Abpsych Summary

lOMoARcPSD|2532716
Summary - book "Abnormal Psychology" - Textbook notes
Abnormal Psychology (University Of Manitoba)
Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

lOMoARcPSD|2532716
CHAPTER 1: Introduction and Historical Overview

 Psychopathology = the field concerned with the nature, development and treatment of
psychological disorders
 Challenge: remaining objective, avoiding preconceived notions, reduce stigma
 Stigma = destructive beliefs and attitudes held by society that are ascribed to groups considered
different in some manner (people with psychological disorders)
o 1) Label is applied to a group of people that distinguishes them from others
o 2) Label is linked to deviant/undesirable attributes by society (crazy people are dangerous)
o 3) People w/label are seen as essentially different from those without the label, contributing
to an “us” versus “them” mentality (we are not like those crazy people)
o 4) People w/label are discriminated against unfairly (clinic for crazy people can’t be built in
our neighborhood)
 Nearly half of US citizens will experience some type of psychological disorder during some point of
their lifetime
Defining Psychological Disorder
 Definition of mental disorder is found in the 5th edition of the American diagnostic manual, the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) *May 2013
 Psychological disorder:
o Occurs within the individual
o Involves clinically significant difficulties in thinking, feeling, or behaving
o Usually involves personal distress of some sort, such as in social relationships or occupational
functioning
o Involves dysfunction in psychological, developmental, and/or neurobiological processes that
support mental functioning
o Is not a culturally specific reaction to an event (e.g. death of a loved one)
o Is not primarily a result of social deviance or conflict with society
 4 key characteristics: personal distress, disability, violation of social norms, dysfunction
1) Personal Distress
 A person’s behaviour may be classified as abnormal if it causes him/her great distress
 Not all psychological disorders cause distress *e.g. antisocial/personality disorder
 Not all behaviour that causes distress is disordered *e.g. hunger due to religious fasting
2) Disability
 Disability = impairment in some important area of life
 E.g. substance use disorders defined in part by social or occupational disability
3) Violation of Social Norms
 Social norms = widely held standards that people use consciously or intuitively to make judgments
about where behaviours are situated on such scales as good-bad, right-wrong, etc.
 Social norms vary a great deal across cultures and ethnic groups
 Make others uncomfortable or causes problems (e.g. antisocial behaviour of psychopath)
4) Dysfunction
 Harmful dysfunction = failure of internal mechanisms in the mind to function properly
o 1) Value judgment (harmful), 2) objective, scientific component (dysfunction)
 Standard of comparison as to what is harmful depends on social norms and values
 Dysfunction = occurs when an internal mechanism is unable to perform its natural function
 Developmental, psychological, and biological dysfunctions are all interrelated
History of Psychopathology
Early Demonology

lOMoARcPSD|2532716
 Before advances in scientific discovery, all good/bad manifestations of power beyond human control
were regarded as supernatural
 It was thought that disturbed behaviour reflected the displeasure of the gods or possession by
demons
 Demonology = the doctrine that an evil being or spirit can dwell within a person and control his/her
mind and body
 Exorcism = the ritualistic casting out of evil spirits
o Rites of prayer, noisemaking, forcing the afflicted to drink terrible-tasting brews, flogging,
starvation
Early Biological Explanations
 Hippocrates (father of modern medicine) separated medicine from religion, magic and superstition
 Insisted that illness had natural causes and should be treated like other more common maladies
 Regarded the brain as the organ of consciousness, intellectual life, and emotion
 Disordered thinking/behaviour indicate brain pathology
 3 categories of psychological disorders: mania, melancholia, and phrentis (brain fever)
 Mental health depends on a balance among 4 humors (fluids of the body)
o Blood, black bile, yellow bile, and phlegm *imbalance produces disorders
 Predominance of phlegm = sluggish/dull, black bile = melancholia, yellow bile =
irritability/anxiousness, blood = changeable temperament
The Dark Ages and Demonology
 Death of Galen said to be the start of the Dark Ages in western European medicine
 Monks in the monasteries cared for and nursed the sick (prayed, touched w/relics, potions)
 The Persecution of Witches:
o 13th century, recurrent famines and plagues *demonological explanations for disasters
o Witchcraft (instigated by Satan) viewed as heresy and a denial of God
o Torture sometimes led to bizarre delusional sounding confessions
o Pope Innocent VIII mandated witch hunts
o Burning used as method of driving out the demon
o Turns out more healthy individuals than mentally ill individuals were tried and/or prosecuted
as witches
 Lunacy Trials:
o Municipal authorities took over some activities of the church, one being care of mentally ill
o 1 purpose of the hospital: mad are kept safe until they are restored of reason
 Not described as being possessed
o Trials conducted under the Crown’s right to protect the people with psychological disorders
 Trials were to determine a person’s mental health/sanity (13th century, England)
 Judgment of insanity allowed the Crown to become guardian of the lunatic’s estate
o Strange behaviour was attributed to physical illness/injury, or emotional shock
o “Lunacy” comes from Swiss physician, attributed odd behaviour to misalignment of the moon
and stars
Development of Asylums
 Very few hospitals for people with psychological disorders until the 15th century
 Many hospitals for people with leprosy
o As leprosy disappeared, these buildings were no longer used, converted to asylums
 Asylums = establishments for the confinement and care of mentally ill
 Bethlehem and Other Early Asylums:
o Priory of St. Mary and Bethlehem founded in 1243 *one of first mental institutions

lOMoARcPSD|2532716
o 1547 Henry VIII devoted the hospital to confinement of people with psychological disorders
o Became a tourist attraction *bought tickets to enter
o Origin of term bedlam (wild uproar or confusion)
o Similar to the Lunatics Tower in Vienna
o Medical treatments were crude and painful
o Benjamin Rush (father of American psychiatry) – believed psyc disorders were caused by
excess blood in the brain, would treat by drawing large quantities of blood from disordered
individuals
 Believed he could cure people by frightening them *convince them death is near
 Pinel’s Reforms:
o Figure for more humane treatment of people with psychological disorders in asylums
o Pinel was thought to have removed the confining chains worn by patients at La Bicetre
 Was really a former patient (Jean-Baptiste Pussin), became an orderly
o Pinel believed that if reason had left a patient because of severe social/personal problems, it
might be restored through comforting counsel and purposeful activity
 Moral Treatment:
o Friend’s Asylum (1817 Pennsylvania), Hartford Retreat (1824 Connecticut)
o Mental treatment = people had close contact with attendants, who talked and read to them
and encouraged them to engage in purposeful activity
o Residents lead lives as close to normal as possible
o Engage in purposeful, calming activities (e.g. gardening)
o Talked with attendants
o In general, took responsibility for themselves
o Dorthea Dix – crusader for improved conditions for people with psychological disorders
 Campaigned to improve the lives of people with psychological disorders
 Efforts lead to 32 public hospitals being built
 Staff unable to provide individual attention, ran by physicians not interested in
psychological well-being, only interested in biological aspects of illness
The Evolution of Contemporary Thought
Biological Approaches
 Biological Origins in General Paresis and Syphilis:
o By mid 1800s, partially understood anatomy and workings of the nervous system
o Not enough to know if structural brain abnormalities that cause psychological disorders were
present
o Many people with psyc disorders had a syndrome of steady deterioration of mental and
physical abilities and progressive paralysis = general paresis
 = Degenerative disorder with psyc symptoms (delusions of grandeur) & physical
symptoms (progressive paralysis)
 Established that some people with general paresis also had syphilis
o Louis Pasteur – germ theory of disease = disease is caused by infection of the body by
minute organisms
 Demonstrated relation between syphilis and general paresis
 Causal link established between infection, damage to certain areas of the brain, and a
form of psychopathology (paresis)
 Genetics:
o Galton – originator of genetic research with twins, attributed many behavioural
characteristics to heredity

lOMoARcPSD|2532716
 Coined the terms nature and nurture (genetics vs. environment)

 Mental illness can be inherited (internal trait)
 Also created the eugenics movement, sought to eliminate undesirable characteristics
from the population by restricting the ability of certain people to have children (=
enforced sterilization)
 Biological Treatments:
o Experimentation with radical interventions began on those with psychological disorders
o Insulin induced coma (Sakel) to treat schizophrenia **serious risks of treatment
o Electroconvulsive therapy = applying electric shocks to the sides of the human head, used to
produce epileptic seizures (used as a technique on patients with schizophrenia & severe
depression)
o Prefrontal lobotomy = a surgical procedure that destroys the tracts connecting the frontal
lobes to other areas of the brain (Moniz) *used especially for violent behaviour
 Recipients became dull and listless, suffered serious losses in cognitive capacities
Psychological Approaches
 Search for biological causes dominated until well into the 20th century
 Mesmer and Charcot:
o Mesmer was a physician with an interest in astronomy who theorized that there was a
natural energetic transference that occurred between all animate & inanimate objects that
he called ANIMAL MAGNETISM, sometimes later referred to as MESMERISM
 Treated patients w/hysteria using animal magnetism (early practitioner of hypnosis)
o Many people were observed to be subject to hysteria in 18th century western Europe
o Hysteria = physical incapacities, such as blindness or paralysis, for which no physical cause
could be found
o Mesmer believed hysteria was caused by a distribution of a universal magnetic fluid in the
body
 One person could influence the fluid of another to bring about change in the other’s
behaviour
 Conducted meeting involving mystery and mysticism, trying to transmit animal
magnetism and adjust universal magnetic fluid in individuals to remove the hysterical
disorder (first using rods, then just by looking)
 Viewed hysteria of having strictly biological causes
 Early practitioner of modern-day hypnosis
o Charcot believed hysteria was a problem of the nervous system, also persuaded by
psychological explanations
 Breuer and the Cathartic Method:
o Anna O had a number of hysteria symptoms: partial paralysis, impairment of sight and
hearing, and difficulty speaking, sometimes went into a dream-like state
o Breuer hypnotized her and she spoke freely about upsetting events from her past
o Felt much better upon being awakened after hypnotic session
o Cathartic method = reliving an earlier emotional trauma and releasing emotional tension by
expressing previously forgotten thoughts about the event
o Published “Studies in Hysteria” with Sigmund Freud
 Freud and Psychoanalysis:
o Much of human behaviour is determined by forces that are inaccessible to awareness
o Psychoanalytic theory = psychopathology results from unconscious conflicts in the individual
 Structure of the Mind (Freud):

lOMoARcPSD|2532716
o Psyche = the mind, divided into 3 principle parts: id, ego and superego
o Id = present at birth, repository of all energy needed to run the psyche, includes basic urges
*aka limbic system
 Libido = biological source of the id’s energy (unconscious)
 Id seeks immediate gratification = pleasure principle (tension is produced if not
satisfied)
o Ego = begins to develop from the id during the second 6 months of life, conscious, deals with
reality
 Operates on the reality principle = mediates between the demands of reality and the
id’s demands for immediate gratification
o Superego = a person’s conscience, develops throughout childhood, arising from the ego
 Incorporate parental values as their own
 Ego and Superego aka frontal lobe
 Defense Mechanisms:
o Discomforts experienced by the ego as it attempts to resolve conflicts and satisfy demands of
the id and superego can be reduced in several ways
o Defense mechanism = a strategy used by the ego to protect itself from anxiety (repression,
denial, projection, regression, rationalization)
 Psychoanalytic Therapy:
o Goal of the therapist is to understand the person’s early-childhood experiences, the nature of
key relationships, and the patterns in current relationships
o Therapist listens for core emotional and relationship themes that surface again and again
o Free association = a person reclines on a couch, facing away from the analyst, and is
encouraged to give free rein to his or her thoughts, verbalizing whatever comes to mind,
without censoring anything
o Transference = the person’s responses to his/her analyst that seem to reflect attitudes and
ways of behaving toward important people in the person’s past
 Analyst could gain insight into childhood origins of a person’s repressed conflicts
o Interpretation = the analyst points out to the patient the meanings of certain of a person’s
behaviour
 Defense mechanisms are a principle focus
 Jung and Analytical Psychology:
o Collective unconscious = part of the unconscious that s common to all human beings and
that consists primarily of archetypes = basic categories that all human beings use in
conceptualizing about the world
o Each of us has masculine and feminine traits that are blended
o People’s spiritual and religious urges are as basic as the id urges
o Extraversion vs. introversion
 Adler and Individual Psychology:
o Individual psychology = regarded people as inextricably tied to their society, fulfillment is
found in doing things for the social good
o Stressed the importance of working toward goals
o Focus on helping people change their illogical and mistaken ideas and expectations
o Feeling and behaving better depend on thinking more rationally (lead to CBT)
 Continuing Influences of Freud and His Followers:
o - Freud conducted no formal research on causes/treatments of psychological disorders
o - Based on anecdotal evidence, not grounded in objectivity

lOMoARcPSD|2532716
o 1) Childhood experiences help shape adult personality (don’t focus on his psychosexual
stages as much)
o 2) There are unconscious influences on behaviour *people can be unaware of the cause of
their behaviour
o 3) The causes and purposes of human behaviour are not always obvious
 The Rise of Behaviourism:
o Dissatisfaction in Freud’s theories bright to a head by John Watson
o Behaviourism = focuses on observable behaviour rather than on consciousness or mental
functioning
o Focus shifted from thinking to learning
o 1) Classical Conditioning:
 Ivan Pavlov
 Unconditioned stimulus = automatically elicits a response without prior learning
 Unconditioned response = response elicited by UCS
 Conditioned stimulus = previously neutral stimulus that elicits a conditioned response
after multiple pairings with UCS
 Conditioned response = response elicited by CS
 Extinction = CR gradually disappears if the CS is no longer followed by the UCS
 John Watson and Little Albert
o 2) Operant Conditioning:
 Thorndike studied the effects of consequences on behaviour
 Law of effect = behaviour that is followed by consequences satisfying to the organism
will be repeated, and behaviour followed by unpleasant consequences will be
discouraged
 Skinner – operant conditioning “Principle of reinforcement”
 Positive reinforcement = strengthening of a tendency to respond by virtue of the
presentation of a pleasant event called a positive reinforcer
 Negative reinforcement = strengthens a response but does so with the removal of an
aversive event
 Operant conditioning principles may contribute to persistence of aggressive
behaviour of conduct disorder
o 3) Modeling:
 We learn by watching and imitating others (even without reinforcement)
 Witnessing someone perform certain activities can increase/decrease diverse kinds of
behaviours (Bandura & Menlove)
 Behaviour Therapy:
o Emerged in 1950s – applied procedures base don classical and operant conditioning to alter
clinical problems = behaviour modification
o Systematic desensitization = includes deep muscle relaxation and gradual exposure to a list
of feared situations, starting with those that arouse minimal anxiety and progressing to these
that are the most frightening (used to treat anxiety & phobias)
o A state opposite to anxiety is substituted for anxiety as the person is exposed gradually to
stronger and stronger doses of what he/she fears
o Modeling also included in behaviour therapy
o Operant techniques using rewards have been particularly successful with treating childhood
problems

lOMoARcPSD|2532716
o Intermittent reinforcement (only rewarding some instances of target behaviour) makes new
behaviour more enduring
 The Importance of Cognition:
o Humans don’t just behave, we think and feel too
o The way in which people think about situations can influence behaviour in dramatic ways
 Cognitive Therapy:
o Based on the idea that people not only behave, they also think and feel
o Emphasize how people construe themselves and the world is a major determinant of
psychological disorders
o Therapist begins by helping clients become more aware of their maladaptive thoughts
o Change cognition to change feelings and behaviour
o Roots in Beck’s cognitive therapy and Ellis’s Rational Emotive Behavioural Therapy
o REBT = sustained emotional reactions are caused by internal sentences that people repeat to
themselves; these self-statements reflect sometimes unspoken assumptions – irrational
beliefs – about what is necessary to lead a meaningful life
CHAPTER 2: Current Paradigms in Psychopathology

 Paradigm = a conceptual framework or approach within which a scientist works – that is, a set of
basic assumptions, a general perspective, that defines how to conceptualize and study a subject
 Goal: Study abnormal behaviour scientifically *try to maintain objectivity (subjective factors always
interfere)
 How to gather and interpret relevant data
 How to think about a particular subject
 Specifies what problems scientists will investigate and how they will do so
 3 main paradigms of psychology: genetic, neuroscience, and cognitive behavioural
o Additional: diathesis-stress
The Genetic Paradigm
 Almost all behaviour is heritable to some degree and despite this, genes do not operate in isolation
from the environment
 “Nature via nurture”
 Genes = carriers of genetic information passed from parents to children
o We have between 20000-25000 genes *impacted by environmental influences (stress,
relationships, culture)
 Gene expression = process by which some proteins switch, or turn on and off other genes
 Psychopathology is polygenic = several genes, operating at different times during the course of
development, turning themselves on and off as they interact with a person’s environment, is the
essence of genetic vulnerability
 Relationship between genes and environment is bidirectional
 We don’t inherit psychological disorders from our genes alone
 We develop them through the interaction of our genes with the environment
 Heritability = the extent to which variability in a particular behaviour (or disorder) in a population
can be accounted for by genetic factors
o Heritability estimates range from 0.0 to 1.0: higher number = greater heritability
o Heritability is relevant only for a large population of people, not a particular individual
 E.g. heritability of ADHD is .70 does not mean 70% of Jane’s ADHD is due to her genes
 Means in a population the variation in ADHD is understood as being attributed to 70%
genetic factors and 30% environmental factors

lOMoARcPSD|2532716
 Shared environment factors = those things that members of a family have in common
o E.g. family income, child-rearing practices
 Non-shared environment “unique environment” factors = those things believed to be distinct
among members of a family
o E.g. relationships, specific events
 Unique/non-shared experiences have much more to do with the development of psychological
disorders
Behaviour Genetics
 Behaviour genetics = the study of the degree to which genes and environmental factors influence
behaviour
 Genotype = total genetic makeup of an individual, consisting of inherited genes *unobservable
o Genes switch on and off
 Phenotype = totality of observable behavioural characteristics
o Changes overtime and is the product of an interaction between the genotype and the
environment
Molecular Genetics
 Molecular genetics = seeks to identify particular genes and their functions
 Human being has 46 chromosomes (23 pairs), each made up of thousands of genes that contain DNA
 Alleles = different forms of the same gene
 Polymorphism = a difference in DNA sequence on a gene that has occurred in a population
 DNA in genes is transcribed into RNA, sometimes translated into amino acids (to make proteins)
 Promoter DNA is recognized by proteins called transcription factors
 Focus on difference between people in the sequence of their genes and in the structure of their
genes
 Single nucleotide polymorphisms (SNPs) = differences between people in a single nucleotide (A, T,
C, G) in the DNA sequence of a particular gene
 Copy number variations (CNVs) = differences between people in gene structure
o Can be present in a single gene or multiple genes
o Abnormal copy of one or more sections of DNA within the gene(s)
o Abnormal copies are additions/deletions
o Found in 5% of human genome (inherited or spontaneous mutation)
o Knockout study = specific gene is taken out of DNA in an animal to observe effect on
behaviour
Gene-Environment Interactions
 Gene-environment interaction = a given person’s sensitivity to an environmental event is influenced
by genes
 Serotonin transporter gene = gene with a polymorphism such that people have two short alleles,
some have two long alleles and some have one short, one long
o Combination of short-short and short-long + child maltreatment = more likely to be
depressed
 Epigenetics = study of how the environment can alter gene expression (“above”/”outside” the gene)
o Marks on DNA control gene expression, the environment can influence them
o Genes predispose individuals to seek out situations that increase the likelihood of developing
a disorder
Evaluating the Genetic Paradigm
 Direct replication = using the same measures and definitions of concepts
 Indirect replication = including broader measures of related constructs

lOMoARcPSD|2532716
The Neuroscience Paradigm

 Neuroscience paradigm = examines the contribution of brain structure & function to
psychopathology
o Mental disorders are linked to aberrant processes in the brain
 1) Neurons and neurotransmitters, 2) Brain structure and function, 3) Neuroendocrine system
Neurons and Neurotransmitters
 Neuron = cell making up the nervous system, composed of (1) cell body, (2) several dendrites, (3)
one or more axon, and (4) terminal buttons on the end branches of the axon
 Nerve impulse = dendrites or cell body stimulated, travels down axon to terminal
 Synapse = small gap between the terming ending of the sending axon and the cell membrane of the
receiving neuron
 Terminal buttons contain synaptic vesicles filled with neurotransmitters
o = Chemicals that allow neurons to send a signal across the synapse to another neuron
 When a neurotransmitter fits into receptor site of receiving neuron, message can be sent
 Reuptake = released neurotransmitters that remain in the synapse are taken back into the
presynaptic neuron
 Key neurotransmitters in psychopathology: dopamine, serotonin, norepinephrine, gamma-
aminobutyric acid (GABA)
o Serotonin & dopamine – depression, mania, schizophrenia
o Norepinephrine – communicates with sympathetic NS, high arousal  anxiety disorders
 Serotonin, dopamine, and norepinephrine are excitatory
o GABA – inhibits nerve impulses anxiety disorders
 Agonist = drug that stimulates a particular neurotransmitter’s receptors
 Antagonist = drug that works on a neurotransmitter’s receptors to dampen the activity of that
neurotransmitter
Structure and Function of the Human Brain
 Corpus callosum = band of nerve fibres that connects the two cerebral hemispheres, allows them to
communicate
 Gray-matter = (cortex) thin outer covering of the brain, composed of neurons (6 layers)
o Gyri = ridges, Sulci = depressions between the ridges *define cerebral lobes
 4 main lobes: frontal (reasoning, problem solving, emotion, working memory), parietal (sensory-
spatial, temporal (discrimination of sound), and occipital (vision)
 Prefrontal cortex = very front of the cortex, helps to regulate the amygdala and is important in many
different disorders
 White matter = large tracts of myelinated fibres that connect cell bodies in the cortex with those in
the spin cord and in other centres lower in the brain
 Basal ganglia = nuclei located deep within each hemisphere, help regulate starting/stopping motor
and cognitive activity
 Ventricles = cavities in the brain filled with cerebrospinal fluid
 Thalamus = relay station for all sensory pathways except olfactory, pass onto cortex
 Brain stem = comprised of the pons, and the medulla oblongata, functions as a neural relay station
 Pons = connects cerebellum with spinal cord and motor areas of cerebrum
 Medulla oblongata = main line of traffic for tracts from spinal cord (up) and higher centres of brain
(down)
 Cerebellum = receives sensory nerves from vestibular apparatus (ear) and from muscles, tendons
and joints *balance, posture, equilibrium, and smooth coordination
 Limbic system = involved in the visceral and physical expression of emotion, and expression of
appetitive and other primary drives

