursuit eye movement is disrupted in schizophrenics and they use saccads. Also, 50% of first degree relatives have trouble with smooth pursuit eye tracking movements. This may represent troubles in the frontal lobes.

Neurobiological Influences

Dopamine

Drugs that are effective in treating schizophrenia alter dopamine levels. Dopamine agonists increase schizophrenic behavior, and antagonists (neuroleptics) decrease schizophrenic behaviour. One proble with the dopamine hypothesis it that the measurement of neurostansmitters in the brain can be measured only indirectly by measuring the byproducts of the neurotransmitters in the brain. This is probably not that accurate. Recent research has suggested an interaction between dopamine and seratonin.

Brain Abnormalities

The search for brain abnormalit was the beginning for a diagnosis for schizophrenia. About 50 studies have looked at the brains of schizophrenics, particularly looking at enlargement of ventrical size in schizophrenics. These studies have mostly confirmed the theory that the ventricles are enlarged in schizophrenics. This means that parts of the brains of schizophrenics haven’t fully developed, or there has been atrophy, where theventricles have grown to fill the space. These findings, however, have mostly bveen found to be true only for men with the illness. People with schizophrenia tend to have hypofrontality (lack of functioning in the frontal lobes), which may be predictive of negative symptoms.

Viral Infection

Early pre-natal exposure to influenza might increase the probability of schizophrenia. In Scandanavia, it was found that after a flue epidemic in Helsincy, mothers who were exposed to flue in the second trimester in pregnancy were much more likely to have children with schizophrenia than were mothers who were not exposed to flue during the second trimester. Cortical development is in a critical stage of growth during the second trimester. Post mortem analysis of schizophrenics have shown reduced numbers of cells in the cortex, particularly in the pre-frontal area, and to some extent in the temporal area. Patients with schizophrenia also have a thinner cortex.

Psychological and Social Influences

The study of High-Risk Children

Mednick et al. (1960s) – “instability of early life environment” predicted whether or not the children would go on to develop schizophrenia. This suggests that an environmental factor is essential for the genetic predisposition to be manifested.

Ventura et al. (1989) – number of steressful life events. Prior to onset, schizophrenic patients report more interpersonal stressors than controls. Also, relapse was more likely to occur when there was stress in the one month previous to the relapse.

Family and Relapse

Early theories focused on the relationship between the mother and the child. This view was so predominant in the 1960s, that they coined the term “schizophrenic mother” where the mother was said to produce the schizophrenia in the children. This theory has been disproved.

Recent work has examined family interaction patterns in relapse. One pattern is expressed emotion. Expressed emotion includes the following dimensions: criticism, hostility, and emotional over-involvement.

Biological Treatments

Insulin Coma therapy

Patients were injected with massive doses of insulin until they became comatose.

Psychosurgery (e.g., prefrontal lobotomies) - 1930s

ECT – 1930s

Neuroleptics – help patients to think more clearly and are effective in reducing hallucinations and delusions. They are dopamine antagonists and act as dopamine reuptake inhibitors. The conventional neuroleptics are effective in about 60% of patients. Upwards of 2/3 of patients may still experience delusions and hallucinations even when they are adhering to their medications. 75% of patients will not be compliant with their medications (both inpatient and outpatients). This may partly be because of the tardative dyskensia. The atypical neuroleptics have less side effects, but the patients may gain 25 to 50 pounds, increasing the risk of diabetes, cardiovascular mortality, and general dysatisfaction. Tardative dyskenesia occurs in about 25% of patients. Medications are an obvious starting place in the treatment of schizophrenia.

Freud believed that patients with schizophrenia were beyond help. This belief was partly predicated on the fact that he believed that they have trouble establishing interpersonal relationships, which are crucial to psychoanalysis.

Neo-Freudians tried to help schizophrenic patients develop an adult communication style.

The overall evaluation of schizophrenic patients being psychoanalyzed has not been good, and a moratorium on schizophrenic psychoanalysis has been enstated.

Family therapy is more helpful. Educating the family about the illness and helping them express both positive and negative feelings in an empathic way help to prevent the stressors that lead to relapse.

Paul and Lentz started the behavioural therapy model, where schizophrenic patients are positively rewarded for their involvement in society.

New Developments in understanding Schizophrenia from a Cognitive Behavioural Standpoint

In the DSM, a delusion is seen as inflexible and stable in time. This is not consistent with the data showing that delusions are not stable over time. As subjects delusions decrease, so does their distress about the delusions. If we help people reduce their delusions, then, they may experience less distress (we should then talk to them about their delusions).

Bizarre Beliefs

Information-processing biases contribute to development

Overstimate coincidences, “jump to conclusions”, engage in self-serving biases (good things are my fault, bad things are the fault of others), or threat-related stimuli biases (actively delusional people have greater sensitivity to threat).

Maintained by recruiting supporting evidence and ignoring or minimizing disconfirming evidence.

Hallucinations

Misinterpret ambiguous external stimuli (e.g. muffled sounds a words). Suggests a cognitive perceptual difficulty.

Maintained by expectancy sets, ongoing stress, or beliefs about the identity of voice. Ongoing stress has been shown to predict hallucinations. Beliefs about the voices cause the disturbance, not the voice itself. If the person thinks the voice is God, they will be more upset than if it was someone of equal status. Distress is not caused by content or frequency.

Cognitive Behavioural Therapy for Schizophrenia

Understand antecedents of beliefs and their relation to early life experiences.

Ask about evidence and then non-confrontational questioning to elicit alternative perspectives.

Behavioral experiments to test delusional beliefs.

Positive Symptom Effect Size

Rector & Beck, 2001

Cognitive behavioural therapy has an effect of 1.2 post treatment (compared to 0 for drug treatment), and have an effect size of 1.4 on follow-up.

CBT Effects for Negative Symptoms of Schizophrenia

CBT also helps treat the negative symptoms of schizophrenia as well.

**Cognitive therapy in research.

Rector