lOMoARcPSD|2532716
o Anterior cingulate
o Septal area
o Hippocampus (memory)
o Hypothalamus (metabolism, temperature, perspiration, blood pressure, sleep, appetite)
o Amygdala (Emotion) *emotional psychological problems
 Key brain structure for psychopathology researchers due to role in attending to
emotionally salient stimuli & in emotionally relevant memories
 Brain development begins in first trimester
 Pruning = process of eliminating a number of synaptic connections *fewer and faster connections
 Cerebellum and occipital lobe develop the quickest
 Frontal lobe develops last
The Neuroendocrine System
 Hypothalamic-pituitary-adrenal axis (HPA) = central to the body’s response to stress, and stress
figures prominently in many psyc disorders
 Hypothalamus releases corticotropin-releasing factor (CRF) when faced with threat
 CRF communicates with the pituitary gland, releases hormone that travels to adrenal gland
 Adrenal cortex promotes the release of hormone cortisol – the stress hormone
o Takes 20-40 minutes for cortisol release to peak
o Takes up to an hour for cortisol levels to return to baseline
 Autonomic nervous system (ANS) = operates very quickly, without our awareness, beyond voluntary
control
o Innervates the endocrine glands, the hearth, and smooth muscles
o 1) Sympathetic NS = prepares body for fight/flight (heart rate, dilates pupils, inhibits
intestinal activity, increases electrodermal activity)
o 2) Parasympathetic NS = helps calm down the body
o Involved in anxiety disorders (panic, PTSD)
The Immune System/Neuroendocrine System
 Psychoneuroimmunology = studies how psychological factors impact the immune system
 Immune system contains many cells and proteins that respond when the body is infected/invaded
 Natural immunity = body’s first and quickest line of defense against infections
microorganisms/invaders *releases cells on invaders to destroy them
o Results in inflammation/swelling
o Cytokines = help initiate bodily responses to infection (fatigue, fever, activation of HPA axis)
 Release of cytokines stimulated by activation of macrophages (cell released)
 Specific immunity = cells respond more slowly to infection (lymphocytes  t-helper and b cells),
involved in responding to specific pathogens or invading agents
o T-helper cells promote the release of cytokines
o B cells release antibodies
 Stress directly effects the immune system (prenatal stress can even affect her offspring)
 Interlukin-6 = cytokine that promotes inflammation in response to infection, linked to human
diseases and psyc disorders (MDD)
 Exposure to stress also slows process of wound healing
 Risk of harmful immune response to stress increases with age
Neuroscience Approaches to Treatment
 Use of psychoactive drugs and antidepressants has been increasing *alter neurotransmitter activity
 Antidepressants are the 3rd most commonly prescribed medications for any type of health issue

lOMoARcPSD|2532716
o Increase neural transmission in neurons that use serotonin as a neurotransmitter by

inhibiting the reuptake of serotonin
 Benzodiazepines used for anxiety to stimulate GABA to inhibit other neural systems that create
physical symptoms of anxiety
 Antipsychotic drugs reduce activity of neurons that use dopamine as neurotransmitter by blocking
receptors
Evaluating the Neuroscience Paradigm
 Reductionism = the view that whatever is being studied can and should be reduced to its most basic
elements of constituents
o E.g. when scientists try to reduce complex mental and emotional responses to biology
 The whole is greater than the sum of its parts, breaking it down into pieces doesn’t mean
understanding it fully
The Cognitive Behavioural Paradigm
 Cognitive behavioural paradigm = rooted in learning principles and cognitive science
Influences from Behaviour Therapy
 Problem behaviour is likely to continue if it is reinforced *to alter behaviour, modify consequences
 Reinforced by 4 consequences: getting attention, escaping from tasks, generating sensory feedback,
gaining access to desirable things/situations
 Time-out = individual is sent for a period of time to a location where positive reinforcers are not
available
 Behavioural activation (BA) therapy = helping a person engage in tasks that provide an opportunity
for positive reinforcement (used to treat depression)
 In-vivo = in real life situations (type of exposure therapy) *opposite, “imaginal exposure”
 Criticized for minimizing the importance of thinking and feeling
Cognitive Science
 Behaviourism criticized for ignoring thoughts and emotions
 Cognition = groups together the mental processes of perceiving, recognizing, conceiving, judging,
and reasoning
 How people structure their experiences, how they make sense of them and how they relate their
current experiences to past ones
 Schema = cognitive set used to fit new information into an organized network of already
accumulated knowledge *we actively interpret new info
 Focuses on studying human attention
 Stroop task (colour names written in different colour ink, asked to label them as the ink colour, not
the word)
The Role of the Unconscious
 Familiarity affects judgments of stimuli
 Implicit memory = the unconscious may reflect efficient info processing rather than being a
repository for troubling material
o A person can be influenced by prior learning without remembering
 People with social anxiety and depression often have trouble with implicit memory tasks
Cognitive Behaviour Therapy
 CBT = incorporates theory and research on cognitive processes
 Pays attention to private events (thoughts, perceptions, judgments, self-statements)
 Cognitive restructuring = changing a pattern of thinking *changes in thinking can change feelings,
behaviour & symptoms
 Beck’s Cognitive Therapy:
o Cognitive therapy for depression

lOMoARcPSD|2532716
o Based on idea that depressed mood is caused by distortions in the way people perceive life
experiences *distorted thinking
 E.g. focus exclusively on negative happenings, ignore positive ones
o Goal: to provide people with experiences, both inside/outside the therapy room, that will
alter their negative schemas, enabling them to have hope rather than despair
o Information processing bias *attention, interpretation, and recall of negative & positive
information biased in depression
o Helps patients recognize and change maladaptive thought patterns
Evaluating the Cognitive Behavioural Paradigm
 Some cognitive explanations do not appear to explain much
 The thoughts are given causal status  negative thoughts cause sadness of depression
 Focus is on current determinants of disorder
o Childhood and other historical antecedents given less attention
 Are distorted thoughts the cause of result of psychopathology?
Factors That Cut Across the Paradigms
 Emotion, sociocultural, and interpersonal factors
Emotion and Psychopathology
 Emotions influence how we respond to problems and challenges in our environment
 Help us reorganize our thoughts and actions
 85% of psyc disorders include disturbances in emotional processing
 Emotions = short-lived states, lasting for a few seconds/minutes/hours
o Expressive, experiential and physiological components
o Expressive/behavioural – facial expressions
o Experiential/subjective – how someone reports he/she feels at a given moment
o Physiological – changes in the body (autonomic NS)
 Moods = emotional experiences that endure for a longer period of time
 Ideal affect = the kinds of emotional states that a person ideally wants to feel
Sociocultural Factors and Psychopathology
 Sociocultural factors: gender, culture, ethnicity, SES *may increase vulnerability to psychopathology
 Environmental factors can trigger, exacerbate, or maintain the symptoms that make up the different
disorders
 Some disorders affect men and women differently (depression 2x common in women as men)
 Poverty is a major influence on psychological disorders
Interpersonal Factors and Psychopathology
 Quality of relationships (family, marital, social support)
 Trauma, serious life events, and stress
 Object relations theory = stresses the importance of long-standing patterns in close relationships,
particularly within the family, that are shaped by the ways in which people think and feel
o Object refers to another person (in most versions)
 Attachment theory = the type/style of an infant’s attachment to his/her caregivers can set the stage
for psychological health or problems later in life
o John Bowlby & Mary Ainsworth
o Securely attached – likely to grow up psychologically healthy
o Anxiously attached – likely to experience psychological difficulties
 Relational self = the self in relation to others
o People will describe themselves differently depending on what other close relationships they
have been asked to think about

lOMoARcPSD|2532716
 Interpersonal Therapy (IPT):

o IPT = emphasizes the importance of current relationships in a person’s life and how problems
in these relationships can contribute to psychological symptoms
o 1) Unresolved grief
o 2) Role transitions
o 3) Role disputes
o 4) Interpersonal/social deficits
Diathesis-Stress: An Integrative Paradigm
 Most disorders are likely to develop through an interaction of neurobiological and environmental
factors
 Diathesis-stress paradigm = integrative paradigm that links genetic, neurobiological, psychological
and environmental factors *multiple causal factors
 Introduced as a way to account for multiple causes of schizophrenia
o Diathesis (disease), stress (environment/life disturbances **may occur at any point after
conception)
o Diathesis = predisposition towards illness/any characteristics a person has that increases
his/her chance of developing a disorder
 Both diathesis and stress are necessary in the development of disorders
 Psychopathology is unlikely to result from the impact of any single factor
CHAPTER 3: Diagnosis and Assessment

 Diagnosis = the classification of disorders by symptoms or signs
o Advantages: facilitates communication among professionals, advances the search for causes
& treatments, cornerstone of clinical care
 Diagnosis can be the first major step in good clinical care
 Correct diagnosis allows the clinician to describe base rates, causes, and treatment
 Diagnosis helps a person understand why symptoms are occurring
 Use assessment procedures to make a diagnosis (e.g. clinical interview)
Cornerstones of Diagnosis and Assessment
 Reliability and validity are the cornerstones of any diagnostic or assessment procedure
Reliability
 Reliability = consistency of measurement
 Interrater reliability = the degree to which 2 independent observers agree on what they have
observed
 Test-retest reliability = measures the extent to which people being observed twice or taking the
same test twice (after a period of break) receive similar scores
o Makes sense to use when we can assume people won’t change of the target variable
appreciably between sessions
 Alternate-form reliability = the extent to which scores on two forms of a test are consistent
 Internal consistency reliability = assesses whether the items on a test are related to one another
 Reliability is measured on a scale from 0 to 1.0 (higher number = better reliability)
Validity
 Validity = index of whether a measure measures what it is supposed to measure
 Validity is related to reliability, unreliable measures will not have good validity
 Reliability does not guarantee validity
 Content validity = whether a measure adequately samples the domain of interest
o E.g. social anxiety measure should have items covering feelings of anxiety in social situations

lOMoARcPSD|2532716
 Criterion validity = evaluated by determining whether a measure is associated in an expected way

with some other measure (the criterion)
o Concurrent validity = both variables are measured at the same point in time
 E.g. showing that a measure of negative thoughts is associated with a measure of
depression symptoms
o Predictive validity = the ability of the measure to predict some other variable that is
measured at some point in the future
 E.g. IQ tests to measure future school performance
 Construct validity = used to interpret a test as a measure of some characteristic/construct that is not
observed overtly
o E.g. people score differently on a measure for anxiousness actually do differ in degree of that
construct
o Evaluated by looking at a wide variety of data from multiple sources
o Related to theory
The Diagnostic System of the American Psychiatric Association: DSM-5
 The Diagnostic and Statistical Manual of Mental Disorders
o USA uses International Classification of Disorders – 10
 Revised 5 times since 1952
 DSM-5 released in 2013
 Introduced in DSM-III:
o Specific diagnostic criteria *symptoms for a given diagnosis
o The characteristics of each diagnosis are described much more extensively
Changes in DSM-5
 Removal of the Multiaxial System:
o DSM-IV-TR had 5 axes, changed to 2 (or 3) in DSM-5 *clinical syndromes & psychosocial &
environmental problems
o First developed in DSM-III (1980)
o In place of first 3 axes, clinicians now note psychiatric and medical diagnoses
o Psychosocial and Environmental Problems Axis changed to be similar to the WHO
International Classification of Diseases (ICD)
o Axis 5 is removed, instead the WHO Disability Assessment Schedule (WHODAS) is included
 Organizing Diagnoses by Causes:
o Defines diagnoses on the basis of symptoms (DSM-IV)
o Chapters are reorganized to reflect patterns of comorbidity and shared etiology (DSM-5)
 OCD moved from anxiety cluster to new cluster that also includes hoarding and body
dysmorphic disorder
 Enhanced Sensitivity to the Developmental Nature of Psychopathology:
o Highlights the continuity between childhood and adulthood forms of disorder
o No separate chapter for childhood disorders
 New Diagnoses:
o E.g. disruptive mood dysregulation disorder (mood changes, irritability and mania symptoms)
o Often incorrectly diagnose these patients with bipolar although they do not correctly fit the
diagnosis for mania
o Hoarding disorder, binge eating disorder, premenstrual dysphoric disorder, gambling disorder
 Combining Diagnoses:
o Not enough evidence for differential etiology for certain disorders
o Substance use disorder (instead of substance abuse and dependence)

lOMoARcPSD|2532716
o Female sexual interest/arousal disorder (instead of hypoactive sexual desire disorder and
female sexual arousal disorder)
o Autism spectrum disorder (autism and Asperger’s)
 Ethnic and Cultural Considerations:
o Many different cultural influences on risk factors for certain psyc disorders, symptoms
experienced, willingness to seek help, treatments available
o DSM-5 includes a list that cross-references the DSM diagnoses with the International
Statistical Classification of Diseases and Related Health Problems (ICD) codes
o Added features to enhance cultural sensitivity
o Includes a section on culture-related diagnostic issues
o Clinicians are cautioned not to diagnose symptoms unless they are atypical and problematic
within a person’s culture
o Includes 9 cultural concepts of distress
 Dhat syndrome – (India) severe anxiety about the discharge of semen
 Shenjing shuairuo – (China) syndrome characterized by fatigue, dizziness, headaches,
pain, poor concentration, sleep problems and memory loss
 Taijin kyofusho – (Japan) fear that one could offend others through inappropriate eye
contact, blushing, perceived body deformation, one’s own foul body odor
 Ataque de nervios – (Latino culture) intense anxiety and fear of screaming and
shouting uncontrollably
Specific Criticisms of the DSM
 Too Many Diagnoses?
o Contains more than 300 different diagnoses
o Seems as though too many problems have been made into psyc disorders
o Some argue that the system includes too many minute distinctions based on small
differences in symptoms
o Classification may emphasize trivial similarities  relevant info may be overlooked
o Comorbidity = the presence of a second diagnosis *norm rather than the exception
 Could be a sign that we are dividing syndromes too finely
 45% of people diagnosed with 1 disorder will meet criteria for a second disorder
o Many risk factors seem to trigger more than one disorder
o Why not lump childhood conduct disorder, adult antisocial personality disorder, alcohol use
disorder, and substance use disorder into “externalizing disorders”
o Research Domain Criteria = roadmap for research that will lead to the development of a new
classification system that is based on neuroscience and genetic data rather than just clinical
symptoms
 Categorical Classification Versus Dimensional Classification:
o Categorical classification = classification requiring the presence of a certain amount of
specific symptoms that fall under a diagnosis category (DSM-5)
 Forces clinicians to define one threshold as “diagnosable”
o Dimensional system = describes the degree of an entity that is present
 Dimensional approach for personality disorders is included in the appendix
o Unspecified – used when a person meets many but not all of the criteria for a diagnosis
 Used to be called NOS
 Reliability of the DSM in Everyday Practice:
o Reliability for diagnosis was poor prior to DSM-III
o Difficult for mental health professionals to always agree on a diagnosis

lOMoARcPSD|2532716
 How Valid Are Diagnostic Categories?

o DSM diagnoses are based on a pattern of symptoms
o We hope a diagnosis will inform us about related clinical characteristics and functional
impairments
o Impairment or distress must be present to meet criteria for diagnosis
o We hope a diagnosis will inform us what to expect next (course of disorder, response to
treatment options)
General Criticisms of Diagnosing Psychological Disorders
 Getting a diagnosis could have a stigmatizing effect
 Family members often also encounter a stigma
 People tend to view the actual disordered behaviour more negatively than the category labels
 Lose sight of personal uniqueness once a diagnosis is applied
Psychological Assessment
 Using multiple techniques and multiple sources of info will provide the best assessment
Clinical Interviews
 Both formal/structured and less structured clinical interviews
 Characteristics:
o Interviewer pays attention to how the respondent answers questions, or doesn’t answer
 Look for emotion that accompanies responses
o Establish rapport with the individual, obtain their trust, empathize
o Interviewer must rely on intuition and general experience to figure out how best to gather
information
o Unstructured interviews are less reliable than structured
 Structured Interviews:
o Structured interview = questions are set out in a prescribed fashion for the interviewer
 E.g. the Structured Clinical Interview (SCID), being revised for DSM-5
 A person’s response to one question determines what the next question will be =
branching interview
 Gives instructions as to when to go into more detail and when to move on
 Most symptoms rated on a 3-point scale of severity
o Clinicians using unstructured diagnostic interviews tend to miss comorbid diagnoses
Assessment of Stress
 Stress = the subjective experience of distress in response to perceived environmental problems
 Life stressors = the environmental problems that trigger the subjective sense of stress
 The Bedford College Life Events and Difficulties Schedule (LEDS):
o Includes an interview that covers over 200 different kinds of stressors
o Semi-structured interview
o Designed to address a number of problems in life stress assessment
o Goal to exclude life events that might just be consequences of symptoms
o Tries to carefully date when a stressor has occurred
o Life stressors are robust predictors of episodes of anxiety, depression, schizophrenia and even
the common cold
 Self-Report Stress Checklists:
o Quicker method of assessing stress
o E.g. the List of Threatening Experiences (LTE) or the Psychiatric Epidemiological Research
Interview Life Events Scale

lOMoARcPSD|2532716
o List different life events, participants are asked to indicate whether or not these events
happened to them in a specified period of time
o Issue: high variability in how people view these events
o Issue: difficulties with recall
o Low test-retest reliability
Personality Tests:
 2 most common types of psyc tests: personality tests & intelligence tests
 Self-Report Personality Inventories:
o Personality inventory = the person is asked to complete a self-report questionnaire including
whether statements assessing habitual tendencies apply to him/her
o Administered to analyze how certain kinds of people tend to respond
o Standardization = process of establishing statistical norms for a test
o Minnesota Multiphasic Personality Inventory (MMPI) = designed to detect a number of psyc
problems based on responses to certain items in a similar manner as individuals with a
particular diagnosis
 MMPI-32 is much more reliable, has adequate criterion validity
 Specific subscale to detect lying & faking “good”/”bad”
 Projective Personality Tests:
o Projective test = a psych assessment tool in which a set of standard stimuli
(inkblots/drawings) ambiguous enough to allow variation in responses is presented to the
person
o Because the stimulus materials are unstructured/ambiguous, the person’s responses will be
determined by unconscious processes and will reveal true attitudes/motivations = projective
hypothesis
o Used when the subject is assumed to be unwilling or unable to express true feelings in asked
directly
o Thematic Apperception Test (TAT) = a person is shown a series of black and white pictures
1@ a time, and asked to tell a story related to each
 Not very reliably scored, low construct validity
o Rorschach Inkblot Test = person is shown 10 inkblots, one at a time, and asked to tell what
the inkblots look like *most well-known
 Exner scoring system, concentrates on perceptual and cognitive patterns in a person’s
responses
 Responses viewed as a sample of how subject perceptually/cognitively organizes real-
life situations
 Norms of this scoring system based on a small sample
 Validity with assessing certain issues, not with others
Intelligence Tests
 Alfred Binet
 Intelligence test (IQ) = used to assess a person’s current mental ability
 Based on the assumption that a detailed sample of a person’s current intellectual functioning can
predict how well he/she will perform in school
 Most common: Wechsler Adult Intelligence Scale & Stanford-Binet
 Regularly updated and standardized
 Other uses:
o Diagnose learning disorders and identify areas of strength/weakness
o Assess whether a person has intellectual disability

lOMoARcPSD|2532716
o Identify intellectually gifted children

o Part of neuropsychological evaluations
 Tap: language skills, abstract thinking, nonverbal reasoning, visual-spatial skills,
attention/concentration, speed of processing
 100 is often the standardized mean (15 or 16 = SD)
 Highly reliable, good criterion validity
 IQ tests explain only a small part of school performance
 IQ is also correlated with health
 Stereotype threat (stigma towards some groups for poor intellectual performance)
Behavioural and Cognitive Assessment
 Assess: aspects of the environment, characteristics of a person, frequency/form of problem
behaviours, consequences of problem behaviour
 Direct Observation of Behaviour:
o Observer divides sequence of behaviour into various parts that make sense within a learning
framework (e.g. antecedents, consequences)
o Behavioural assessment = observing behaviour and coding it
 Self-Observation:
o Self-monitoring = patients observe and track their own behaviour and responses
 Used to collect wide variety of data (moods, stressful experience, coping behaviour,
thoughts)
o Ecological momentary assessment (EMA) = collection of data in real time (rather than
reflecting back), a person is signaled several times a day, asked to enter responses directly
into device
o Behaviour can be altered by the mere fact that it is being self-monitored = reactivity
 Cognitive-Style Questionnaires:
o Used to help plan targets for treatment and to determine whether clinical interventions are
helping
o Dysfunctional Attitude Scale (DAS) *based on Beck’s theory
Neurobiological Assessment
Brain Imaging: “Seeing” the Brain **used less frequently (expensive)
 Neurological tests: checking reflexes, examining the retina, evaluating motor
coordination/perception
 CT/CAT scan (computerized axial tomography) = x-rays pass into horizontal cross section of brain,
scanning it through 360 degrees, scanner on other side measures radioactivity that penetrates
o Detects subtle differences in tissue density
o Constructs a 2D, detailed image of cross-section
o Reveals structural abnormalities by detecting differences in tissue density (e.g. enlarged
ventricles)
 MRI (magnetic resonance imaging) = produces pictures of higher quality than CT, does not rely on
radiation
o Person placed inside a large magnet, causes H atoms of body to move
 fMRI (functional MRI) = allows researchers to measure brain structure and function
o Quick pictures allow metabolic activity to be measured
o Measures blood flow in the brain = BOLD signal (blood oxygenation level dependent)
o As neurons fire, blood flow increases
 PET scan (positron emission tomography) = more expensive and invasive, allows measurement of
brain structure and function, not as precise as MRI/fMRI

lOMoARcPSD|2532716
o Radioactive isotope injected into bloodstream, binds to glucose

o Red = most activity, blue/black = least activity *used less often
 Functional connectivity analysis = tries to identify deficits in the ways in which different areas of the
brain communicated and connect with one another
Neurotransmitter Assessment
 Post mortem studies
 Bind receptors in deceased patients to detect amount of certain receptors in the brain
 Metabolite assays = an acid/by-product that is produced when a neurotransmitter is deactivated
o Often found in urine, blood serum, and cerebrospinal fluid
o Not direct reflections of neurotransmitter levels in the brain (blood and urine)
 Metabolite studies are correlational *not always accurate
Neuropsychological Assessment
 Neurologist = a physician who specializes in diseases/problems that affect the nervous system
o E.g. stroke, muscular dystrophy, cerebral palsy, Alzheimer’s
 Neuropsychologist = a psychologist who studies how dysfunctions of the brain affect the way we
think, feel, and behave
 Neuropsychological tests = used with brain imaging to detect brain dysfunction and to help pinpoint
specific areas of behaviour that are impacted by problems in the brain
 Based on idea that different psyc functions rely on different areas of the brain
 Halstead-Reitan neuropsychological test battery (group of tests):
o Tactile performance test-time = while blindfolded, person tries to fit differently shaped
blocks into spaces of a form board, using the preferred hand, than the other, then both
o Tactile performance test-memory = person asked to draw the form board from memory,
showing blacks in their proper location
 Both above 2 are sensitive to damage in parietal lobe
o Speech sounds perception test = participants listen to series of nonsense words, each made
of 2 consonants with a long-e sound in the middle, then select the “word” they heard from a
set of alternatives
 Measures left-hemisphere function *temporal and parietal areas
 Luria-Nebraska battery – 269 items, 11 sections, determine basic/complex motor skills, rhythm and
spatial abilities, tactile and kinesthetic skills, verbal and spatial skills, receptive speech ability…
o Helps reveal potential damage in frontal, temporal, sensorimotor, or parietal-occipital area of
either hemisphere
o Reliable scoring, can control for educational level
Psychophysiological Assessment
 Psychophysiology = concerned with the bodily changes that are associated with psychological events
 Measure heart rate, muscle tension, blood flow, electrical activity in brain
 Not sensitive enough to be used for diagnosis
 Assess activity of ANS to understand emotion
 Electrocardiogram (EKC) = measures electrical charge generated by heartbeat
 Electrodermal responding = skin conductance *sympathetic NS *sweat gland activity
 Electroencephalogram (EEG) = measures brain activity using electrodes on the scalp
o Abnormal patterns can indicate seizure activity, help locate lesions or tumors
o Used to measure attention and alertness
A Cautionary Note About Neurobiological Assessment
 Many measurements do not differentiate clearly among emotional states
o E.g. skin conductance increases with many emotions

lOMoARcPSD|2532716
 Being in a scanner can generate anxiety on its own, it’s a scary experience
Cultural and Ethnic Diversity and Assessment
Cultural Bias in Assessment
 A measure developed for one culture/ethnic group may not be equally reliable and valid with a
different group **not simply a matter of language translation
 Cultural assumptions/biases may cause clinicians to over/under estimate psyc problems
Strategies for Avoiding Cultural Bias in Assessment
 Students need to learn how culture/ethnicity may impact assessment
 But that it may not impact assessment in every individual case
CHAPTER 4: Research Methods in Psychopathology

Science and Scientific Methods
 Science = the systematic pursuit of knowledge through observation
 Theory = a set of propositions meant to explain a class of observations
o Goal to understand cause-effect relationships
o A good theory is falsifiable *allows for disconfirmation
 Hypotheses = expectations/predictions about what should occur if a theory is true
o Must be able to be systematically tested
o Focus is on disproving rather than proving
 Scientific approach requires that theory and hypothesis are stated precisely
 Scientific observations must be replicable
 Use assessments with strong validity and reliability to make replication possible
Approaches to Research Psychopathology
The Case Study
 Case study = most familiar method of observing human behaviour, involves recording detailed info
about one person at a time
o Covers: developmental milestones, family history, medical history, educational background,
employment history, marital history, social adjustment, peer/romantic relationships,
personality, environment, etc.
 Lack control and objectivity *validity is questionable
 Clinician’s paradigm will shape the kinds of info reported in a case study
 Uses: (1) provide rich description of a clinical phenomenon, (2) disprove an allegedly universal
hypothesis, (3) generate hypotheses that can be tested through controlled research
 Limitations: paradigm may influence observations, cannot rule out alternative explanations, cannot
prove hypotheses
 Case Study as a Rich Description:
o Includes much more detail that other research methods
o Provide detailed description of how a new intervention works
 Case Study Can Disprove but Not Prove a Hypothesis:
o Do not provide good enough evidence in support of a particular theory, don’t provide a way
to rule out alternative hypotheses
o Data collected from case study doesn’t allow to determine true cause of change
 Using Case Study to Generate Hypotheses:
o Helps to generate hypotheses for causes/treatments for disorders
The Correlational Method
 Correlational method = variables are measured as they exist in nature
 Different from an experiment during which a variable is manipulated

lOMoARcPSD|2532716
 Rely on correlational method when cannot do an experiment for ethical reasons

 4 shapes: positive linear, negative linear, curvilinear, (increases in one variable have both increases
and decreases in other), no relationship (straight line)
 Measuring Correlation:
o Step 1: obtain pairs of observations of the 2 variables in question
o Step 2: determine correlation strength using correlation coefficient (r)
 Measures magnitude and direction of relationship
 Higher the absolute value, the stronger the relationship
 Statistical and Clinical Significance:
o Statistical significance = asserts that a correlation was unlikely to have occurred by chance
 Less than 5 in 100 (due to chance)
 Alpha level = level of significance, p < .05
 Higher r = less likely to have occurred by chance
o Not statistically significant correlation does not provide evidence for an important
relationship
o Statistical significance influenced by size of relationship between variables AND sample size
o Clinical significance = defined by whether a relationship between variables is large enough to
matter
 Problems of Causality:
o Correlational designs do not allow determination of causality
o Directionality problem = inability to determine which variable has causal significance
o Causes must precede effects *temporal precedence
o Longitudinal design = researcher tests whether causes are present before a disorder has
developed
 Studies participants over time
o Cross-sectional design = the causes and effects are measured at the same point in time
o High-risk method = only evaluates those at high risk for developing the target problem
 Reduces the cost of longitudinal method
o Third-variable problem = a third factor might have produced the correlation *confound*
o Confound = a variable that produces changes in the 2 correlated variables
 One Example of Correlational Research: Epidemiological Research:
o Epidemiology = study of the distribution of disorders in a population
o Data are gathered about rates of a disorder and its correlated in a large sample
o Focuses on 3 features of a disorder:
 1) Prevalence – the proportion of people with disorder either currently or during their
lifetime
 2) Incidence – the proportion of people who develop new cases of the disorder in
some period, usually a year
 3) Risk factors – variables that are related to the likelihood of developing the disorder
o Usually are correlational
o Designed to be representative of the population
o E.g. National Comorbidity Survey-Replication (large scale national survey, uses structured
interviews to collect info on prevalence of several diagnoses)
 Behaviour and Molecular Genetics:
o Behavioural Genetics = methods to determine genetic predisposition (concordance) to
psychopathology
o 3 methods to uncover whether a genetic predisposition for psychopathology is inherited:

lOMoARcPSD|2532716
 1) Comparison of members of a family, 2) comparison of pairs of twins, 3)

investigation of adoptees
o Family method = used to study genetic predisposition among family members
 *Average number of genes shared by 2 blood relatives is known
 1st degree share 50%, 2nd degree share 25%
 Concordance = co-occurrence or similarity of diagnosis
 Index cases/probands = persons with the diagnosis in question
o Twin method = monozygotic and dizygotic twins are compared
 MZ (identical) – develop from 1 egg, genetically the same
 DZ (fraternal) – develop from separate eggs, share 50% genes
 When MZ concordance is higher than DZ concordance, characteristic is heritable
o Adoptees method = studies children who were adopted and reared apart from their
biological parents
 Stronger evidence that a disorder is genetic if biological parents and child (who was
not raised by bio parents) both have disorder
 Cross-fostering = children are adopted and reared apart from their biological parents
 Adoptive parent has a disorder
o Molecular Genetics:
o Association study = researchers examine the relationship between a specific allele and a
trait/behaviour in the population *precise measurement
o Genome-wide association studies (GWAS) = examines entire genome of a large group of
people to identify variations between people
 Require very large samples
 Most often look for single nucleotide polymorphisms (SNPs)
The Experiment
 Experiment = involves random assignment of participants to conditions, the manipulation of an IV
and the measurement of a DV
o Provides info about a causal relationship
o Can evaluate treatment effectiveness
o Experimental effect = differences between conditions on the DV
 Internal Validity:
o Internal validity = the extent to which the experimental effect can be attributed to the IV
o Control group = does not receive experimental treatment
 Shows effects in other group are due to IV
o Random assignment helps ensure groups are similar on variables other than the IV
 External Validity:
o External validity = the extent to which results can be generalized beyond the study
 Treatment Outcome Research:
o Treatment outcome research = designed to address whether or not treatment works
o Moderately positive effect of treatment (75% have some sort of improvement)
o Treatment study should include:
 Clear definition of the sample being studied e.g. description of diagnoses
 Clear description of treatment being offered (in a manual)
 Inclusion of a control/comparison treatment method
 Radom assignment
 Reliable/valid outcome measures
 Large enough sample for statistical tests

lOMoARcPSD|2532716
o Randomized controlled trials (RCTs) = studies in which clients are randomly assigned to
receive active treatment of a comparison
 IV is treatment, DV is patient outcome
 Defining the Treatment Condition: The Use of Treatment Manuals:
o Treatment manuals = detailed books on how to conduct a particular psyc treatment
o Provide specific procedures for therapist to follow at each stage of treatment
o Help therapist achieve greater uniformity in how they conduct therapy
 Defining Control Groups:
o No-treatment control group = allows researchers to test whether the mere passage of time
helps as much as treatment does
o Placebo = a pretend treatment, uses the power of suggestion, allows researchers to control
for expectations of a symptom relief
o Active-treatment control group = researchers compare new treatment against a well-tested
treatment
o Double-blind procedure = psychiatrists and patient are not told whether the patient received
active medication or placebo *reduces bias in evaluating outcomes
o Placebo effect = a physical or psyc improvement that is due to the patient’s expectations of
help rather than to any active ingredient in a treatment
 Defining a Sample:
o Often there is a failure to include people from diverse cultural/ethnic backgrounds
o People from minority groups are about half as likely to receive mental health treatment
 Assessing How Well Treatments Work in the Real World:
o Efficacy = whether a treatment works under the purest of conditions
o Effectiveness = how well the treatment works in the real world
 The Need for Dissemination of Treatment Outcome Findings:
o Dissemination = the process of facilitating adoption of efficacious treatments in the
community
 Most typically by offering clinicians guidelines about the best available treatments
along with training on how to conduct those treatments
 Analogue Experiments:
o Analogue experiment = investigators attempt to create/observe a related phenomenon (an
analogue) in the laboratory to allow more intensive study
o Can obtain results with good internal validity, less external validity
o Single-Case Experiments:
 Single-case experiments = experimenter studies how one person responds to
manipulations of the IV *high internal validity
 Lack of external validity
 Just because treatment works for one person doesn’t mean it will work for
another
 Reversal design (ABAB design) = participant’s behaviour must be carefully measured
in a specific sequence (baseline, treatment intro, reinstatement of baseline,
reintroduction of treatment)
 No control group, but time period of baseline serves as control aspect
Integrating the Findings of Multiple Studies
 Meta-analysis = thorough literature search, followed by putting together all the results into a
common scale, using effect size
 Criticism: sometimes include studies of poor quality

lOMoARcPSD|2532716
CHAPTER 5: Mood Disorders

Clinical Descriptions and Epidemiology of Mood Disorders
 2 broad types of mood disorders according to DSM-5: 1) Depressive, 2) Manic (bipolar)
Depressive Disorders
 Cardinal symptoms: profound sadness, and/or inability to experience pleasure
 Physical symptoms: fatigue, low energy, physical aches/pains *convince individual they are suffering
from serious medical conditions
o Difficulty falling asleep, bland taste, change in appetite, disappearance in sexual interest,
limbs feel heavy
o Psychomotor retardation = thoughts and movements slow
o Psychomotor agitation = inability to sit still (pace, fidget, wring their hands)
 I. Major Depressive Disorder (MDD):
o MDD – diagnosis requires 5 depressive symptoms to be present for at least 2 weeks, must
include either depressed mood or loss of interest and pleasure
o Additional symptoms must also be present: changes in sleep, appetite,
concentration/decision making, feelings of worthlessness, suicidality, psychomotor
retardation/agitation
o Episodic disorder = symptoms tend to be present for a period of time and then clear
o Untreated episode may stretch for 5 months+
o Episodes tend to reoccur, 2/3 who experience 1 episode, will experience at least 1 more
o Average: 4 episodes (with each new episode, chance of reoccurrence goes up 16%)
 DSM-5 Criteria:
 1) Sad mood or loss of pleasure in usual activities
 2) At least 5 symptoms (counting sad mood and loss of pleasure)
 Sleeping too much/too little
 Psychomotor retardation/agitation
 Weight loss/change in appetite
 Loss of energy
 Feelings of worthlessness/excessive guilt
 Difficulty concentrating, thinking or making decisions
 Recurrent thoughts of death/suicide
 3) Symptoms are present nearly every day, most of the day for at least 2 weeks
 4) Symptoms are distinct & more severe than a normative response to significant loss
o Sub-clinical depression = sadness plus 3 other symptoms for 10 days
 Significant impairments in functioning even though full diagnostic criteria are not met
 II. Persistent Depressive Disorder (PDD):
o PDD –chronically depressed, more than half of the time for at least 2 years, have at least 2 of
the other symptoms of depression
o Central feature: chronicity of symptoms
o Similar to a DSM-IV-TR diagnosis of dysthymia
 DSM-5 Criteria:
 1) Depressed mood for most of the day more than half of the time for 2 years (1 for
children/adolescents)
 2) At least 2 of the following during that time:
 Poor appetite/overeating, Sleeping too much/too little, Low energy, Poor SE,
Trouble concentrating/making decisions, Feelings of hopelessness
 3) The symptoms do not clear for more than 2 months at a time

lOMoARcPSD|2532716
 4) Bipolar disorders are not present

 Other DSM-5 Depressive Disorders:
o Disruptive mood dysregulation disorder = newly defined depressive disorder, a diagnosis
specific to children and adolescents
o Premenstrual dysphoric disorder = moved from DSM-IV appendix to main diagnostic section
 Epidemiology and Consequences of Depressive Disorders:
o MDD – one of the most common psyc disorders (16.2% US will meet criteria at some point)
o Chronic forms are rarer (PDD), about 2.5% US meet criteria for dysthymia (DSM-IV-TR)
o Twice as common among women as among men
o MDD is 3x as common among impoverished
o Prevalence varies considerably across cultures
o Rates of winter depression (SAD) higher farther from the equator, days are shorter
o Countries with more fish consumption have lower MDD/bipolar rates
o Child symptoms: stomach/headache, Adult: distracted, forgetfulness
o Adolescent males: irritability, anger
o Korea – less likely to describe sad mood/suicidal thoughts
o Latino culture – complaints of nerves/headaches
o Asian culture – reports of weakness, fatigue, and poor concentration
o Smaller distance from equator and higher fish consumption associated w/lower rates
o Age of onset has become lower for each recent generation of people in US
o Age of onset: late teens, early 20s
o 60% who meet criteria for MDD will also meet criteria for anxiety
o Other comorbidities: substance use, sexual dysfunction, personality disorders
o MDD is a leading cause of disability in the world
o 2/3 will also meet criteria for anxiety disorder
Bipolar Disorders
 3 forms (DSM-5): bipolar-I, bipolar-II, cyclothymic disorder
 Manic symptoms are the defining feature (most also experience depression)
 Episode of depression is not required for bipolar-I, it is required for bipolar-II
 Mania = a state of intense elation, irritability, or activation accompanied by other symptoms
 Flight of ideas = difficult to interrupt, shifting rapidly from topic to topic
 Stop sleeping, extremely self-confident, incredibly energetic
 Risky sexual activities, overspending, reckless driving
 Hypomania = less extreme than mania (under mania), does not involve significant impairment,
involves a change in functioning that does not cause serious problems
 I. Bipolar I Disorder:
o Formerly known as manic-depressive disorder
o Diagnosis: includes a single episode of mania during the course of a person’s life
o Bipolar episodes tend to recur
o More than 50% experience 4+ episodes during their life time
o Toughest to diagnose
 II. Bipolar II Disorder:
o Midler form
o Must experience at least one major depressive episode and at least one episode of
hypomania (and no lifetime episode of mania)
 III. Cyclothymic Disorder:
o Aka cyclothymia – a second chronic mood disorder (like PDD)

lOMoARcPSD|2532716
o Symptoms must be present of at least 2 years among adults (1 year in children)

o Frequent, but mild symptoms of depression, alternating with mild symptoms of mania
o Symptoms don’t clear for more than 2 months at a time
 Epidemiology and Consequences of Bipolar Disorders:
o 1% prevalence in USA, 0.6% worldwide (Bipolar I), 0.4% Bipolar II, 4% cyclothymia
o Bipolar I is much rarer than MDD
o More than 50% report onset prior to age 25
o Being seen with increased frequency among adolescents and children
o Occurs equally often in women and men
o Women diagnosed experience more depression than men
o 2/3 diagnosed meet diagnosis for comorbid anxiety
o Many report a history of substance abuse
o Bipolar I is one of the most severe psyc disorders
o Suicide rates high for bipolar I and II
o People hospitalized for bipolar I 2x as likely to die from medical illnesses in a given year
compared to people without mood disorders
DSM-5 Criteria for Manic and Hypomanic Episodes:
 Distinctly elevated or irritable mood
 Abnormally increased activity or energy
 At least 3 of the following are noticeably changed from baseline (4 if irritable mood):
o Increase in goal-directed activity or psychomotor agitation
o Unusual talkativeness – rapid speech
o Flight of ideas or subjective impression that thoughts are racing
o Decreased need for sleep
o Increased SE, belief that one has special talents, powers, or abilities
o Distractibility, attention easily diverted
o Excessive involvement in activities that are likely to have painful consequences, such as
reckless spending, sexual indiscretions, or unwise business investments
o Symptoms are present most of the day, nearly everyday
 For a manic episode:
o Symptoms last 1 week, require hospitalization, or include psychosis
o Symptoms cause significant distress or functional impairment
 For a hypomanic episode:
o Symptoms last at least 4 days
o Clear changes in functioning are observable to others, but impairment is not marked
o No psychotic symptoms are present
Subtypes of Depressive Disorders and Bipolar Disorders
 Mood disorders are highly heterogeneous – people diagnosed with the same disorder may show
very different symptoms
 Rapid cycling = pattern of episodes over time (aka seasonal specifier) *for bipolar only
 Melancholic = episode specifier specific to depression
Etiology of Mood Disorders
 Etiology studies tend to focus on MDD and bipolar-I
Genetic Factors
 Heritability estimate of 37% for MDD (twin studies) *higher estimate when studying more severe
samples
 Bipolar is among the most heritable disorders – heritability estimate of 93%

lOMoARcPSD|2532716
 Unlikely that there is a single gene that explains mood disorders – due to high heterogeneity
 GWAS studies for responsible genes have been inconclusive
o DRD 4.2 gene influences dopamine function, related to MDD
 Have identified several genetic polymorphisms related to bipolar disorder
 Polymorphism of serotonin transporter gene is related to MDD
o Greater risk for depression after a stressful life event with this polymorphism
o Having at least one short allele associated with elevated reactivity to stress
 Neurotransmitters:
o Norepinephrine, dopamine and serotonin are related to mood disorders
o People with depression are less responsive than others to drugs that increase dopamine
levels
o It is thought that the functioning of dopamine might be lowered in depression
o Dopamine is involved in the reward system of the brain = guides pleasure, motivation, and
energy in the context of opportunities to obtain rewards
o Drugs that increase dopamine levels are found to trigger manic symptoms in bipolar
individuals *overly sensitive dopamine receptors
o To lower serotonin levels, deplete levels of tryptophan *major precursor or serotonin
 Causes temporary depressive symptoms in those with family history for depression or
depressive symptoms
o Bipolar disorder may be related to diminished sensitivity of serotonin receptors
o Medication alters levels immediately but takes 2-3 weeks for relief
o New modes focus on sensitivity of post-synaptic receptors
Brain Function: Regions Involved in Emotion
 5 primary brain structures most studied in depression: amygdala, anterior cingulate, dorsolateral
prefrontal cortex, hippocampus, and the striatum
 Amygdala – helps assess how salient/emotionally important a stimulus is
o People with MDD have more intense reactions to stimuli with emotion
 MDD associated with greater activation of anterior cingulate and diminished activation of the
hippocampus & dorsolateral prefrontal cortex when viewing negative stimuli
 MDD – diminished activation of striatum – specifically when receiving positive feedback
o Nucleus accumbens – central component of rewards system, plays a key role in motivation to
pursue rewards
 Bipolar I – elevated responsiveness in the amygdala, increased activity of anterior cingulate,
diminished activity of hippocampus and dorsolateral prefrontal cortex
o High activation of striatum***
The Neuroendocrine System: Cortisol Dysregulation
 HPA axis overactive during MDD *stress reactivity **overactive amygdala
 Overactive amygdala sends signals to HPA axis, triggers release of cortisol (stress hormone)
 Cortisol increases immune system activity to help body prepare for threats
 Cushing’s syndrome = causes over-secretion of cortisol, frequent depressive symptoms
 80% of people hospitalized for depression show poor regulation of HPA system
Social Factors in Depression: Childhood Adversity, Life Events, and Interpersonal Difficulties
 Often interpersonal factors precede onset of depression
 Childhood adversity: parental death, physical abuse, sexual abuse increases risk that later the
individual will develop depression *depressive symptoms likely will be chronic
 Child abuse linked to anxiety even more strongly than to depression

lOMoARcPSD|2532716
 Common stressful life events for triggering depressive symptoms include: losing a job, a key
friendship or a romantic relationship
 Lack of social support is common amongst depressed individuals *lessens ability to handle stress
 Expressed emotion = a family member’s critical or hostile comments toward or emotional over-
involvement with the person with depression
o High EE strongly predicts relapse in depression
 Excessive need for reassurance has been found to be predictive of depression
 Low social competence among elementary school children is a predictor of depression, poor-
interpersonal problem solving skills among adolescents
 Marital conflict can predict depression
Psychological Factors in Depression
 Neuroticism:
o Neuroticism = a personality trait that involves the tendency to experience frequent and
intense negative affect *predicts the onset of depression
o Explains part of genetic vulnerability to depression
o Also associated with anxiety
 Cognitive Theories:
o Pessimistic and self-critical thoughts are major causes of depression
o Beck’s Theory:
 Depression is associated with a negative triad = negative views of the self, their
world, and the future (hopelessness)
 In childhood, people with depression acquired negative schemas through experiences
 Negative schema is activated whenever the person encounters situations similar to
those that originally caused the schema to form
 Cause cognitive biases = tendencies to process info in certain negative ways
 Depression associated with a tendency to stay focused on negative info once it is
initially noticed
o Hopelessness Theory:
 Hopelessness theory = most important trigger of depression is hopelessness *the
belief that desirable outcomes will not occur and that there is nothing a person can
do to change this
 Attributions = the explanations a person forms about why a stressor has occurred:
 1) Stable (permanent) vs. unstable (temporary) causes
 2) Global vs. specific causes
 Stable and global Attributional style more likely linked to depression
o Rumination Theory:
 Rumination = tendency to repetitively dwell on sad experiences and thoughts, or to
chew on material again and again
 Most detrimental form: to brood regretfully about why a sad event happened
 Tendencies to ruminate have been found to predict onset of MD episodes
 Women tend to ruminate more than men
 Rumination increases negative moods, particularly when people focus on negative
aspects of their mood and their self
 Evolutionarily adaptive to focus on negative events in order to solve problems
Social and Psychological Factors in Bipolar Disorder
 Most people who experience a manic episode will also experience a major depressive episode
 Depression in Bipolar Disorders:

lOMoARcPSD|2532716
o Triggers of depression in bipolar disorder are similar to those of MDD

o Negative life events are important triggers, neuroticism, negative cognitive styles, expressed
emotion, lack of social support
 Predictors of Mania:
o Reward sensitivity:
 Disturbance in reward system of the brain
 Highly responsive to rewards
 Life events involving success may trigger cognitive changes in confidence
 Then spirals into excessive goal pursuit, which helps trigger manic symptoms
o Sleep deprivation:
 Sleep deprivation can precede onset of manic episodes
 Protecting sleep can help reduce symptoms of bipolar disorder
Treatment of Mood Disorders
 About 50% of people who meet diagnostic criteria for major depression do not receive care
Psychological Treatment of Depression
 Interpersonal Psychotherapy (IPT):
o Builds on the idea that depression is closely tied to interpersonal problems
o Examine major interpersonal problems
o Focus on 1 or 2 issues with the goal of helping the person identify his feelings about these
issues, make important decisions and effect changes to resolve problems related to these
issues
o Typically brief treatment (16 sessions)
o Techniques: discussing interpersonal problems, exploring negative feelings and encouraging
their expression, improving verbal/nonverbal communications/problem solving
o Effective in relieving MDD and prevents relapse when continued after recovery
o 1) Short-term psychodynamic theory 2) Focus on current relationships
 Cognitive Therapy (CT):
o Depression is caused by negative schema and cognitive biases
o Aims to alter maladaptive thought patterns
o Client taught to understand how powerfully our thoughts can influence our moods
o Help client change his opinions of himself
o Teaches client to challenge negative beliefs and to learn strategies that promote making
realistic/positive assumptions
o Thought-monitoring homework ***emphasis on cognitive restructuring
o Behavioural activation (BA) – people are encouraged to engage in pleasant activities that
might bolster positive thoughts about one’s self and life
o Mindfulness-based cognitive therapy (MBCT) = focuses on preventing relapse after
successful treatment
 Based on the assumption that a person becomes vulnerable to relapse because of
repeated associations between sad mood and patterns of self-devaluing, hopeless
thinking during MD episodes
 Goal: teach people to reorganize when they start to become depressed and to try
adopting a decentered perspective
 = Viewing their thoughts as mental events rather than as core aspects of the
self or accurate reflections of reality
 Detached relationship to depression-related thoughts/feelings
o Monitor and identify automatic thoughts, replace negative with neutral/positive

lOMoARcPSD|2532716
 Behavioural Activation Therapy (BA):

o Originally developed as a standalone treatment
o Based on idea that many risk factors for depression interfere with receiving positive
reinforcement
o Goal: to increase participation in positively reinforcing activities to disrupt depression
 Behavioural Couples Therapy:
o Depression is often tied to relationship problems
o Researchers work with both members of a couple to improve communication and
relationship satisfaction
Psychological Treatment of Bipolar Disorder
 Medication is a necessary component, can have psychological treatment as a supplement
 Psychotherapy can also help reduce bipolar’s depressive symptoms
 Psychoeducational approaches = help people learn about the symptoms of the disorder, expected
time course of symptoms, biological/psychological triggers for symptoms, and treatment strategies
 Can help people adhere to treatment with medications (e.g. lithium)
 Half of patients on medication for bipolar do not take medication consistently
 Psycho-ed helps patients understand rationale for taking medication
 CT and family-focused therapy (FFT) have received strong support
 FFT educates the family about the illness, enhances family communication and develop problem-
solving skills
Biological Treatment of Mood Disorders
 Electroconvulsive Therapy for Depression (ECT):
o Only used to treat MDD that has not responded to medication
o Induces a momentary seizure
o Bilateral ECT = electrodes placed on each side of the forehead
o Unilateral ECT = currents passes only through the non-dominant (typically right) cerebral
hemisphere *less pronounced side effects
o Patient is now given a muscle relaxant prior to ECT so they sleep through it
o Receive 6-12 treatments typically
o More powerful than antidepressant medication especially when there are psychotic features
o Associated deficiencies in cognitive functioning
 Medications for Depressive Disorders:
o Most commonly used and best-researched treatments for depression
o 75% of treated depression patients are prescribed antidepressants
o 3 categories of antidepressants:
 Monoamine oxidase inhibitors (MAOIs)
 Tricyclic antidepressants
 Selective serotonin reuptake inhibitors (SSRIs)
o Recommended treatment for at least 6 months after an episode ends
o Concern: may not be more affective than placebos for mild/moderate symptoms of MDD
o 40% of patients on antidepressants stop taking them after the 1st month *tough side effects
o MAOIs have possible life threatening side effects if combined with certain foods
o SSRIs are most common
 Transcranial Magnetic Stimulation (TMS) for Depression:
o Allowed for patients who have failed to respond to a first antidepressant but not yet tried a
second

lOMoARcPSD|2532716
o Electromagnetic coil placed against scalp, pulses of magnetic energy used to increase activity
in dorsolateral prefrontal cortex (30 mins, for 5-10 days)
o Can help relieve treatment resistant depression
o Star-D sequenced treatment alternatives to relieve depression
 Comparing Treatments for Major Depressive Disorder:
o Combining psychotherapy and antidepressant use raises odds of recovery by 10-20%
o Antidepressants work more quickly than psychotherapy
 Medications for Bipolar Disorder:
o Mood-stabilizing medications = medications that reduce manic symptoms
o Lithium = naturally occurring chemical element, first mood stabilizer identified
o Most medicated patients still experience mild manic/depressive symptoms
o 40% of people relapsed while taking lithium, 60% while taking a placebo
o Lithium levels are toxic if too high *ingestions requires regular blood tests
o 2 other types of medications for acute mania: *also help relieve depression
 Anticonvulsant (antiseizure) medication (divalproex sodium)
 Antipsychotic medication (olanzapine)
 Recommended for those who don’t respond to lithium
o Patients often begin with lithium alongside psychotherapy (lithium takes a long time to start
working)
 A final note on treatment:
o Deep brain stimulation = involves implanting electrodes into the brain, applying small
current to the electrodes, can manipulate activity to those brain regions
o Studies done with patients who have not responded to other forms of treatment
o 10-20% better chance at recovery when combining medication w/therapy
o Medication takes 2-3 weeks to kick in
o CT can be as effective as medications for severe depression, more effective than medication
at preventing relapse
Suicide
 Suicidal ideation = thoughts of killing oneself, more common than attempted/completed suicide
 Most suicide attempts do not result in death
 Suicide attempt = behaviour intended to kill oneself
 Suicide = involves behaviours that are intended to cause death and actually do so
 Non-suicidal self injury = involves behaviours meant to cause immediate bodily harm but are not
intended to cause death
Epidemiology of Suicide and Suicide Attempts
 9% report ideation (worldwide), 2.5% have made at least 1 attempt
 Suicide rates are underestimated – often circumstances of some deaths are ambiguous
 Every 20 minutes someone in the US dies from suicide
 Men (adolescent males especially) are 4 times more likely to kill themselves than women
 Women are more likely to make suicidal attempts that do not result in death
 Men choose to shoot/hang themselves, women are more likely to use pills
 Suicide rate increases in old age *white males over 50 have highest rate in US
 Being divorced or widowed increased risk 4 or 5 fold
 6% of undergrads, 4% grad students seriously contemplate attempting
o 1 in 12 make a plan, ½ don’t tell anyone
Risk Factors for Suicide
 Psychological Disorders:

lOMoARcPSD|2532716
o Many individuals with mood disorders have suicidal thoughts

o More than 50% of those who attempt, are depressed at the time
o 15% of those hospitalized with depression end up killing themselves
o 90% of attempts are suffering from some psyc disorder
 5-7% bipolar, 5% schizophrenia, impulse control disorders, substance use disorders,
PTSD, borderline personality disorder, panic disorders, eating disorders
o Most likely when a person is experiencing comorbid depression
o Most people with psyc disorders do not die from suicide
 Neurobiological Factors:
o Heritability accounts for 48% of suicide attempts
o Serotonin (violent suicide) and cortisol are important factors
 Social Factors:
o Suicide rates have increased over the past 100 years (economic recession)
o Major effect from media reports on suicide (e.g. after Marilyn Monroe’s suicide)
o Social isolation and lack of social belonging are powerful predictors
 Psychological Factors:
o Related to poor problem solving skills
o Difficulty solving problems leads to increased vulnerability to hopelessness *strongly tied to
suicidality
o Many think about suicide, only few act on those thoughts **impulsivity
Preventing Suicide
 Talking about suicide might help relieve a sense of isolation
 Treating the Associated Psychological Disorder:
o Most people who kill themselves are suffering from a psyc disorder
o Decrease in psyc disorder symptoms also decreases risk of suicide
o Many antidepressants and other medications for mood disorders reduce risk of suicide
 Treating Suicidality Directly:
o Cognitive behavioural approaches are most promising
o Reduce risk of future attempt by 50% in those who have already attempted/failed
o Also reduce suicidal ideation
 Broader Approaches to Suicide Prevention:
o Rates of suicide are much higher in the military *use this setting to conduct research on
prevention methods
o Public health prevention tries to make it more difficult to access means used for suicide
CHAPTER 6: Anxiety Disorders

 Anxiety = apprehension over an anticipated problems
 Fear = a reaction to immediate danger
 Both fear and anxiety can involve arousal or sympathetic nervous system activity *both can be
adaptive
 Anxiety involves moderate arousal, fear involves high arousal
 Fear is fundamental for fight or flight reactions
 Anxiety disorders – fear system misfires, when there is no real immediate danger
 Anxiety is adaptive in helping us plan for future threats
 Small degree of anxiety improves performance on laboratory tasks
 Anxiety has an inverse-U shaped relationship with test performance
 Most common type of psyc disorder, phobias in particular *28% report anxiety symptoms

lOMoARcPSD|2532716
 Associated with twice the average rate of medical costs, higher risk of cardiovascular disease, twice
the risk of suicidal ideation and attempt
Clinical Description of Anxiety Disorders
 1) Symptoms interfere with important areas of functioning or cause marked distress
 2) Symptoms are not caused by a drug or a medical condition
 3) Symptoms persist for at least 6 months or at least 1 month for a panic disorder
 4) The fear and anxieties are distinct from the symptoms of another anxiety disorder
Specific Phobias
 Specific phobia = a disproportionate fear caused by a specific object or situation
 Recognizes fear is excessive, goes to great lengths to avoid feared object/situation
 May elicit intense disgust
 Must be severe enough to cause distress/interfere with job or social life *avoidance
 Common: Claustrophobia and Acrophobia (fear of heights)
 Specific phobias are highly comorbid
 Criteria:
o Marked and disproportionate fear consistently triggered by specific objects or situations
o The object or situation is avoided or else endured with intense anxiety
o Symptoms persist for at least 6 months
Social Anxiety Disorder
 Social anxiety disorder = a persistent, unrealistically intense fear of social situations that might
involve being scrutinized by, or even exposed to, unfamiliar people
 Labeled as social phobia in DSM-IV-TR
 Feel as though all eyes are watching them, others waiting to evaluate them and record embarrassing
acts
 Avoid social situations, feel social discomfort and experience symptoms for longer time than people
who are shy
 Common fears: public speaking, speaking up in meetings or classes, meeting new people, talking to
people in authority
 Those with broader array of fears more likely to experience comorbid depression and alcohol abuse
 Often work in occupations far below their talents
 1/3 meet the criteria for avoidant personality disorder
 Generally begins during adolescence when peer relationships become particularly important
 Tends to be chronic without treatment
 Critera:
o Marked and disproportionate fear consistently triggered by exposure to potential social
scrutiny
o Exposure to the trigger leads to intense anxiety about being evaluated negatively
o Trigger situations are avoided or else endured with intense anxiety
o Symptoms persist for at least 6 months
Panic Disorder
 Panic disorder = characterized by recurrent panic attacks that are unrelated to specific situations and
by worry about having more panic attacks
 Panic attack = a sudden attack of intense apprehension, terror and feelings of impending doom,
accompanied by at least 4 other symptoms
 Physical symptoms: shortness of breath, head palpitations, nausea, upset stomach, chest pain,
feelings of choking and smothering, dizziness, light headedness, faintness, sweating/chills, heat
sensation, numbness/tingling and trembling

lOMoARcPSD|2532716
 Depersonalization = a feeling of being outside one’s body

 Derealization = feeling of the world not being real
 Fear of losing control, going crazy or even dying
 Intense urge to flee
 Symptoms come on rapidly and peak within 10 minutes
 Feel amount of sympathetic nervous system arousal compared to normal when faced with
immediate threat to life
 Must experience recurrent panic attacks that are unexpected
 Must worry about the attacks for at least 1 month
 Onset typically in adolescence, symptoms wax and wane over time
 Criteria:
o Recurrent unexpected panic attacks
o At least 1 month of concern about the possibility of more attacks, worry about the
consequences of an attack, or maladaptive behavioral changes because of the attacks
Agoraphobia
 Agoraphobia = anxiety about situations in which it would be embarrassing or difficult to escape if
anxiety symptoms occurred *e.g. crowds, crowded places or situations (trains, bridges, road trips)
 Unable to leave home
 Coded as subtype panic disorder in DSM-IV-TR
 At least half of people with agoraphobia do not experience symptoms of panic attacks
 Related to significant impairment in daily functioning
 Criteria:
o Disproportionate and marked fear or anxiety about at least 2 situations where it would be
difficult to escape or receive help in the event of incapacitation or panic-like symptoms, such
as:
 Being outside of the home alone; traveling on public transportation; open spaces such
as parking lots and marketplaces; being in shops, theaters, or cinemas; standing in
line or being in a crowd
 These situations consistently provoke fear or anxiety
 These situations are avoided, require the presence of a companion, or are endured
with intense fear or anxiety
o Symptoms last at least 6 months
Generalized Anxiety Disorder
 GAD = central feature is worry, persistently worried often about minor things
 Worry = cognitive tendency to chew on a problem and to be unable to let go of it
 Cannot settle on a solution to the problem
 Worry is excessive, uncontrollable and long-lasting
 DSM Criteria:
o 1) Excessive anxiety and worry at least 50% of days about a number of events or activities
o 2) The person finds it hard to control the worry
o 3) The anxiety and worry are associated with at least 3 (or 1 in children) of the following:
 Restlessness/feeling keyed up/on edge, easily fatigued, difficulty concentrating/mind
going blank, irritability, muscle tension, sleep disturbance
 Typically begins in adolescence, often chronic
 More strongly related to marital dissatisfaction than any other anxiety disorder
Comorbidity in Anxiety Disorders
 More than 50% meet criteria for another anxiety disorder during lifetime

lOMoARcPSD|2532716
 Highly comorbid with other disorders (75%)

 ¾ meet criteria for some other psyc disorder
 60% meet criteria for MDD (others: substance abuse, personality disorders, medical disorders)
Gender and Cultural Factors in the Anxiety Disorders
Gender
 Women are more vulnerable than men (2:1 gender ratio)
 Women are more likely to report their symptoms, gender roles play a role
 Men face more pressure to face fears
 Women more likely to experience childhood sexual abuse
 Women show more biological reactivity to stress than men (HPA)
Culture
 Culture and environment influence what people tend to fear
 Japan – fear of displeasing others
 Inuit – fear of being alone at sea and drowning
 Koro – fear that genitals will recede into body
 Shenkui – fear of loss of semen due to masturbation
 Susto – fear that fright has caused soul to leave body
 Rate of anxiety disorders varies by culture, ration of somatic to psychological symptoms is similar
Common Risk Factors Across the Anxiety Disorders
Fear Conditioning
 Mowrer’s two-factor model = suggests 2 steps in the development of an anxiety disorder:
o 1) Classical conditioning – a person learns ot fear a neutral stimulus (CS) that is paired with an
intrinsically aversive stimulus (UCS)
o 2) A person gains relief by avoiding CS, through operant conditioning, this avoidant response
is maintained because it is reinforcing (reduces fear) *helps maintain phobia
 Different ways in which classical conditioning could occur:
o 1) Direct experience (e.g. dog bite)
o 2) Modeling (e.g. witnessing a dog bite someone)
o 3) Verbal instruction (e.g. hearing a parent warn that dogs are dangerous)
 People with anxiety disorders acquire fears through classical conditioning more readily, and show
slower extinction once fear is acquired
Genetic Factors
 Heritability of 20-40% for specific phobias, social anxiety disorder and GAD
 50% for panic disorder
Neurobiological Factors: The Fear Circuit and the Activity of Neurotransmitters
 Fear circuit = set of brain structures that are engaged when people feel anxious or fearful
 Includes the amygdala (temporal lobe) – involved in assigning emotional significance to stimuli
 Medial prefrontal cortex = helps to regulate activity of amygdala, involved in extinguishing fears and
appears to be engaged when people are regulating their emotions
o Less activity when viewing appraising threatening stimuli in anxiety disorders
 Pathway connecting medial prefrontal cortex and amygdala may be deficient
 Disruptions in serotonin and GABA receptors
 GABA is believed to help inhibit anxiety
 Increased levels of norepinephrine and changes in receptor sensitivity
o Key in activation of SNS, for fight or flight responses
Personality: Behavioural Inhibition and Neuroticism

lOMoARcPSD|2532716
 Behavioural inhibition = tendency to become agitated and cry when faced with novel toys, people,
or other stimuli
 May be inherited and set the stage for later development of anxiety disorders
 Strong predictor of social anxiety disorder
 Neuroticism = personality trait defined by tendency to experience frequent/intense negative affect
o Predicts onset of anxiety disorders and depression, 2x as likely with high levels
Cognitive Factors
 Sustained Negative Beliefs About the Future:
o Believe that bad things are going to happen
o Safety behaviours = behaviours that maintain feared beliefs (e.g. stop all physical activity if
believe they will die from fast heart rate)
o Believe only their safety behaviours are what have kept them alive
 Perceived Lack of Control:
o May be promoted by childhood traumatic events, punitive parenting or abuse
o Often develop after serious life events that threaten the sense of control over one’s life
o More than 70% report serious life event before onset of disorder
 Attention to Threat:
o Pay more attention to negative cues in environment than those w/o anxiety disorder
o Heightened attention to threatening stimuli *automatically and quickly
o Stay focused on threatening object longer than others do
Etiology of Specific Anxiety Disorders
Etiology of Specific Phobias
 2-factor model of behavioural conditioning (classical and operant)
 Specific phobias seen as a conditioned response that develops after a threatening experience and is
maintained by avoidant behaviour
 Phobias could be conditioned by direct trauma, modeling, or verbal instruction
 People may forget conditioning experiences that lead to phobia
 Only certain kinds of stimuli and experiences will contribute to the development of a phobia
o Could have evolutionary/adaptability basis
o Prepared learning = evolution may have prepared our fear circuit to learn fear of certain
stimuli very quickly and automatically
Etiology of Social Anxiety Disorder
 Behavioural Factors: Conditioning of Social Anxiety Disorder:
o 2-factor conditioning model
o Negative social experience can lead to conditioned fear of stimulus, person avoids those
situations/stimuli
o Safety behaviours: avoiding eye contact, disengaging from conversation, standing apart from
others
 Cognitive Factors: Too Much Focus on Negative Self-Evaluations:
o Unrealistically negative beliefs about the consequences of their behaviour
o Attend more to how they are doing in social situations and their own internal sensations than
most people do
o Overly negative in evaluating their social performance
o Attend more to internal cues than external
Etiology of Panic Disorder
o Locus coeruleus = major source of norepinephrine in the brain

lOMoARcPSD|2532716
o Surges of norepinephrine are a natural response to stress, associated with increased activity
of sympathetic nervous system
 Faster heart rate, other fight or flight responses
o W/anxiety disorder, show more dramatic biological response to drugs that trigger release of
norepinephrine
o Drugs that increase activity in locus coeruleus can trigger panic attacks, decrease (clonidine
and antidepressants) decrease risk of panic attacks
Behavioural Factors: Classical Conditioning
 Panic attacks are often triggered by internal bodily sensations of arousal
 Panic attacks are classically conditioned responses to situations that trigger anxiety or internal bodily
sensations of arousal
 Interoceptive conditioning = classical conditioning of panic attacks in response to bodily sensations
 Cognitive Factors in a Panic Disorder:
o Focus on catastrophic misinterpretations of somatic changes
o Panic attacks develop when a person misinterprets bodily sensations as signs of impeding
doom (increased heart rate = heart attack)
o Anxiety sensitivity index = measures the extent to which people respond fearfully to their
bodily sensations
 Can predict onset of panic attacks in longer-term studies
 Putting it All Together: A Gene that Influences Neurobiological and Psychological Risk Factors for
Panic Disorder:
o Polymorphism in gene guiding neuropeptide S function – NPSR1 gene – tied to increased risk
of panic disorder
o Neuropeptide S related to anxiety-like behaviours in mice
o NPSR1 gene related to increased amygdala response to threat stimuli, larger cortisol
response to stressor, higher anxiety sensitivity scores
Etiology of Agoraphobia
 Related to genetic vulnerability and life events
 Fear-of-fear hypothesis = agoraphobia is driven by negative thoughts about the consequences of
experiencing anxiety in public
Etiology of GAD
 Tends to co-occur with other anxiety disorders
 People who meet diagnostic criteria are much more likely to experience episodes of MDD
 Seems to involve general tendency to experience general distress more than a specific pattern of
intense fear
 Related to a more amorphous profile of general distress
 Worry is reinforcing because it distracts people from more powerful negative emotions and images
 Worry does not involve powerful visual images and doesn’t produce the physiological changes that
accompany emotion
 More of a repetitive self-talk about bad things that might happen
 Worrying decreases psycho-physiological arousal
 Maltreatment predicts a 4 fold risk of developing GAD *worry distracts from remembering trauma
 People with GAD may be avoiding emotions
 People who have a hard time accepting ambiguity are more likely to worry and develop GAD
Treatment of Anxiety Disorders
 Most individuals visit a family doctor for treatment and are prescribed benzodiazepines
Commonalities Across Psychological Treatments

lOMoARcPSD|2532716
 Common focus: exposure

 CBT begins by making a list of triggers = situations and activities that might elicit anxiety or fear
 Create an exposure hierarchy = a graded list of the difficulty of these triggers
 Begin with exposure to less challenging triggers
 Exposure treatment is effective for 70-90% of clients
 1) Exposure should include as many features of the feared objects as possible
 2) Exposure should be conducted in as many different contexts as possible
 Works by extinguishing the fear response
 Extinction involves learning new associations to stimuli related to the feared stimulus *which inhibit
activation of fear
 Extinction involves learning not forgetting
 Cognitive - Exposure helps people correct their mistaken beliefs that they are unable to cope with
the stimulus
o Relieves symptoms by allowing people to believe that they can tolerate aversive situations
o Focus on: 1) Challenging a person’s beliefs about the likelihood of negative outcomes if he
faces an anxiety-evoking situation, and 2) Challenging the expectation that he will be unable
to cope
 Exposure to simulated situations can be just as effective as in-vivo exposure
Psychological Treatments of Specific Anxiety Disorders
 Psychological Treatment of Phobias:
o Exposure treatment including in-vivo exposure to feared objects
o Brief treatments lasting only a couple hours can be very effective
 Psychological Treatment of Social Anxiety Disorder:
o Exposure therapy
o Begin with role playing with therapist or small therapy group
o Prolonged exposure can typically extinguish anxiety
o Teach clients to stop using safety behaviour (e.g. avoiding eye contact)
o Learn not to focus attention internally
 Psychological Treatment of Panic Disorder:
o CBT focuses on exposure
o Panic control therapy (PCT) = based on the tendency of people with panic disorder to over
react to the bodily sensations
 Therapist uses exposure – persuades client to deliberately elicit bodily sensations
associated with panic
 Learn to stop seeing physical symptoms as signals of los of control
 Psychological Treatment of Agoraphobia:
o CBT focuses on exposure – systematic exposure to feared situations
o Gradually coached to tackle leaving home, driving a couple miles away, sitting in a public
place for a short amount of time
o Enhanced results when patient’s partner is involved in exposure
 Psychological Treatment of GAD:
o Behavioural technique – relaxation training to promote calmness
o E.g. muscle relaxation or generating calming images
o Cognitive therapies to target worry – asking them to worry only during scheduled times
Medications That Reduce Anxiety
 Anxiolytics = drugs that reduce anxiety

lOMoARcPSD|2532716
 Benzodiazepines e.g. Valium, Xanax & antidepressants e.g. SSRIs, serotonin-norepinephrine

reuptake inhibitors (SNRIs)
 Benzodiazepines referred to as mild tranquilizers/sedatives
 Provide more benefits than placebos
 Use buspirone for GAD
 Antidepressants are preferred over benzodiazepines *severe withdrawal symptoms due to
addictiveness, cognitive and motor side effects, increased risk of car accidents
 Compared to tricyclic antidepressants, SSRIs and SNRIs tend to have fewer side effects *first choice
o Can experience: restlessness, insomnia, headache, diminished sexual functioning
 Many people relapse once they stop taking medications
 Psychological treatment is preferred method with exception of for GAD
Medication to Enhance Learning During Psychological Treatment
 D-cycloserine (DCS) = a drug that enhances learning *used to bolster exposure treatment
CHAPTER 7: Obsessive-Compulsive Related and Trauma-Related Disorders

 Obsessive-compulsive disorders are defined by repetitive thoughts and behaviours that are so
extreme that they interfere with everyday life
 Trauma-related: PTSD and acute stress disorder
 Often experience other anxiety disorders alongside
Obsessive-Compulsive and Related Disorders
 OCD defined by: repetitive thoughts and urges (obsessions) as well as an irresistible need to engage
in repetitive behaviours or mental acts (compulsions)
 Body dysmorphic and hoarding disorder share symptoms of repetitive thoughts and behaviours
o BDD – preoccupation with imagined flaws in one’s appearance & excessive repetitive
behaviours or acts regarding appearance
o HD – acquisition of an excessive number of objects & inability to part with those objects
 These syndromes often co-occur
 1/3 of those with body dysmorphic disorder meet criteria for OCD
 ¼ of people with hoarding disorder meet criteria for OCD
 1/3 of people with OCD experience symptoms of hoarding
Clinical Descriptions of the OC and Related Disorders
 All share repetitive thoughts and irresistible urge to engage repetitively in some behaviour/mental
act
 OCD:
o = Based on the presence of obsessions or compulsions (most experience both)
o Obsessions = intrusive and recurring thoughts, images or impulses that are persistent and
uncontrollable and that often appear irrational to the person having them
o Interfere with normal daily activities
o Often involve fear of contamination from germs/disease
o Compulsions = repetitive, clearly excessive behaviours or mental acts that the person feels
driven to perform to reduce the anxiety caused by obsessive thoughts or to prevent some
calamity from occurring
o Feel compelled to repeat a ritual if feel as though did not execute it with precision
o DO not regard pleasurable behaviours as compulsions (eating, drinking, gambling)
o Tends to begin before age 10, fairly chronic
o Pattern of symptoms appears to be similar across cultures
o Prone to extreme doubts, procrastination, and indecision

lOMoARcPSD|2532716
 Body Dysmorphic Disorder (BDD):

o = Preoccupied with one or more imagined or exaggerated defects in their appearance
o Women focus on their: skin, hair, facial features, breasts, hips, legs
o Men focus on their: height, penis size, body hair
o Find it very hard to stop thinking about these concerns (3-8 hours/day)
o Compelled to engage in certain behaviours: checking appearance in mirror, comparing their
appearance to other people, asking others for reassurance, using strategies to change their
appearance/camouflage
o 1/5 endure plastic surgery
o 1/3 have suicidal ideation, 20% have attempted suicide
o Avoid contact with others
o Begins in adolescence
o Social/cultural factors play a role in how people decide whether they are attractive
o Women are more likely than men to report appearance dissatisfaction
o Symptoms/outcomes are similar across cultures
 Hoarding Disorder:
o = Need to acquire is excessive, abhor parting with their objects even when others cannot say
any potential value in them
o Extremely attached to possessions, many collections of different categories of objects
o Poor hygiene, exposure to dirt, difficulties cooking
o ¾ engage in excessive buying and many are unable to work
o 10% threatened with eviction
o 1/3 also hoard animals (more often women than men) *view as animal rescuer
o Usually begins in childhood or early adolescence
o Animal hoarding doesn’t tend to emerge until middle age+
Prevalence and Comorbidity of the OC and Related Disorders
 Lifetime prevalence: 2% for OCD and BDD, 1.5% for hoarding
 OCD and BDD slightly more common among women, hoarding is equally common
 Very few men seek treatment for hoarding
 High rates of comorbidity
 Often co-occur with anxiety and depression
 OCD and BDD tend to co-occur with substance use disorders
Etiology of the Obsessive-Compulsive and Related Disorders
 Moderate genetic contribution, heritability estimate of 40-50%
 3 closely related areas of the brain unusually active in people with OCD:
o Orbitofrontal cortex = area of medial prefrontal cortex above the eyes
o Caudate nucleus = part of basal ganglia
o Anterior cingulate
 Etiology of OCD:
o Many of the disruptive thoughts and behaviours have adaptive value
o Goal of CBT: understand why the person with OCD continues to show the
behaviours/thoughts used to ward off an initial threat well after that threat is gone
 OCD related to deficit in the intuitive sense of feeling security and closure
 Yedasentience = subjective feeling of knowing that you have thought enough, cleaned
enough, or in other ways done what you should to prevent chaos and danger from
low-level threats in the environment ***biological deficit for OCD
 Compulsions are reinforcing because they relieve the sensation

lOMoARcPSD|2532716
o Thought Suppression:
 People with OCD try harder to suppress their obsessions than other people and may
actually make the situation worse
 Feelings of responsibility for what occurs
 Etiology of BDD:
o People with BDD can accurately see and process their physical features
o They are detailed oriented and this influences how they look at facial features, examine one
feature at a time instead of examining the whole
o Become engrossed in considering a small flaw
o Consider attractiveness to be more important than others, self-worth is dependent upon it
 Etiology of Hoarding Disorder:
o Evolutionary perspective – would be adaptive to store any resources
o Behavioural model: related to poor organizational abilities, unusual beliefs about
possessions, and avoidance behaviours
o Slow at sorting objects into categories, find it anxiety-provoking
o Demonstrate an extreme emotional attachment to possessions *especially to animals
o Avoidance (of anxiety from organizing clutter) helps maintain the clutter
Treatment of the OC and Related Disorders
 Medications:
o Antidepressants most commonly used
o Clomipramine used for OCD (50% reduction in symptoms) *youth and adults
o Antidepressants more helpful than placebos for BDD *using clomipramine and fluoxetine
(continue to experience mild symptoms)
o Hoarding symptoms respond less to medication treatment than other OCD symptoms
 Psychological Treatment:
o Exposure and response prevention (ERP) = exposure treatment to address compulsive rituals
people with OCD use to ward off threats
o OCD:
 Hold belief that compulsive behaviours will prevent awful things from happening
 ERP – exposure themselves to situations that elicit the compulsive act and refrain
form performing the compulsive ritual
 Not performing the ritual exposes the person to the full force of the anxiety
provoked by the stimulus
 The exposure promotes the extinction of the conditioned response (the
anxiety)
 Uses exposure hierarchy, highly effective *more than clomipramine
 25% of clients refuse ERP treatment
 Cognitive – challenging beliefs about what will happen if one doesn’t engage in
rituals, also use exposure to test beliefs
o BDD:
 ERP – exposure to feared activity e.g. interact with people who could be critical of
their looks, response prevention  avoid looking in the mirror
 Supplemented with strategies to address cognitive features
o Hoarding Disorder:
 Adaptation of ERP – focuses on getting rid of objects
 Response prevention – halting the rituals engage in to reduce anxiety e.g. counting or
sorting possession

lOMoARcPSD|2532716
 Facilitate insight as to why this is a problem

 Build family rapport
 Deep Brain Stimulation: A Treatment in Development for OCD:
o Involves implanting electrodes into the brain for those with chronic OCD that fails to respond
after multiple pharmacological treatments
o Implanted into nucleus accumbens or region at the margin of the ventral striatum
o 50% attaint significant relief within a couple of month *still experimental
Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)
 Diagnosed only when a person develops symptoms after a traumatic event
 Horrific life experiences can trigger serious psychological symptoms
Clinical Description and Epidemiology of PTSD and ASD
 PTSD = an extreme response to a severe stressor, including recurrent memories of the trauma,
avoidance of stimuli associated with the trauma, negative emotions and thoughts, and symptoms of
increased arousal
 Diagnosis was developed after the Vietnam War
 Serious trauma = an event that involved actual or threatened death, serious injury, or sexual
violation
 Military trauma is most common for men, rape trauma for women (1/3 of female rape victims meet
criteria)
o 70% of rapes are committed by someone known to the woman
 In addition to exposure to trauma, diagnosis of PTSD requires a set of symptoms be present
o 1) Intrusively re-experiencing the traumatic event (1) (dreams/nightmares, memories,
flashbacks)
o 2) Avoidance of stimuli associated with the event (1) *avoidance usually fails
 Avoid internal or external reminders
o 3) Other signs of negative mood and thought that developed after the trauma (2) *feeling
detached from friends/family
o 4) Symptoms of increased arousal and reactivity (2) – continuously on guard, monitoring
environment for danger, irritability, sleep disturbance
o 5) Symptoms began or worsened after the trauma and continued for at least 1 month
o 6) Among children younger than 7, diagnosis requires only 1 symptom from each category
 Symptoms may develop soon after trauma or not until years after
 Symptoms are relatively chronic
 Suicidal thoughts are common, so is non-suicidal self-injury
 Prolonged exposure to trauma might lead to a broader range of symptoms = complex PTSD
 ASD = diagnosed when symptoms occur after a trauma, symptoms are fairly similar to PTSD but the
duration is shorter
o Only applicable when symptoms last for 3 days to 1 month
o 1) Diagnosis could stigmatize short-term reactions to serious traumas, even though they are
quite common
o 2) Most people who go on to meet diagnostic criteria for PTSD do not experience DSM-IV-TR
diagnoses of ASD in the first month after the trauma
o Elevated risk of developing PTSD within 2 years
 PTSD is highly comorbid with other conditions: anxiety, depression, substance abuse, conduct
disorder
 Women are 2x as likely to develop PTSD after trauma then men
 Some cultural groups are exposed to higher rates of trauma (e.g. minority populations in US)

lOMoARcPSD|2532716
Etiology of PTSD
 2/3 of people with PTSD have a history of an anxiety disorder
 PTSD related to genetic risk for anxiety disorders *high activity in fear circuit areas (amygdala),
childhood trauma, tendencies to attend selectively to cues of threat
 Neuroticism and negative affectivity predict the onset of PTSD
 Related to Mowrer’s 2-factor model of conditioning (classical conditioning and operant conditioning)
 Nature of the Trauma: Severity and the Type of Trauma Matter:
o PTSD rates are doubled with soldiers who have a second tour of duty
o More prisoners of war develop PTSD than those only wounded in war
o Traumas caused by humans are more likely to cause PTSD than natural disasters
 Neurobiology: The Hippocampus:
o PTSD uniquely related to the function of the hippocampus
o Hippocampus volume is smaller in those with PTSD
o Smaller than average hippocampus volume precedes the onset of the disorder
o Plays role in ability to locate autobiographical memories in space, time and context, and in
organizing our narratives of those memories
o Decreased hippocampus volume could explain deficit in verbal memory
 Coping:
o People who cope with trauma by trying to avoid thinking about it are more likely to develop
PTSD
o Dissociation = feeling removed from one’s body or emotions or being unable to remember
the event *may keep the person from confronting the event
o Symptoms of dissociation after trauma are predictive of development of PTSD
o High intelligence and strong social support may help cope with severe trauma more
adaptively
Treatment of PTSD and ASD
 Medication Treatment of PTSD:
o SSRIs receive strong support as a treatment
o Relapse is common if medication is discontinued
 Psychological Treatment of PTSD:
o Exposure treatment
o Client is asked to face his worst fears, by working up an exposure hierarchy
o Extinguish fear response or help challenge the idea that the person could not cope with
anxiety/fear generated by those stimuli
o Exposure focused on memories/reminders of trauma
o In-vivo – returning to scene of the crime
 Imaginal exposure = the person deliberately remembers the event
o Virtual reality technology sometimes used
o More effective that medication
o Cognitive processing therapy  designed to help victims of rape and sexual abuse dispute
tendencies towards self-blame
 Psychological Treatment of ASD:
o Short-term CBT include exposure therapy
o Decreases chances of ASD developing into PTSD (reduced to 32% compared to 58%)
o Exposure more effective than cognitive restructuring in preventing development of PTSD

lOMoARcPSD|2532716
CHAPTER 8: Dissociative Disorders and Somatic Symptom-Related Disorders

 Dissociative  experience disruptions of consciousness, lose track of self-awareness, memory and
identity
 Somatic symptom-related  complains of bodily symptoms that suggests a physical
defect/dysfunction *often no physiological basis can be found
 Both are related to stress, they both tend to be comorbid
1. Dissociative Disorders
 1) Depersonalization/derealization: alteration in the experience of the self and reality
 2) Dissociative amnesia: lack of conscious access to memory, typically of a stressful experience
(7.5%)
o The fugue subtype involves travelling or wandering coupled with loss of memory for one’s
identity or past
 3) Dissociative identity disorder (DID): at least 2 distinct personalities that act independently of each
other (1-3%)
 Dissociation is the core feature = involves some aspect of emotion, memory, or experience being
inaccessible consciously
 Dissociation is an avoidance response that protects a person from consciously experiencing stressful
events
o Can also be result of sleep deprivation
Memory
 Interference memory formation – not accessible to awareness later
 Memory deficits in EXPLICIT but not implicit memory (with dissociative disorder)
o Explicit memory = involves conscious recall of experiences (factual)
o Implicit memory = underlies behaviours based on experiences that cannot be consciously
recalled (e.g. playing tennis)
 Distinguishing other causes of memory loss from dissociation:
o Dementia – memory fails slowly over time *not linked to stress (brain dysfunction)
 Accompanied by other cognitive deficits (e.g. processing speed)
 Inability to learn/code new information
o Memory loss after brain injury
o Substance abuse
I. Depersonalization/Derealization Disorder (DDD)
DSM-5 Criteria:
 = Involves a disconcerting and disruptive sense of detachment from one’ self or surroundings
 1) Depersonalization = sense of being detached from one’s self - OR:
 2) Derealization = sense of detachment from one’s surroundings, surroundings seem unreal
o Outside their bodies, viewing themselves from a distance, looking at the world through fog
o Feel mechanical, like robots
 3) Reality testing remains intact
 4) Symptoms are not explained by substances, another dissociative disorder, another psyc disorder,
or by a medical condition
 Symptoms usually triggered by stress, no disturbance in memory or psychosis
 Usually begins in adolescence, abruptly or insidiously
 Symptoms often continually present for years
 Comorbid personality disorders are frequent, 90% experience anxiety and depression
 Childhood trauma often reported
 Symptoms can co-occur with other disorders but cannot be entirely explained by them

lOMoARcPSD|2532716
II. Dissociative Amnesia

DSM-5 Criteria:
 1) Inability to remember important autobiographical information, usually of a traumatic or stressful
nature, that is too extensive to be of ordinary forgetfulness
 2) The amnesia is not explained by substances, or by other medical or psychological conditions
 3) Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently
purposeful wandering
 Information is not permanently lost but cannot be retrieved during episode of amnesia (several
hours – several years)
 Amnesia usually disappears as suddenly as it began
 Complete recovery and only small chance of reoccurrence
 Procedural memory remains intact
 Fugue = memory loss is more extensive, the person typically disappears from home and work
o May take on new name/job/personality *identity
o Inability to recall one’s past
o Brief duration, remits spontaneously
 Psychodynamic theory:
o Traumatic experiences are repressed *hippocampus is vulnerable to stress, memories are
forgotten because they are so aversive
 Cognitive: extreme stress usually enhances rather than impairs memory
o Norepinephrine (associated with heightened arousal) enhances memory consolidation and
retrieval
 Nature of attention and memory change during periods of intense stress
o Focus on central features of threatening situation
o Stop paying attention to peripheral features
o Retain emotionally relevant information rather than neutral details
 Perhaps extremely high levels of stress hormones interfere with memory formation
III. Dissociative Identity Disorder (DID) *formerly Multiple Personality Disorder
DSM-5 Criteria:
 1) Disruption of identity characterized by 2 or more distinct personality states (alters) or an
experience of possession
o These disruptions lead to discontinuities in the sense of self or agency, as reflected in altered
cognition, behaviour, affect, perceptions, consciousness, memories, or sensory-motor
functioning
o This disruption may be observed by others or reported by the patient
 2) Recurrent gaps in memory for events or important personal information that are beyond ordinary
functioning
 3) Symptoms are not part of a broadly accepted cultural or religious practice
 4) Symptoms are not due to drugs or a medical condition
 5) In children, symptoms are not better explained by an imaginary playmate or by fantasy play
 Each alter determine the person’s nature and activities when it is in command
 Primary alter may not be aware that any other alter exists *it is the primary alter than usually seeks
treatment
 Most often 2-4 alters are identified when diagnosed
 Personalities of alters are quite different from one another
 Rarely diagnosed until adulthood, can recall symptoms dating back to childhood
 More severe and extensive than other dissociative disorders *less complete recovery

lOMoARcPSD|2532716
 More common in women than in men

 Other diagnoses are often present: PTSD, MDD, somatic symptom disorders, personality disorders
 No thought disorder or behavioural disorganization
 Accompanied by other symptoms: headaches, hallucinations, suicide attempts, self-injurious
behaviour, amnesia, depersonalization
Epidemiology: Increases over time
 Almost no reports of DID or dissociative amnesia before 1800
 1-3% prevalence estimate
 Heightened professional media attention may had led some therapists to suggest strongly to clients
that they had DID
 Sometimes use hypnosis to probe for alters
 Diagnosis criteria was more explicit in DSM-III
 Appearance of DID in pop culture (Sybil, 3 faces of eve)
Etiology
 Almost all patients in therapy report severe childhood abuse
 Posttraumatic Model:
o Some people are particularly likely to use dissociation to cope with trauma
o Children who are abused are at risk for developing dissociative symptoms
o Evidence that children who dissociate are more likely to develop psychological symptoms
after trauma
 Sociocognitive Model:
o People who have been abused seek explanations for their symptoms and distress, alters
appear in response to suggestions by therapists, exposure to media reports of DID or other
cultural influences
o Iatrogenic = created within treatment  the person learns to role-play these symptoms
within treatment
 DID symptoms can be role-played:
o Usually under hypnosis
 Alters share memories, even when they report amnesia:
o Defining feature: inability to recall information experienced by one alter when a different
alter is present
o Implicit memory seems to be intact and shared
 Symptoms may only emerge after therapy begins
Treatment
 Important to have an empathic, gentle stance
 Goal of helping the person function as one holly integrated person
o Convince the person that splitting into different personalities is no longer necessary to deal
with trauma
 Teach more effective ways of coping with stress *emotional regulation strategies
 Psychoeducation – help understand why dissociation occurs, identify triggers
 Psychodynamic treatment – goal to overcome repressions
o Use hypnosis to help client gain access to repressed material
o Age regression = encourage client to go back in his/her mind to traumatic events in
childhood
o Help realize that childhood threats are no longer present
o Can possibly worsen DID symptoms

lOMoARcPSD|2532716
 Often comorbid with anxiety and depression, use antidepressants to lessen *have no effect on DID
itself
2. Somatic Symptom and Related Disorders (previously known as somatoform disorders)
 1) Somatic symptom disorder: excessive thought, distress, and behaviour related to somatic
symptoms
 2) Illness anxiety disorder: unwarranted fears about a serious illness in the absence of any significant
somatic symptoms
 3) Conversion disorder: neurological symptoms that cannot be explained by medical disease or
culturally sanctioned behaviour
 4) Malingering: intentionally faking psychological or somatic symptoms to gain from those symptoms
 5) Factitious disorder: falsification of psychological or physical symptoms, without evidence of gains
from those symptoms
 Defined by excessive concerns about physical symptoms or health
 Hypochondriasis = chronic worries about developing a serious medical illness **not a DSM-5
diagnosis
 Seek frequent medical treatment, hospitalizations and surgery are common
 Conditions are remarkably varied
 Health concerns are cause of excessive anxiety or involve too much expenditure of time and energy
*very subjective criteria
 Diagnosis of these disorders often is found to be stigmatizing
 New to DSM-5: somatic symptom disorder does not have to be medically unexplained
 Tend to develop in early adulthood, wax and wane over time, recovery can occur naturally
 Tend to co-occur with anxiety disorders, mood disorder, substance use disorders & personality
disorders
 More common in women than in men
I. Somatic Symptom Disorder (SSD)
DSM-5 Criteria
 1) At least one somatic symptom that is distressing or disrupts daily life
 2) Excessive thought, distress and behaviour related to somatic symptoms or health concerns, as
indicated by at least one of the following:
o Health-related anxiety, disproportionate and persistent concerns about the seriousness of
symptoms, excessive time and energy devoted to health concerns, duration of at least 6
months
 3) Specify if predominant pain
 Diagnosed regardless of whether symptoms can be explained medically
 DSM-5 label “Psychological Factors Affecting Other Medical Conditions” used when psychological
factors are the cause of symptoms
 May begin/intensify after some conflict or stress
 Might seem that the person is using the symptom to avoid some unpleasant activity or to get
attention/sympathy
 Experience symptoms as completely physical
 3x as common as illness anxiety disorder
II. Illness Anxiety Disorder (IAD)
DSM-5 Criteria:
 1) Preoccupation with and high level of anxiety about having or acquiring a serious disease
 2) Excessive illness behaviour (e.g. checking for signs of illness, seeking reassurance) or maladaptive
avoidance (avoiding medical care)
 3) No more than mild somatic symptoms are present

lOMoARcPSD|2532716
 4) Not explained by other psychological disorders

 5) Preoccupation lasts at least 6 months
 Often co-occurs with anxiety and mood disorders
III. Conversion Disorder (CD)
DSM-5 Criteria:
 1) One or more symptoms affecting voluntary motor or sensory function
 2) The symptoms are incompatible with recognized medical disorder
 3) Symptoms cause significant distress or functional impairment or warrant medical evaluation
 Sensory/motor function impairment with no neurological cause
o May experience partial or complete paralysis of arms/legs, seizures and coordination
disturbances, sensation of prickling/tingling/creeping on the skin, insensitivity to pain, or
anesthesia (loss of sensation)
 May become partially/completely blind, tunnel vision
 Aphonia = loss of the voice other than whispered speech
 Many do not connect medical symptoms with stressful situations
 Hysteria = term originally used to describe the disorder
o Hippocrates considered it to be an affliction limited to women, brought on by the wandering
of the uterus
 Originally known as hysteria (Greek word for uterus)
o Symbolized the longing of the women’s body for a child
 Conversion originated from Freud, thought anxiety and psyc conflict were converted into physical
symptoms (Anna O)
 Genuinely physical problems are misdiagnosed as conversion disorder 4% of the time
 Symptoms usually develop in adolescence or early adulthood, typically after a major life stressor
 Episode may end abruptly, likely to return
 Less than 1% prevalence rate, more women diagnosed than men
 Likely to meet criteria for other somatic symptom disorder, ½ meet criteria for dissociative disorder
 Other common comorbid disorders: MDD, substance use disorders, personality disorders
Etiology (CD)
 Psychodynamic perspectives:
o Clear role of unconscious
o Physical symptom is a response to an unconscious psychological conflict
o Conversion disorder involving blindness might involve:
 1) Unconscious processing of perceptual stimuli
 2) Motivation to be symptomatic
 Social and Cultural Factors:
o Shape the symptoms *more common among people from rural areas and of lower SES
o Modeling and social factors shape how conversion symptoms unfold
Etiology of Somatic Symptom-Related Disorders
 Little evidence for heritability
I. Neurobiological Factors that increase awareness and distress over somatic symptoms:
 Focus is on brain regions activated by unpleasant body sensations *anterior insula and anterior
cingulate cortex (ACC)
o Have strong connections with the somatosensory cortex – involved in processing body
sensations
 Some people may have hyperactive brain regions that are involved in evaluating the unpleasantness
of body sensations

lOMoARcPSD|2532716
 Depression and anxiety related to increased activity in ACC and also related to increase in somatic
symptoms & pain
o Emotional pain can also activate the ACC and anterior insula
 No support for genetic influence (concordance rates in MZ twins don’t differ from DZ twins)
II. Cognitive Behavioural Factors that increase awareness and distress over somatic symptoms:
 Focus on mechanisms that could contribute to the excessive focus on and anxiety over health
concerns
 Once a somatic symptom develops, 2 cognitive variables appear important:
o Attention to body sensations & interpretation (attributions) of those sensations
 Use version of emotion Stroop task – people with somatic symptom-related disorders had more
difficulty ignoring words related to physical health
 Believe symptoms are a sign of an underlying long-term disease
 2 behavioural consequences:
o Person may assume the role of being sick and avoid work, exercise and social tasks, these
avoidant behaviours in turn can intensify symptoms by limiting other healthy behaviours
o Person may seek reassurance from doctors and from family members, this help-seeking
behaviour may be reinforced if it results in the person getting attention/sympathy
III. Psychodynamic Perspective
 Unconscious psychological factor cause
 Blindsight = not consciously aware of visual input (implicit component still often intact)
o Failure to be explicitly aware of sensory information
IV. Social & Cultural Factors
 Decrease in incidence of conversion disorder since last half of 19 th century
o Higher incidence may have been due to more repressed sexual attitudes or low tolerant for
anxiety symptoms
 More prevalent: in rural areas, in individuals of lower SES, in non-Western cultures
Treatment
 Most people with these disorders usually want medical care, not mental health care
 Most somatic and pain concerns have both physical and psychological components
Interventions in Primary Care
 Teach primary care teams to tailor care for people with osmatic symptom-related disorders
 Goal: to establish a strong doctor-patient relationship to bolster the patient’s sense of trust/comfort
so the patient will feel more reassured about his/her health
 Informing physicians when a patient appears to be an intensive user of health care services so they
can minimize the use of diagnostic tests and medications
Cognitive Behavioural Treatment
 1) Help people identify and change the emotions that trigger their somatic concerns
 2) Help people change their cognitions regarding their somatic symptoms
 3) Help people change their behaviours to stop playing the role of a sick person and to gain more
reinforcement for engaging in other types of social interactions
 Treating anxiety and depression will help reduce somatic symptoms *antidepressant: Tofranil =
effective even at low dosages that do not alleviate depression symptoms
 Psychoeducation programs help patients recognize links between negative moods and somatic
symptoms
 Train people to pay less attention to their body
 Help people identify and challenge negative thoughts about their bodies
 Help people resume healthy activities and build a lifestyle that has been damaged by too much focus
on illness-related concerns

lOMoARcPSD|2532716
 Family therapy to change patient’s reliance on playing the role of a sick person
 CBT helps reduce distress about symptoms, less able to reduce the actual symptoms
 Internet based CBT not strong enough to reduce health anxiety
 Mindfulness helps reduce health anxiety
Treatment for Somatic Symptom Disorder with Pain
 Hypnosis helps reduce pain levels, influences brain regions involved in experiencing and interpreting
pain
 Acceptance and commitment therapy (ACT) – variant of CBT, the therapist encourages the client to
adopt a more accepting attitude towards pain, suffering and moments of depression and anxiety,
and to view these as a natural part of life
o Coached not to struggle intensely to avoid these situations
 Antidepressants can also be helpful (low doses can reduce pain)
CHAPTER 9: Schizophrenia
 = A disorder characterized by disordered thinking, in which ideas are not logically related; faulty
perceptions and attention; a lack of emotional expressiveness; and disturbances in behaviour, such
as a disheveled appearance
 Withdraw from other people and everyday reality, experience delusions and hallucinations
 Substance use rates are high, suicide rates are high *12x more likely to die of suicide
 Mortality rates are as high, or higher than people who smoke
 1% life prevalence, affects men more than women
 Diagnosed more frequently among some groups: African Americans *may reflect diagnostic bias
 Sometimes begins in childhood, usually appears in late adolescence/early adulthood *earlier in men
than women
o Late onset (30s) = more severe
 3 domains of symptoms: positive, negative, and disorganization
DSM-5 Criteria:
 1) Two or more of the following symptoms for at least 1 month: one symptom should be either 1, 2,
or 3
o 1. Delusions, 2. Hallucinations, 3. Disorganized speech, 4. Disorganized/catatonic behaviour,
5. Negative symptoms (diminished motivation or emotional expression)
 2) Functioning in work, relationships of self-care has declined since onset
 3) Signs of disorder for at least 6 months;
o Or, if during a prodromal or residual phase, negative symptoms or 2+ symptoms 1-4 in less
severe form
Positive Symptoms
 = Comprise excesses and distortions, and include hallucinations and delusions
 Acute episodes are characterized by positive symptoms
 Delusions:
o = Beliefs contrary to reality and firmly held in spite of disconfirming evidence
o Precursory delusions (“CIA planted a listening device in my head”) *found in 65%
o Forms:
 Thought insertion = belief that thoughts that are not his/her own have been placed in
his/her mind by an external source
 Thought broadcasting = belief that thoughts are broadcasted or transmitted, so that
others know what one is thinking
 Belief that an external force controls one’s feelings or behaviours

lOMoARcPSD|2532716
 Grandiose delusions = an exaggerated sense of one’s own importance, power,

knowledge or identity
 Ideas of reference = incorporating unimportant events within a delusional framework
and reading personal significance into the trivial activities of others
 Hallucinations and other disturbances of perception:
o Hallucinations = sensory experiences in the absence of any relevant stimulation from the
environment
 Most dramatic distortions of perception
o More often auditory than visual (74% have auditory hallucinations)
o Hear one’s own thoughts spoken by another voice
o Hear voices arguing or commenting on one’s behaviour *increased activity in Broca’s area
o Hallucinations believed to come from a known person are experienced more positively
o Possible explanation: misattribute their own voice as someone else’s
o Greater activity in Broca’s area (frontal cortex) during auditory hallucinations *supports
ability to produce speech
 And in Wernicke’s area (temporal cortex) *supports ability to understand speech
**hearing voices
Negative Symptoms
 = Consist of behavioural deficits in motivation, pleasure, social closeness, and emotion expression
 Tend to endure beyond an acute episode
 Have profound effects on the lives of people with schizophrenia
 Presence of negative symptoms is a strong predictor of a poor quality of life
 Represent 2 domains: 1) experience: motivation, emotion, sociality & pleasure, 2) expression
(outward expression of emotion)
 Avolition = A lack of motivation and a seeming absence of interest in or an inability to persist in what
are usually routine activities, including work or school, hobbies, or social activities
o Spend much of their lifetime sitting around doing nothing
o Less motivated by goals about autonomy, gaining new knowledge or skills, or praise by others
o Equally motivated by goals that have to do with relatedness to others and with avoiding a
negative outcome
 Asociality = Severe impairments in social relationships
o Few friends, poor social skills, very little interest in being with other people
o May not desire close relationships with family/friends/romantic partners
 Anhedonia = A loss of interest in or a reported lessening of the experience of pleasure

o Consummatory pleasure = the amount of pleasure experienced in the moment or in the
presence of something pleasurable
o Anticipatory pleasure = the amount of expected or anticipated pleasure from future events
or activities
o Deficit in anticipatory pleasure, not in consummatory
 Blunted affect = A lack of outward expression of emotion
o Stare vacantly, face muscles motionless, eyes lifeless, toneless voice
o Found in 66%
o Only refers to outward expression of emotion, not to inner experience (not impoverished)
 Alogia = A significant reduction in the amount of speech
o Do not talk much
Disorganized Symptoms

lOMoARcPSD|2532716
 Include disorganized speech and disorganized behaviour

Disorganized Speech (formal thought disorder)
 Disorganized speech = problems in organizing ideas and in speaking so that a listener can
understand
o Incoherence = inability to organize ideas
 Loose associations/derailment = the person may be more successful in communicating with a
listener but has difficulty sticking to one topic
 Disorganized speech is associated with problems in executive functioning: problem solving, planning,
and making associations between thinking and feeling
 Also related to the ability to perceive semantic information
Disorganized Behaviour
 Disorganized behaviour = may go into inexplicable bouts of agitation, dress in unusual clothing, act
in a silly manner, hoard food, or collect garbage
 Lose the ability to organize behaviour and make it conform to community standard
 Difficulty performing tasks of everyday living
Movement Symptoms
 Catatonia = gesture repeatedly, using peculiar and sometimes complex sequences of finger, hand,
and arm movements, which often seem to be purposeful *excitable flailing of the limbs
o Seldom seen today
o Similarity with encephalitis lethargica
 Unusual increase in overall activity, much excitement, flailing of the limbs, great expenditure of
energy similar to mania
 (Catatonic) Immobility = adopt unusual postures and maintain them for very long periods of time
 Waxy flexibility = limbs can be manipulated & posed by another person
Schizophrenia and the DSM-5
 Symptoms must last at least 6 months, must include 1 month of an acute episode, or active phase =
presence of at least 2 symptoms: delusions, hallucinations, disorganized speech, disorganized
behaviour, and negative symptoms
 Remaining time for diagnosis can occur before or after active phase
 Removal of subtypes of schizophrenia (paranoid, disorganized, catatonic, undifferentiated) *poor
reliability, questionable usefulness, poor predictive validity
 Addition of severity ratings for each of the 5 symptoms
 Part of category: Schizophrenia spectrum and other psychotic disorders
o Schizophreniform disorder = same symptoms of schizophrenia, last only 1-6 months
 Must include hallucinations, delusions, or disorganized speech
o Brief psychotic disorder = lasts from 1 day to 1 month, often brought on by extreme stress
 Symptoms MUST include hallucinations, delusions, or disorganized speech
o Schizoaffective disorder = comprised of a mixture of symptoms of schizophrenia and mood
disorders
 Either depressive or manic episode required (mood symptoms present for majority of
duration)
o Delusional disorder = troubled by delusions (persecution/jealousy, grandiose, erotomania,
somatic delusions)
 New category to “Conditions for Further Study”  attenuated psychosis syndrome
Etiology
Genetic Factors

lOMoARcPSD|2532716
 Genetically heterogeneous  genetic factors may vary from case to case, not likely caused by 1
gene
 People with schizophrenia in their family histories have more negative symptoms that no family
history
o Negative symptoms may have stronger genetic component
 Incidence of schizophrenia highest if both biological parents were diagnosed (27.3%), (7% if one
parent)
 Risk for MZ twins is 44.3%, 12,08% for DZ
 Even with adopted children whose biological parent had schizophrenia, there is still a heightened risk
for developing
 Familial high-risk study = begins with 1 or 2 biological parents with schizophrenia, follow their
offspring longitudinally to identify how many develop schizophrenia
 6x more likely to develop by age 40 if have a parent with schizophrenia
 Predisposition is not transmitted by a single gene
 Multiple common genes associated with schizophrenia and bipolar
 1) DTNBP1 & NGR1 – associated w/schizophrenia, 2) COMT & BDNF – associated w/cognitive deficits
associated w/schizophrenia
o DTNBP1 codes for a protein ‘dysbindin’ – impacts dopamine and glutamate NTM systems
o COMT associated with cognitive control processes relying on the prefrontal cortex
o BDNF – linked to cognitive functioning in people with and without schizophrenia
(polymorphism Val66Met)
o ***These genes do not appear in GWAS
 SNPs associated with schizophrenia are also associated with bipolar disorder
 Genome-wide scans: identification of several gene mutations
The Role of Neurotransmitters
 Dopamine theory:
o Drugs effective in treating schizophrenia reduce dopamine activity (antipsychotic drugs)
o Side effects resembling symptoms of Parkinson’s disease *caused by low dopamine in
particular area of brain
o Antipsychotic drugs block postsynaptic dopamine receptor D2, in the mesolimbic pathway
o Amphetamines amplify dopamine activity, can produce state closely resembling
schizophrenia
o Only related to positive and disorganized symptoms of schizophrenia
o Dopamine neurons in prefrontal cortex (mesocortical pathway) may be underactive & fail to
inhibit dopamine neurons in subcortical brain areas **negative symptoms
 Antipsychotics do not have major effect on dopamine neurons in prefrontal cortex
o Take several weeks for antipsychotics to lessen positive symptoms, although receptors are
rapidly blocked
o To be effective, must reduce DA to below normal levels
 New drugs related to serotonin, block D2 receptors, also block serotonin receptor 5HT2
 GABA transmission in prefrontal cortex is disrupted in those with schizophrenia
 Glutamate may also play a role *low levels in cerebrospinal fluid ***medication targeting glutamate
shows promise
o Also low levels of enzyme needed to produce glutamate
 Elevated AA homocysteine – interacts with NMDA receptor in pregnant women whose child
develops schizophrenia
 PCP drug can induce positive and negative symptoms in people without schizophrenia

lOMoARcPSD|2532716
Brain Structure & Function

 Enlarged ventricles:
o 4 ventricles (spaces filled with cerebrospinal fluid)
o Larger ventricles implies a loss of brain cells
o Origin of enlarged ventricles may not be genetic
o Correlated with impaired performance on neuropsychological tests, poor functioning prior to
the onset of the disorder and poor response to medication treatment
o Not specific to schizophrenia (bipolar, other psychotic features)
 Prefrontal cortex:
o Plays a role in speech, decision making, emotion and goal directed behaviour **all disrupted
in schizophrenia
o Reduction in grey matter and volume of prefrontal cortex = reduced connectivity
o Perform more poorly on neuropsychological tests on working memory
 Some declines occur before onset (late 30s)
o Lower glucose metabolism in prefrontal cortex when performing neuropsychological tests
(PET scan)
o Less blood flow to these areas during fMRI
o Failure to show frontal activation related to severity of negative symptoms
o Loss of dendritic spines, not loss of neurons *disrupts neuron communication =
disconnection syndrome
 Could lead to behavioural and speech disorganization symptoms
 Temporal cortex:
o Abnormalities in temporal gyrus, hippocampus, amygdala, anterior cingulate
o Reduction in cortical grey matter, reduced volume in basal ganglia, hippocampus and limbic
structures
o Reduced hippocampus volume may reflected combination of genetic and environmental
factors
 Closely relates to HPA axis and chronic stress (reduction in volume)
 More reactive to stress in schizophrenia, rather than experiencing more
Connectivity in the Brain
 3 types of connectivity:
o Structural/anatomical connectivity = how different structures of the brain are connected via
white matter
 Less white matter connectivity in schizophrenia in frontal and temporal lobes
o Functional connectivity = connectivity between brain regions based on correlations between
blood oxygen level dependent signal measured with fMRI
 Particularly reduced connectivity in frontal cortex
o Effective connectivity = combines both types of connectivity, shows correlations between
BOLD activations in different regions and the direction & timing of activations
 Less connectivity in between brain networks, including frontoparietal and default-mode networks
o Correlated with poor performance on cognitive tests
o Might be part of genetic diathesis
Environmental Factors Influencing the Developing Brain
 Possible damage during gestation
 High rates of delivery complications in those with schizophrenia
o Reduced oxygen supply to brain, resulting in loss of cortical grey matter
 Maternal infections during pregnancy

lOMoARcPSD|2532716
 Exposure to prenatal influenza (especially in 2nd trimester)

 Stress linked to release of cortisol, cortisol related to increased dopamine activity in mesolimbic
pathway
 Development of symptoms in adolescence related to loss of synapses due to excessive pruning
 Cannabis use in adolescence studied as a risk factor *associated with worsening of symptoms among
those diagnosed
o Greater risk of developing symptoms with cannabis use
Psychological Factors
 Very reactive to stressors
 Socioeconomic Status:
o Found at all levels of SES
o Highest rates in lowest SES group
o Sociogenic hypothesis = stress associated with poverty such as low education, limited
opportunities and stigma from others of high status contributes to development of
schizophrenia
o Social selection hypothesis = during the course of developing illness, people with
schizophrenia drift into poor neighborhoods because their illness impairs their earning
power, cannot afford to live elsewhere **research supports
 Family-Related Factors:
o Mother-son relationship (schizophrenogenic mother)
o Vague communication between family members, high levels of family conflict
o Expression of hostility towards schizophrenic family member
 Critical comments, hostility, emotional overinvolevment = expression emotion (EE)
 Linked to relapse rates
o Negative symptoms most likely to elicit critical comments
o Expression of unusual thoughts by schizophrenia linked to higher critical comments, and
higher critical comments lead to increased unusual thoughts *bidirectional
Developmental Factors
 Retrospective studies = begin with a group of adults with schizophrenia (or other diagnosis) and
follow back to childhood to unearth records and tests from their early years
o Lower IQs as children, more often delinquent and withdrawn
o Boys rated by teachers as disagreeable, girls as passive
o Poorer motor skills, more expression of negative emotions as children *coding home videos
 Prospective studies:
o Look at identifying childhood characteristics associated with development of schizophrenia in
early adulthood
o Lower IQ scores as children predicted onset of schizophrenia in young adulthood (beginning
at age 7)
o Clinical high-risk study = identifies people with early, attenuated signs of schizophrenia, most
often milder forms of hallucinations, delusions, or disorganization that causes impairment
Treatment
 Most often includes combination of short-term hospitalization, medication and psychosocial
treatment
 Some schizophrenics lack insight into their impairments and refuse any treatment
 Gender (female) and age (older) are predictors of better insight during first episode of illness
Medications

lOMoARcPSD|2532716
 Antipsychotic drugs = used to treat symptoms of schizophrenia (aka neuroleptics  produce side
effects similar to symptoms of a neurological disease)
 First generation antipsychotics:
o Reduce positive and disorganized symptoms (also reduce agitation & violent behaviour), little
or not effect on negative symptoms
o Block dopamine D2 receptors
o 30% do not respond favourably to first generation, 50% quit after 1 year, 75% quit before 2
years because of side effects
o Side effects: sedation, dizziness, blurred vision, restlessness, sexual dysfunction, dystonia
(rigidity), dyskinesia (abnormal muscle motion), akasthesia (inability to remain still)
o Extrapyramidal side effects = resemble the symptoms of Parkinson’s disease (tremors,
shuffle, drooling)
o Tardive dyskinesia = mouth muscles involuntarily make sucking, lip-smacking and chin-
wagging motions
 Mainly in older people with schizophrenia who had been treated with 1 st generation
drugs
o Neuroleptic malignant syndrome = (1% of cases) sometimes fatal, severe muscular rigidity
develops, accompanied by fever
 Second generation antipsychotics:
o Approval of clozapine – therapeutic gains in those who didn’t respond well to 1st generation
medication, produce fewer side effects, less relapse and treatment noncompliance *impacts
serotonin receptors
 Side effects: impair immune system functioning, agranulocytosis (lower amount of
WBC), seizures, dizziness, fatigue, drooling, weight gain *fewer motor side effects
o Olanzapine and risperidone – produce fewer side effects
o Equally as effective in reducing positive and disorganized symptoms, slightly more effective in
reducing negative symptoms and improving cognitive deficits
o Less treatment noncompliance
o No differences in relapse *reduces relapse?
o Can also produce extrapyramidal side effects
o Less often given to African-Americans
 Medical review: 2nd generation not more effective, did not produce fewer unpleasant side effects,
nearly ¾ stopped taking before study ended
o Can lead to serious side effects: pancreatitis, weight gain, diabetes
Psychological Treatments
 Psychosocial treatments are recommended alongside medication (Patient Outcome Research Team
“PORT” recommendation)
o Skills training, CBT, family-based treatment
 Social skills training = designed to teach people with schizophrenia how to successfully manage a
wide variety of interpersonal situations
o (Discussing medications with psychiatrist, ordering meals in a restaurant, filling out a job
application, saying no to drug dealers, reading bus schedules)
o Involves role-playing and other group exercises the practice skills (in therapy and real social
situations)
o Help achieve fewer relapses, better social functioning, higher quality of life
o May also be effective in reducing negative symptoms
 Family therapies:

lOMoARcPSD|2532716
o Developed to try and decrease expressed emotion within the family (hostility, critical
comments and emotionally overinvolved)
o 1) Education about schizophrenia – about genetic/neurobiological factors, cognitive problems
associated, symptoms, and signs of relapse
o 2) Information about antipsychotic medication – importance of taking, effects and side
effects
o 3) Blame avoidance and reduction – encourage family members not to blame themselves of
their ill relative
o 4) Communication and problem-solving skills – express feelings in constructive, empathic,
nondemanding manner
o 5) Social network expansion – encouraged to expand social contacts
o 6) Hope – hope for improvement, not to return to hospital
 CBT:
o Encouraged to test out delusional beliefs
o Helped to attach nonpsychotic meaning to paranoid symptoms to reduce intensity and
aversive nature
o Helps reduce negative symptoms *recognize & challenge expectations associated w/negative
symptoms
 Cognitive Remediation Therapies:
o Improvement in basic cognitive processes hold promise for improving social and emotional
lives of schizophrenics
o Try to normalize attention and memory
o Cognitive remediation training/cognitive enhancement therapy (CET) = seek to enhance
basic cognitive functions such as verbal learning ability
 Effective in reducing symptoms and improving cognitive abilities, linked to good
functional outcomes
o Can include computer-based training in memory, problem solving and attention
o Enriched supportive therapy (EST) = includes supportive and educational elements
 Psychoeducation:
o Educate patients about their illness, symptoms, time course, triggers, treatment strategies
o Reduces relapse and rehospitalization
 Case Management:
o Case managers – familiar with the mental health system, able to connect people with
schizophrenia to whatever services they required
o Often provided direct clinical services
o Multidisciplinary team that provides services in the community (medication, treatment for
substance abuse, help in dealing with stressors, psychotherapy, vocational training,
assistance in obtaining housing and employment
o Has not shown improvement in social functioning
 Residential Treatment:
o “Halfway houses” – alternative for those who do not need to be in the hospital but are not
well enough to live on their own or with family
o Protected living units
o Vocational rehabilitation – learn skills to help secure employment and return to the
community
o Staff may include psychiatrists/clinical psychologists
o Often include group meetings

lOMoARcPSD|2532716
CHAPTER 10: Substance Use Disorders

Clinical Descriptions, Prevalence, and Effects of Substance Use Disorders
Substance Percentage Reporting Use
Alcohol 52.1
Cigarettes 22.1
Marijuana 7.3
Nonmedical psychotherapeutics 2.6
Cocaine 0.6
Heroin 0.1
Hallucinogens including PCP 0.4
Inhalants 0.2
DSM-5 Criteria:
 1) Problematic pattern of use that impairs functioning
 2) 2 or more symptoms within a 1 year period:
o Failure to meet obligations, repeated use in situations where it is physically dangerous
o Repeated relationship problems, continued use despite problems caused by substance
o Tolerance, withdrawal, substance taken for longer time or in greater amounts than intended
o Efforts to reduce or control use do not work, much time spent trying to obtain the substance
o Social/hobbies/work activities given up or reduced, craving to use the substance is strong
 Severity: Mild = meet 2-3 criteria, Moderate = meet 4-5 criteria, Severe = meet 6+ criteria
 Marijuana is most popularly used illegal drug
 Alcohol is the most used substance
 DSM-IV-TR had 2 categories: substance abuse and substance dependence, DSM-5 only has substance
USE
o DSM-5 now includes gambling disorder in chapter on substance-related and addictive
disorders
 Addiction = a severe substance use disorder with 6+ symptoms
o Using more than intended amounts, trying unsuccessfully to stop, physical/psyc problems
made worse by drug, problematic relationships
o Physiological dependence = presence of either tolerance or withdrawal
o W/o physiological dependence = absence of tolerance and withdrawal
 Tolerance and withdrawal often part of severe substance use disorder
 Tolerance = indicated by: 1) larger doses of the substance being needed to produce the desired
effect, or 2) the effects of the drug becoming markedly less if the usual amount is taken
 Withdrawal = negative physical and psychological effects that develop when a person stops taking
the substance or reduces the amount
o Muscle pain, twitching, sweats, vomiting, diarrhea, insomnia
 Drug and alcohol use disorder are among most stigmatized disorders
I. Alcohol Use Disorder
 Generally show more severe symptoms: tolerance, withdrawal
 Delirium tremens (DTs) = person becomes delirious when alcohol level in blood suddenly drops, as
well as tremulous and has hallucinations that are primarily visual and may be tactile as well
 Often associated with other drug use, 80-85% are smokers
 Nicotine and alcohol are cross-tolerant  can induce tolerance for the rewarding effects of the other
 Nicotine influences the way alcohol works in the brain’s dopamine pathways associated with reward

lOMoARcPSD|2532716
Prevalence
 8.5% meet criteria for DSM-IV-TR categories of alcohol dependence/abuse (rates are declining)
 Binge drinking = having 5+ drinks in a short period of time *common among college-age students
(39.5%)
 Heavy-use drinking = having 5 drinks on the same occasion five or more times in 30-day period
(12.7%)
 More men than women have problems with alcohol
 European American and Hispanic adolescents/adults more likely to binge drink than African
American
o Least likely among Asian American and African American
 Most prevalent among Native Americans and Hispanics
 Comorbid with personality disorders, mood disorders, schizophrenia, and anxiety disorders (and
other drug use)
 6.8% have another psyc disorder
Short-Term Effects of Alcohol
 Alcohol being metabolized by enzymes enter small intestine and is absorbed into blood
 Broken down in liver, can metabolize 1 ounce or 100-proof (50%) liquor per hour
 Women achieve higher blood alcohol concentrations after adjustments for body weight
 Alcohol stimulates GABA receptors (reduces tension)
 Increases levels of serotonin and dopamine *pleasurable effects
 Inhibits glutamate receptors *causes cognitive effects (slowed thinking, memory loss)
Long-Term Effects of Prolonged Alcohol Abuse
 Impairs digestion of food and absorption of vitamins
 Deficiency of B-complex vitamins can cause amnestic syndrome = severe loss of memory for recent
and long-past events
 Alcohol use plus reduction in protein intake leads to developed or cirrhosis of the liver
o Liver cells become engorged with fat and protein, impeding their function
 Damage to: endocrine glands, brain, pancreas, heart failure, erectile dysfunction, hypertension,
stroke, capillary hemorrhages (redness in face)
 Fetal alcohol syndrome = growth of fetus is slowed, production of cranial, facial and limb
abnormalities as a result of heavy alcohol consumption while pregnant
 Benefits: physiological (increases coronary blood flow), psychological (less-driven lifestyle and
diminished hostility)
 Low-moderate consumption of red wine may lower bad cholesterol and raise god cholesterol
II. Tobacco Use Disorder
 Nicotine = addicting agent of tobacco *activates neural pathways that stimulate dopamine neurons
in mesolimbic area
Prevalence and Health Consequences
 18% prevalence rate
 Smoking is the single most preventable cause of premature death in the US
 People in US who are most likely to smoke are those with a psyc disorder
 Consequences: emphysema, cancer of larynx/esophagus/pancreas/bladder/cervix/stomach,
pregnancy complications, SIDS, periodontitis, cardiovascular disorders
 Harmful ocmponents: nicotine, carbon monoxide, tar
 Similar rates among adolescent males/females, higher among Hispanic and white adolescents than
African/Asia American **African Americans retain nicotine in their blood longer (metabolize it more
slowly) *less likely to quit, more likely to get lung cancer **smoke more menthol (inhaled more
deeply and longer)

lOMoARcPSD|2532716
 More men than women smoke *except in 12-17 year-olds

 More prevalent in those of low SES
 Those who smoke menthol cigarettes inhale more deeply and hold smoke in for a longer time
Secondhand Smoke
 Secondhand smoke = smoke coming from the burning end of the cigarette, AKA environmental
tobacco smoke (ETS)
o Contains higher concentration of ammonia, carbon monoxide, nicotine, and tar than the
inhaled smoke
 1) Lung damage – those living with smokers are at greater risk
 2) Babies of women exposed to secondhand smoke during pregnancy more likely to be born
prematurely, LBW and defects
 3) Children of smokers more likely to have upper respiratory infections, asthma, bronchitis, inner-ear
infections, SIDS
 No safe level of exposure to secondhand smoke
E-Cigarettes
 Heat up nicotine liquid, inhale/exhale vapor
 Do not contain tar and carbon monoxide
 Often called vape pipes/hookah pens
 Can still be used with nicotine, which is still an addictive drug
III. Marijuana & Cannabis Use Disorder
 Marijuana = consists of dried and crushed leaves and flowering tops of hemp plant Cannabis sativa
 Hashish = stronger than marijuana, produced by removing and drying resin exudate of the tops of
cannabis plants
 Synthetic marijuana sold under names: Spice or K2, illegal as of 2011
Prevalence
 Most frequently used illicit drug (19,000,000 reported use in 2012)
 Most commonly used drug across all age groups
 Higher prevalence among men than women (2x as man men 18+ than women) *11.8% vs. 6.6%
 Fairly equivalent use across racial and ethnic groups
 Legal use in adults over 21 in Colorado and Washington
Effects
 Major active chemical: delta-9-tetrahydrocannabinol (THC)
 Marijuana is now more potent than it used to be (30 years ago) and users smoke more now than in
the past
 Psychological Effects:
o Depend on potency and dose size
o Feel relaxed and sociable
o Rapid shifts in emotion, dull attention, fragment thoughts, impaired memory, sense that time
moves slowly
o Extreme doses can induce hallucinations, extreme panic
o May take up to 30 minutes for effects to appear
o Can interfere with cognitive functioning: planning, decision making, working memory,
problem solving
o Being high impairs psychomotor skills necessary for driving
 Physical Consequences:
o Bloodshot and itchy eyes, dry mouth/throat, increased appetite, reduced pressure within the
eye, raised blood pressure

lOMoARcPSD|2532716
o Long-term use can impair lung structure and function

o Smoke less cigarettes than tobacco smokers, but inhale more deeply and retain in lungs
longer
 1 marijuana cigarette equivalent to 5 tobacco cigarettes in CO content, 4 in tar intake
and 10 in terms of damage to cells lining the airways
o CB1 and CB2 (cannabinoid brain receptors)
 CB1 throughout body and brain, high number in hippocampus *effects memory &
learning
o Increased blood flow to brain regions associated with emotion (amygdala, anterior cingulate)
o Decreased blood flow to temporal lobe (auditory attention)
o Habitual use does produce tolerance (addictive evidence)
o Withdrawal symptoms can occur
 Therapeutic Effects and Legalization:
o Reduction in nausea and loss of appetite that accompany chemotherapy for some people
with cancer, glaucoma, chronic pain, muscle spasms, seizures, discomfort from AIDS
IV. Opiates & Opioid Use Disorder
 Opiates = include opium and its derivatives: morphine, heroin and codeine *group of addictive
sedatives
o In moderate doses can relieve pain and induce sleep
 Synthetic sedatives – separate category from DSM-5 sedative/hypnotic/anxiolytic use disorder
 Hydrocodone and oxycodone are prescribed as pain medications, but are also abused
 Vicodin (hydrocodone and acetaminophen) is one of the mot commonly abused drugs containing
hydrocodone
 OxyContin is one of the most commonly abused drugs containing oxycodone
Prevalence of Abuse and Dependence
 More common to begin taking heroin after first taking prescription pain medication
 Most commonly abused opiates are prescription pain medication taken for nonmedical purposes
(more men than women)
o Highest abuse among European Americans and Native Americans
 Prescriptions are forged, stolen or diverted to dealers on black market
 6.8 million pain medication users for nonmedical purposes
o OxyContin prescriptions jumped 1800% between 1996 and 2000
o Hydrocodone use increased from 4.5-5.7 million users
o Oxycodone abuse increased 43% in just 1 year (1997-98)
 Rates of abuse of pain medications have remained stable since 2002
Psychological and Physical Effects
 Produce euphoria, drowsiness, lack of coordination
 Produce a “rush” – feeling of warm, suffusing ecstasy immediately after injection
 Shed worries and fears, great self confidence 4-6 hours, followed by a severe letdown
 Stimulate neural receptors of the body’s opioid system (endorphins and enkephalins)
o Heroin converted to morphine in the brain, binds to opioid receptors
 ½ million addicted to heroin in USA *difficult to get accurate prevalence rates
 Accounted for 62-82% of drug-related hospital admissions 2003
 Affect the nucleus accumbens (or possibly dopamine system)
 Show tolerance and withdrawal (even after 8 hours of last injection) *muscle pain, sneezing,
sweating, tearful, yawns

lOMoARcPSD|2532716
o Withdrawal symptoms more severe after 36 hours *muscle twitching, cramps,

chills/sweating, rise in heart rate
o Unable to sleep, vomiting, diarrhea ***symptoms persist for 72 hours
 Drug and process of obtaining it become centre of the person’s existence
 Costs upwards of $200/day
 Needle sharing leads to exposure to infectious agents (e.g. HIV)
V. Stimulants
 Stimulants = act on the brain and sympathetic nervous system to increase alertness and motor
activity
 Synthetic: amphetamines, Natural: cocaine (coca leaf)
Amphetamines (synthetic stimulant)
 E.g. Benzedrine, Dexedrine, methedrine – produce effects by causing release of norepinephrine and
dopamine, block reuptake
 Orally or intravenously taken, addicting
 Heightens wakefulness, intestinal functions inhibited, appetite reduced (used in dieting), increased
heart rate, blood/mucous membranes/vessels constrict
 Person becomes alert, euphoric, outgoing, boundless energy and self-confidence
 Large dose – nervous, agitated, confused, palpitations, headaches, dizziness, sleeplessness
 Tolerance develops rapidly (after 6 days of repeated use)
 Methamphetamine:
o Most commonly abused stimulant
o More often used by men
o Used in small towns more than big cities
o Taken orally, intravenously, nasally
o Crystal meth – when in clear crystal form
o Craving lasts for several years after discontinuing use
o Immediate rush that lasts for hours followed by a crash (tweaking)
o Both tolerance and withdrawal symptoms
o Long term use affects dopamine and serotonin systems of the brain
o Smaller volume of hippocampus
o Lower brain activation in several areas (predicts relapse) **especially with decision making
tasks
 Cocaine:
o Comes from leaves of coca shrub, crack comes in rock-crystal form (heated, melted then
smoked)
o Crack is cheaper than cocaine, used in urban areas
o Used by men more often than women
o Cocaine use declined between 2002-09, dropping from 1.4% from 2%
o Acts rapidly on brain, blocking reuptake of dopamine in mesolimbic areas
o Increased sexual desire and feelings of self-confidence, well-being, indefatigability
o Overdoes: chills, nausea, insomnia, paranoia, hallucinations
o Long-term use: heightened irritability, impaired social relationships, paranoid thinking,
eating/sleeping disturbances
o Some develop tolerance, others become more sensitive to effects (can lead to death)
o Severe withdrawal symptoms
o Vasoconstrictor – causes blood vessels to narrow *often die of overdose leading to heart
attack

lOMoARcPSD|2532716
o Increased risk for stroke, causes cognitive impairments

o Lower volumes of grey matter in prefrontal cortex if exposed prenatally
o Freebase cocaine produces powerful effects, absorbed so rapidly (heated by ether)
 Induces an intense 2-minute high followed by restlessness and discomfort
VI. Hallucinogens, Ecstasy and PCP
LSD and Other Hallucinogens – Hallucination Persisting Perception Disorder
 Hallucinogen = refers to the main effects of such drugs, hallucinations
 Used more by men than women
 LSD = lysergic acid diethylamide – no evidence of withdrawal, tolerance appears to develop rapidly
o Can alter sense of time (seems to pass slowly), sharp mood swings, expanded consciousness
o Intense anxiety – perceptual experiences/hallucinations can provoke fears that they are going
crazy
 Flashbacks = visual recurrences of perceptual experiences after physiological effects of the drug have
worn off
Ecstasy and PCP – Other Hallucinogen Use Disorder
 Ecstasy = made from MDMA (methylenedioxymethamphetamine) *became illegal in 1985
 Contains compounds from hallucinogen and amphetamine families
 Popular on college campuses and in clubs
 Taken in pill form, often mixed with other substances making the effects vary dramatically
 Molly = purer powder version of ecstasy
 Average age of first use is 20
 Affects release and reuptake of serotonin
 May have neurotoxic effects on serotonin system
 Enhances intimacy and insight, improves interpersonal relationships, elevates mood and self-
confidence, promotes aesthetic awareness
 Can cause muscle tension, rapid eye movements, jaw clenching, nausea, faintness, chills, sweating,
anxiety, depression, depersonalization, confusion
 PCP (phencyclidine) = “angel dust”, phencyclidine use disorder
o Causes serious negative reactions, severe paranoia, violence, coma and death
o Affects multiple NTMs in the brain
o Likely to have used other drugs before or concurrently
Etiology of Substance Use Disorders
 Positive attitude  Experimentation  Regular Use  Heavy Use  Dependence or Abuse
Developmental Approach (to alcohol abuse)
o 1) First group began drinking in early adolescence, increased drinking throughout high school and
adulthood
o More common in boys
o 2) Second group drank less in early adolescence, increased drinking in middle school & again in high
school
o Developmental studies d not account for all cases
o Not an inevitable progression through stages
Genetic Factors
 High genetic component of alcohol use disorder (also true for smoking, marijuana and other drugs in
general)
 Peers are particularly important environmental variables among adolescents
 Alcohol dehydrogenase = enzymes involved in alcohol metabolism *difficult to build tolerance if
have inherited deficiency

lOMoARcPSD|2532716
o Mutations ADH2 and ADH3 genes linked with alcohol use disorders
 People who are more sensitive to effects of nicotine are more likely to get addicted (dopamine
release, inhibit reuptake)
o Gene SLC6A3 related to reuptake regulation of dopamine
 One form of the gene related to lower likelihood of smoking, greater likelihood of
quitting and greater sensitivity to smoking cues
o CYP2A6 gene contributes to body’s ability to metabolize nicotine *less likely to become
dependent
 Slower metabolism = stays in brain longer
 Ability to tolerate large quantities of alcohol may be an inherited diathesis
o Asians have lower rates of alcohol abuse
o Deficient enzymes (ADH or alcohol dehydrogenase)
Neurobiological Factors
 Dopamine pathways in the brain are linked to pleasure and reward ***particularly mesolimbic
pathway is affected
o Possible deficiency in DA receptor DRD2
 Vulnerability model – do problems in the dopamine system increase vulnerability to substance
dependence
 Toxic effect model – dopamine system problems are the consequence of substance dependence
 Support for both models for cocaine use
 People take drugs to avoid bad feelings associated with withdrawal *explains frequency of relapse
 Insensitive-sensitization theory – considers both the craving for drugs and the pleasure that comes
with taking the drugs
o Dopamine system linked to pleasure/liking, becomes supersensitive to the drug and to cues
associated with it (needles, spoons, rolling paper)
o Sensitivity to cues induces craving
o Overtime, liking decreases and wanting remains intense
 More craving is associated with more usage, even when trying to quit
 Brain imaging studies show that cues for a drug activate the reward & pleasure areas of the brain
involved in drug use
 Greater activation in basal ganglia, inferofrontal gyrus, and pre-motor areas = better at inhibiting a
response when needed
 Self-reports of liking and wanting are important for predicting drinking behaviour
 Short Term Over Long Term:
o People with substance use disorders often value the immediate, impulsive pleasure and
reward that comes from taking a drug more than the delayed reward (e.g. monthly paycheck)
o Delay discounting – can compute extent to which people discount the value of larger, delayed
rewards
o People on opiates, nicotine, cocaine and alcohol discount delayed rewards more steeply than
others
o Valuing delayed rewards is associated with prefrontal cortex activation
o Valuing immediate rewards is associated with amygdala and nucleus accumbens activation
 Mood Alteration:
o Drug use is reinforced because it enhances positive moods or diminishes negative ones
o Alcohol use reduces anxiety and stress *also lessens positive emotions in response to
anxiety-provoking situations

lOMoARcPSD|2532716
 Tension reduction  “alcohol myopia”

o Nicotine reduces tension and negative affect during early phases of smoking
o Other studies show sensory aspect of smoking (inhaling) reduces tension
o Tension reduction more likely when distractions are present
o Alcohol and nicotine may increase tension when no distractions are present
o Other use drugs due to expectations that they will increase positive affect
o User focuses reduced cognitive capacity on immediate distractions
o Less attention focused on tension-producing thoughts
o Alcohol and nicotine ay increase tension when no distractions are present (crying in one’s
beer)
 Expectations About Effects:
o People who expect alcohol to reduce anxiety and stress are more likely to be frequent users
o People who believe that drug intake will have positive effects are more likely to become
frequent users
o The greater perceived risk of a drug, the less likely it is to be used
 Personality Factors:
o High levels of negative affect – neuroticism/negative emotionality – important in predicting
later onset of substance use disorders
 Also predicts persistent desire for arousal along with increased positive affect
o Constraint = cautious behaviour, harm avoidance, conservative moral standards
o Low in constraint, high in negative emotionality = more likely to develop substance use
disorder
o Low agreeableness and conscientiousness, high disinhibition (low constraint) and moderate
neuroticism
o Kindergarten children high in anxiety & novelty seeking more likely to get drunk, smoke & use
drugs in adolescence
 Sociocultural Factors:
o Interest in and access to drugs influenced by peers, the media, and cultural norms
o Alcohol is the most commonly abused substance, followed by marijuana
o High alcohol consumption often found in wine-drinking societies (France, Spain, Italy)
o Men consume more alcohol than women (differs by country)
o Easy accessibility affects usage
 2003 – drug use more common among youths who’d been approached by drug dealer
(35% compared to 7&)
o Family factors: parental use, marriage conflict, lack of parental monitoring (drug), lack of
emotional support from parents (cigarettes, marijuana, alcohol)
o Social Network:
 Having peers who drink influences drinking behaviours (social influence)
 Individuals also choose friends with drinking patterns similar to their own (social
selection)
Treatment
 First step to successful treatment is admitting there is a problem
 Many treatment programs require individuals to begin by stopping use, which can exclude many
individuals
Treatment of Alcohol Use Disorder
 Only 24% who are physiologically dependent on alcohol ever receive treatment
 Impatient Hospital Treatment:

lOMoARcPSD|2532716
o Detoxification = first step in treatment for many substance use disorders

o Inpatient treatments are more expensive, not necessarily more effective, but sometimes
needed if individual lacks social support
o Outpatient treatment is more common
 Alcoholics Anonymous (AA):
o Largest and most widely known self-help group
o Regular and frequent meetings, newcomers rise to announce that they are alcoholics and
give testimonials, share stories of how their lives are better now without alcohol
o Provides emotional support, understanding and close counseling, plus a social network
o Urged to call on one another around the clock when they need encouragement not to
relapse
o Alcohol dependence is a disease that can never be cured, continuing vigilance is necessary
o An alcoholic is always an alcoholic, carrying the disease even if it is currently under control
o 12 step program, spiritual aspect, belief in the philosophy linked to achieving abstinence
o Rational recovery – focuses on promoting renewed self-reliance rather than reliance on a
higher power
o High dropout rates
 Couples Therapy:
o Reduction in problem drinking even a year after treatment has ended
o Improve overall couple distress
o Combines skills from individual CBT with a focus on couple’s relationship and dealing with
alcohol-related stressors
 Cognitive and Behavioural Treatments:
o Contingency management therapy = CBT for alcohol and drug use disorders that involves
teaching people to reinforce behaviours inconsistent with drinking
 Based on belief that environmental contingencies can play a role in
encouraging/discouraging drinking
 Can exchange earned tokens for desirable objects
 Also includes teaching job0hunting and social skills, assertiveness training for refusing
drinks
o Relapse prevention – goal is to help people avoid relapsing once they have stopped
substance use
 Motivational Interventions:
o Tracking drinking behaviour as well as showing statistics on national averages/education
about effects of alcohol can reduce drinking behaviour
 Moderation in Drinking:
o Controlled drinking & the guided self-change approach = people have more potential control
over their immoderate drinking than they typically believe and that heightened awareness of
the costs of drinking to excess & benefits of abstaining or cutting down can help
 Medications:
o Antabuse (disulfiram) = drug that discourages drinking by causing violent vomiting if alcohol
is ingested
 Must be strongly committed to change
o Opiate antagonist naltrexone – blocks activity of endorphins that are stimulated by alcohol,
reducing the craving for it *additionally effective when combined with CBT
o Acamprosate = impacts glutamate and GABA NTM systems, reduces cravings associated with
withdrawal

lOMoARcPSD|2532716
Treatments for Smoking

 More likely to quit smoking of other people around you quit
 Peer pressure to quit seems to be equally as effective as it was to start
 Only about 50% who go through smoking-cessation programs succeed in abstaining by the time the
program is over
o Only small amount who have succeeded short term remain nonsmoking a year later
 Psychological Treatments:
o Most common: being told to stop by a physician
o Scheduled smoking – get users to agree to increase the time in between cigarettes *limits on
amount of cigarettes/day, decrease each week
 Only smoke on schedule, not as a result of craving to smoke
o Project EX = school based program, includes training in coping skills and Psychoeducational
component about harmful effects
 Nicotine Replacement Treatments and Medications:
o Goal of NRT = reducing a smoker’s craving for nicotine by providing it in a different way (gum,
patches, inhalers)
o Nicotine gum is absorbed much more slowly and steadily than that in tobacco – help smoker
cut back and eliminate reliance
 If dose is too high, causes cardiovascular changes
o Patches slowly release the drug into the bloodstream transdermally and then to the brain
 Only need 1 patch/day, effective after about 8 weeks, use smaller patches as
treatment progresses
o NRT more effective when combined with antidepressant use or psychological treatment
Treatment of Drug Use Disorders
 Detoxification = withdrawal from the drug itself, is central for treatment
 Psychological Treatments:
o CBT more effective than antidepressants for those with high degree of drug dependence
 Learn how to avoid high-risk situations, recognize lure of the drug, and develop
alternatives to drug usage
 Learn strategies to cope with the craving and resistance of use
o Contingency management with vouchers (CBT with vouchers most likely to remain abstinent)
o Motivational enhancement therapy – involves combination of CBT and helping clients
generate solutions for alcohol and drug use disorders
o Self-help residential homes:
 Separation of people from previous social contacts (relationships helped maintain
drug use disorder)
 Comprehensive environment, drugs are not available, support is offered
 Charismatic role models – formerly dependent on drugs, meet life’s challenges
without drugs
 Direct confrontation in group therapy, accept responsibility for problems, take charge
of life
 Respectful setting, no stigmatization as failures/criminals
 **High dropout rate
o Proposition 36 – Substance Abuse and Crime Prevention Act – allows nonviolent drug
offenders to be sent to drug treatment rather than prison *voluntary
 Drug Replacement Treatments and Medications:

lOMoARcPSD|2532716
o Heroin substitutes = drugs chemically similar to heroin that can replace the body’s craving for
it
 Methadone – addicting on its own
 Synthetic narcotics are cross-dependent with heroin = by acting on the same CNS
receptors, they become a substitute for the original dependency
 Less severe withdrawal reactions
 Side effects: insomnia, constipation, excessive sweating, diminished sexual
functioning
 Stigma associated with going to methadone clinics
o Opiate antagonists = drugs that prevent the use from experiencing the heroin high
 Naltrexone
 Gradually weaned from heroin, receiving increasing doses of naltrexone
 Molecules occupy receptors to which opiates usually bind, without stimulating them
 Requires frequent visits to a clinic (motivation required)
o Buprenorphine – partial opiate agonist (less addictive than heroin), also contains naloxone
(opiate antagonist)
 Less intense high
 Do not need to go to clinic to receive *prescribed
 Effective at relieving withdrawal symptoms
o Drug replacement therapy does not seem to be effective for cocaine use disorders
o Vaccine to prevent the high associated with cocaine, contains tiny amounts of cocaine
attached to harmless pathogens
 Body responds by developing antibodies
 Not all users develop enough antibodies to keep cocaine from reaching the brain
o Methamphetamine Treatment Project – Matrix treatment – 16 CBT group sessions, 12
family education sessions, 4 individual therapy sessions, 4 social support sessions
 Positive short-term results, long-term results were equally comparable to treatment
as usual (TAU)
Prevention
 Half of adult smokers began before age 15, nearly all before age 19
 Top priority to discourage youth
 Family interventions
 Statewide comprehensive tobacco control programs: increasing taxes on cigarettes, restricting
advertising, conducting public education campaigns, creating smoke free environments
 New health warnings including graphic images on packaging
 School programs:
o Peer-pressure resistance training *learn to say no
o Correction of beliefs and expectations – believe it is more prevalent than it actually is
o Inoculation against mass media messages – media makes smoking look positive
 Truth campaign – aims to share health and social consequences of smoking
o Peer leadership
CHAPTER 11: Eating Disorders

 Became a distinct category in DMS-IV, DSM-5: eating disorders found in “Feeding & Eating Disorders”
chapter
o Pica = eating nonfood substances for extended periods
o Rumination = repeated regurgitation of foods

lOMoARcPSD|2532716
Clinical Descriptions of Eating Disorders

I. Anorexia Nervosa (AN)
DMS-5 Criteria:
 1) Restriction of food that leads to very low body weight; body weight is significantly below normal
BMI less than 18.5)
o Weight loss achieved through dieting and perhaps purging and excessive exercise
 2) Intense fear of weight gain/being fat or repeated behaviours that interfere with weight gain *fear
not reduced by weight loss
 3) Body image disturbance *distorted body image or sense of body shape
o Particularly the abdomen, hips, thighs are too fat
o Weight themselves frequently, measure themselves, gaze in the mirror critically
o Often assessed via questionnaire
o Women ideal: very thin (compared to normal), overestimate their own size, Male ideal: same
as normal, overestimate their own size
 SEVERITY: (BMI) Mild = =/< 17, Moderate = 16-16.99, Severe = 15-15.99, Extreme = <15
o Healthy BMI is between 20-25
 Amenorrhea = loss of menstrual period, is no longer a criteria
 Term anorexia refers to loss of appetite, nervosa indicates loss is due to emotional reasons
 2 subtypes:
o 1) Restricting type: weight loss is achieved by severely restricting food intake
o 2) Binge eating/purging: person has also regularly engaged in binge eating and purging
 Nearly 2/3 who meet category 1, switched over to 2 eight years later
 Typically begins in middle teenage years, often after episode of dieting an occurrence of life stress
 Prevalence: less than 1% (stable), 10x as frequent in women as men *greater cultural emphasis on
women’s beauty
o Higher mortality from men with disorder than women
 Comorbid with: depression, OCD, specific phobia, panic disorder and personality disorders
 High suicide rates: 5% complete, 20% attempt
Physical Consequences
 Low blood pressure, slow heart rate, kidney/gastrointestinal problems, bone mass declines, skin
dries, brittle nails, mild anemia
 Lanugo = fine, soft hair, loss of hair from scalp
 Loss of Na and K electrolytes  tiredness, weakness, cardiac arrhythmias, sudden death
Prognosis
 50-70% eventually recover, often after 6-7 years, common relapses before
 Death rates are 10x higher than the general population, 2x as high as those with other psyc disorders
 3-5% mortality rates among women *most often from physical complications (heart failure) and
suicide
o Death most likely among those who have had it for the longest
II. Bulimia Nervosa (BN)
DSM-5 Criteria
 1) Recurrent episodes of binge eating
o Eating an excessive amount of food within a short period of time
o Accompanied by feeling of losing control over eating – feel like one cannot stop
 2) Recurrent compensatory behaviour to prevent weight gain, for example, vomiting
 3) Body shape and weight are extremely important for self-evaluation
 Bulimia comes from a Greek word for ox hunger – rapid consumption of a large amount of food

lOMoARcPSD|2532716
 People with bulimia are distinct from anorexia because they do not lose an excessive amount of
weight
 Binges occur in secret, triggered by stress and negative emotions they arouse, continue until
uncomfortably full
o Often involves soft, sweet foods that can be rapidly consumed: ice cream, cake
o More likely to binge while alone, during morning/afternoon
o Avoiding a craved food can lead to a binge the next day
o Likely to occur after negative social interaction
 Severity: (Compensatory behaviours) Mild = 1-3/week, Moderate = 4-7/week, Severe = 8-13/week,
Extreme = 14+/week
 Must occur at least once a week for 3 months
 Self-esteem depends heavily on maintaining normal weight
 More accurate than normal population in reporting height/weight
 DSM-IV-TR included subtypes which were removed
 Begins in late adolescence/early adulthood, 90% are women, 1-2% prevalence among females
 Many are somewhat overweight before onset
 Comorbid with: depression, personality disorders, anxiety disorders, substance use disorders,
conduct disorder
o Increase likelihood in both directions, except bulimia usually precedes substance use
disorders
 Higher suicide rates than normal population (lower than anorexia)
 Typically have a normal BMI but amenorrhea can still occur
 Frequent purging can lead to K depletion, loss of electrolytes, irregular heartbeat
 Vomiting can lead to tearing of stomach tissue and throat tissue, loss of dental enamel
 Swollen salivary glands
 Mortality rate of 4% for women
Prognosis
 Close to75% recover, 10-20% remain fully symptomatic
 Earlier intervention linked to better prognosis
III. Binge Eating Disorder (BED)
DSM-5 Criteria:
 1) Recurrent binge eating episodes
o 1+/week for 3 months
 2) Binge eating episodes include at least 3 of the following:
o Eating more quickly than usual, eating until over full, eating large amounts even if not hungry,
eating alone due to embarrassment about large food quantity, feeling bad after binge
 3) No compensatory behaviour is present
 Most often are obese (BMI greater than 30), prevalence among 2-25% of obese people
o Many have a history of dieting
 Severity (# binges/week): Mild 1-3/week, Moderate = 4-7/week, Severe = 8-13, Extreme = 14+/week
 Comorbid with: mood disorders, anxiety disorders, ADHD, conduct disorder, substance use disorder
 Risk factors: childhood obesity, critical comments about being overweight, weight-loss attempts in
childhood, low self-concept, depression, and childhood abuse
 More prevalent than other eating disorders, 0.2-4.7% prevalence, more common in women (less
gender difference)
 Equally prevalent cross-culturally

lOMoARcPSD|2532716
 Increased risk of type II diabetes, cardiovascular problems, chronic back pain, headaches
 Sleep problems, anxiety, depression, IBS, early onset menstruation for women
Prognosis
 25-82% of people recover
 Lasts approximately 14.4 years (longer than anorexia/bulimia) or just over 4 years?
Etiology of Eating Disorders
Genetic Factors
 Unlikely caused by 1 gene, although they do run in the family
 1st degree relatives of women with anorexia are 10x more likely to have the disorder, 4x for bulimia
o Same for men with anorexia, but not bulimia
 Higher MZ than DZ concordance rates for anorexia and bulimia
 Environmental factors are also very important (higher proportion of bulimia due to environmental
than genetic factors)
 Heritable: dissatisfaction with one’s body, strong desire to be thin, binge eating, preoccupation with
weight
 Genetic factors may link to negative emotionality and constraint with eating disorders
 Hypothalamus is a key brain structure involved in regulating hunger *not dysfunctional in anorexia
 Endogenous opioids reduce pain sensations, enhance mood and suppress appetite
o Released during starvation, related to anorexia, bulimia and BED **increased levels
o Excessive exercise increases opioids *reinforcing
 Low levels of beta-endorphin in bulimia *not sure if this is a cause or effect
 Serotonin – related to eating and satiety (feeling full) *promotes satiety
o Binges could result from serotonin deficit
o Food restriction interferes with serotonin synthesis
o Low levels of serotonin metabolites in AN and BN = underactive NTM activity
o Show poor response to 5-HT agonists in AN if haven’t been restored to healthy weight
o Linked to comorbid depression
 Dopamine – related to reward/pleasure aspects of food
o Linked to motivation to obtain food
o Restrained eaters more sensitive to food cues
o Ventral striatum linked to DA level and reward
 More activated in people with AN when looking at images of thin women
o People with AN or BN show greater expression of DA transported gene DAT
o Bingeing on sucrose leads to increased release of DA in the striatum
Cognitive-Behavioural Factors
 Focus on distorted body image, fear of fat, loss of control of over eating
 Anorexia Nervosa:
o Emphasis on fear of fatness and body image disturbance as motivating factor that reinforced
weight loss
o Onset often follows a period of weight loss and dieting
o Behaviours to achieve thinness are negatively reinforced by reduction of anxiety about
becoming fat
 Positively reinforced by comments form others
o Dieting and weight loss positively reinforced by sense of mastery or self-control

lOMoARcPSD|2532716
o Perfectionism and sense of personal inadequacy may lead a person to become concerned
with appearance
 Compare oneself to portrayals in media of thin ideal, being overweight and
comparing to attractive others all lead to greater dissatisfaction in one’s body image
o Criticism from peers and parents about being overweight
o Experience many negative emotions but also positive emotions (e.g. pride) after losing
weight or avoiding treats
 Low positive emotion differentiation: may confuse this feeling with happiness or
success
 Low positive emotion differentiation predicts eating disorder behaviours (same with
high negative)
 Bulimia Nervosa and BED:
o View self-worth in terms of body weight and shape
o Low self-esteem, hope control over body will help feel better generally
o Try to follow strict eating plan, rules are inevitably broken, escalates into binge
o Feelings of disgust and fear build up after binge, leading to compensatory actions
o Purging temporarily reduces anxiety but lowers self-esteem, and cycle repeats
 Low SE and high negative affect  Dieting to feel better about self  Food intake
restricted too severely  Diet is broken  Binge  Compensatory behaviours to
reduce fear of weight gain
o Restraint scale – questionnaire measure of concerns about dieting and overeating
o Bingeing helps regulate amount of negative affect, although tend to experience more
negative affect after binge
o Purging is reinforced by decreasing negative affect
o Concerns about body shape and weight predict restrained eating, which predicts increased
bingeing
o Attention, memory and problem solving are affected with eating disorders
 Attention focused on food-related images/words longer
 Remember food words more when full w/AN
Sociocultural Factors
 BMI of ideal female models has decreased over time, male BMI increased due to increased
muscularity
 As cultural standards moved more towards thin ideal, more and more people were becoming
overweight
 Over 2/3 of Americans are overweight
 Dieting has become more common (29% of men and 44% of women diet)
 A 1/3 of women 25-45 report spending over half their lifetime trying to lose weight
 Diets are equally effective whether fats, carbs, or proteins are cut as long as number of calories are
reduced
 Women are more likely to diet than men
 Highest risk for developing eating disorders with high BMI and body dissatisfaction
 Sociocultural ideal of thinness leads to people learning to fear being/feeling fat
 “Pro-eating disorder” websites – women who visit these sites are more dissatisfied with their bodies,
have more eating disorder symptoms and more likely experienced hospitalizations for eating
disorders
o Viewing these websites has potential to cause unhealthful changes in eating behaviours
 Gender Influence:

lOMoARcPSD|2532716
o More common in women than men

o Western culture emphasizes thin ideal more in women
o Highest among groups expected to be concerned with thinness/weight: gymnasts, models,
dancers
o Objectification of women’s bodies – women are defined by their bodies, men are esteemed
for their accomplishments
o Objectification theory = prevalence of objectification message has led some women to self-
objectify *see their own body through the eyes of others
 Causes women to feel more shame about their bodies
o As women get older, become less concerned with body weight, diet less (even though they
tend to weight more then)
 Changes in life roles: having a life partner, having a child associated with decreased
eating disorder symptoms
 Men more concerned about body image, increased dieting
 Cross-Cultural Studies:
o AN observed in a number of cultures/countries with very little Western cultural influence
 Doesn’t include same degree of fear of gaining weight as it does in Western culture
o In other cultures higher weight has greater value, better potential for fertility and happiness
o BN more common among industrialized nations
 Ethnic Differences:
o Greater incidence among white than black women *most pronounced among college
students
o White/Hispanic report greater body dissatisfaction than African American
o Acculturation can be stressful
 High levels of acculturation stress in African American and Hispanic related to greater
body dissatisfaction and bulimia symptoms
o Found among all levels of SES
Other Contributing Factors
 Personality Factors:
o Personality in those with AN is affected by weight loss
o Become preoccupied with food, increased fatigue, poor concentration, lack of sexual interest,
irritability, moodiness, insomnia
o Before onset of AN: perfectionistic, shy, compliant
o BN: adds, histrionic features, affective instability, outgoing social description
o Poor interoceptive awareness = extent to which people can distinguish between different
biological states of their bodies
o Propensity to experience negative emotions
o Perfectionism is multifaceted and may be self-oriented (setting high standards for self), other-
oriented or socially oriented (trying to conform to high standards imposed by others
 Remains high even after successful treatment
 Mothers of girls with AN score higher on perfectionism
 Characteristics of Families:
o Self-reports reveal high level of family conflict, parental reports do not agree
o Parents of child with eating disorders do not seem to differ from parents of those without in
frequency of positive and negative messages
 Parents of children with eating disorders more self-disclosing
 Lack some communication skills

lOMoARcPSD|2532716
 Child Abuse and Eating Disorders:

o Higher self-reports of sexual abuse among those with eating disorders, especially BN
Treatment of Eating Disorders
 Hospitalization is frequently required for AN to increase food ingestion and carefully monitor
 IV feeding might be necessary to save life
Medications
 BN comorbid with depression, treated with various antidepressants, reduces purging and binge
eating
 Many people don’t maintain medication treatment
 Many relapse after medication is withdrawn (less so alongside CBT)
 Medication also used to treat AN, anti-obesity drugs show some promise with BED
Psyc Treatment of AN
 2 tiered process:
o 1) Immediate goal is to help person gain weight to avoid medical complications/possibility of
death
 Use operant conditioning behaviour therapy: provide reinforcers for gaining weight
*affective short term
o 2) Long-term maintenance of weight gain *challenge
 CBT – effective after hospitalization to reduce risk of relapse
 CBT and psychotherapy + education are equally effective in reducing eating disorder symptoms and
depression
 Older women with more severe symptoms benefit most from CBT
 Family therapy – interactions among members of patient’s family can play a role in treating the
disorder
o Higher rates of remission compared to individual therapy
 Early weight gain is an important predictor of a good outcome
Psyc Treatment of BN
 CBT is standard treatment
o Question society’s standards for physical attractiveness
o Uncover and change beliefs that encourage starvation in order to avoid becoming overweight
o Normal body weight can be maintained without severe dieting
o Unrealistic restriction of food intake can trigger a binge
o All is not lost with one bite of high calorie food, snacking need not trigger a binge
o *Alter the all-or-nothing thinking
 Goal to develop more typical eating patterns: 3 meals a day with some snacks
 CBT therapist challenges unrealistic beliefs about ties between weight gain and self-worth
 Challenge cognitive distortions: e.g. that eating a small amount of high-calorie food = utter failure
 Reductions in bingeing/purging in 70-90% of patients with CBT
 CBT more effective than drug treatment
 ERP (exposure & response prevention) – discouraging person form purging *more effective in
addition to CBT in short term
 Guided self-help – receive self-help books on topics such as: perfectionism, body image, negative
thinking, food & health
o Greater confidence in one’s ability to change is related to better outcomes
 Interpersonal therapy (IPT) – did not produce results as quickly as CBT
 Family therapy – superior to supportive psychotherapy
Psyc Treatment of BED

lOMoARcPSD|2532716
 CBT shown to be effective

 Targets binges and restrained eating by emphasizing self-monitoring, self-control, and problem
solving with eating
 Gains last up to 1 year after treatment
 IPT is as effectives as CBT and guided self-help for BED
 Having a therapist lead CBT may help keep people in treatment and reduce binges
Preventive Interventions for Eating Disorders
 Intervene with children/adolescents before onset
 1) Psycho-educational approaches – educate children/adolescents about eating disorders in order to
prevent them from developing symptoms
 2) Deemphasizing sociocultural influence – helping children and adolescents resist/reject
sociocultural pressures to be thin
 3) Risk factor approach – identifying people with known risk factors and intervening to alter these
factors
 Most effective: interactive, include teens 15+ years-old, girls only, multiple sessions
 Body project – dissonance reduction intervention focused on deemphasizing sociocultural influences
 Healthy weight intervention – targets risk factors
CHAPTER 12: Sexual Disorders

 Sexual dysfunctions = persistent disruptions in the ability to experience sexual arousal, desire or
orgasms, or pain associated with intercourse
 Paraphilic disorders = persistent and troubling attractions to unusual sexual activities or objects
Sexual Norms and Behaviour
 Inhibition of sexual expression is seen as a problem
 Used to be that excessive masturbation in childhood widely believed to lead to sexual problems in
adulthood
o Victorian view – sexual appetite is dangerous and must be restrained
o Corn Flakes and Graham Crackers were developed as foods that would lessen sexual interest
(failed to do so)
 New easy accessibility to sexual content using technology
 Newer STIs related to increased risk with sexual activity
 Newfound emphasis on right to a good sex life until the day one dies *increasing array of
medications to promote this
 Culture influences attitudes and beliefs: important part of well-being vs. for procreation only
Gender and Sexuality
 Men report more engagement in sexual thought and behaviour than women
o More thinking about sex, masturbating, and desiring sex more often
 Women tend to be more ashamed of any flaws in their appearance, can interfere with sexual
satisfaction
 For women sexuality is more closely tied to relationship status *less sexual drive and masturbating
when not in relationship
 More than half of women with sexual dysfunction believe it is caused by relationship problems
 Men think about their sexuality in terms of power
 Primary motivation for having sex: sexual attraction and physical gratification
 Women are much more likely to report symptoms of sexual disorders
 Men are much more likely to meet criteria for Paraphilic disorder
The Sexual Response Cycle

lOMoARcPSD|2532716
 1) Desire phase = sexual interest or desire, often associated with sexually arousing fantasies or
thoughts
 2) Excitement phase = men and women experience increased blood flow to genitalia (produces
erection in male penis & enlargement of breasts & increased lubrication in female vagina)
 3) Orgasm phase = sexual pleasure peaks, male ejaculation almost always occurs, in women the
outer walls of the vagina contract (general muscle tension)
 4) Resolution phase = relaxation and sense of well-being that usually follows orgasm
o Men – associated refractory period during which further erection isn’t possible
o Women often able to respond again immediately
 Many women report that desire and excitement co-occur and cannot be made distinct
 Vaginal plethysmograph = used to measure women’s physiological arousal
o Amount of blood flow has little correlation to subjective level or desire/excitement
1. Sexual Dysfunctions (SD)
Clinical Descriptions
 Symptoms must last at least 6 months (common to have for just a month)
 3 categories:
I. Involving sexual desire, arousal, and interest (low sex drive)
 Women: female sexual interest/arousal disorder
o 1) Diminished, absent or reduced frequency of at least 3 of the following:
 Interest in sexual activity, erotic thoughts/fantasies, initiation of sexual activity &
responsiveness to partner’s attempts to initiate, sexual excitement/pleasure during
75% of sexual encounters, sexual interest/arousal elicited by any internal or external
erotic cues, genital or non-genital sensations during 75% of sexual encounters
 Overall, deficits in sexual interest, biological arousal or subjective arousal
 Men: male hypoactive sexual desire disorder
o 1) Sexual fantasies and desires, as judged by clinician, are deficient or absent
 Men: erectile disorder
o On at least 75% of sexual occasions:
 1) Inability to attain an erections, or
 2) Inability to maintain an erection for completion of sexual activity, or
 3) Marked decrease in erectile rigidity interferes with penetration or pleasure
o 13-28% rates
o Prevalence increases with age (50% are 60+)
 More than 50% seeking treatment report low desire, women more likely than men to report
 2-4x more likely if post-menopausal *although older women are less likely to be distressed about it
 Women more concerned about lack of subjective desire *previously arousing stimuli no longer
affective
 Often have normative biological arousal even with lack of subjective desire
 Dysfunction should be persistent and recurrent and should cause clinically significant distress or
problems with functioning
o Diagnosis not made if cause is entirely due to a medical illness (e.g. advanced diabetes) or
other psyc disorder
 More women than men report symptoms of sexual dysfunction (43% vs. 31%)
 Clinical diagnosis not made unless symptoms cause distress/impairment (only 11-23% of women)
II. Orgasmic disorders
 Women: female orgasmic disorder
o On at least 75% of sexual occasions:

lOMoARcPSD|2532716
 1) Marked delay, infrequency, or absence of orgasm, or

 2) Markedly reduced intensity of orgasmic sensation
o 1/3 of females report they do not consistently have orgasms with their partners
 Men: Premature ejaculation
o 1) Tendency to ejaculate during partnered sexual activity within 1 minute of penile insertion
on at least 75% of occasions
 Delayed ejaculation
o 1) Marked delay, infrequency, or absence of orgasm on t least 75% of sexual occasions
o Least common
III. Sexual pain
 Women: Genito-pelvic pain/penetration disorder
o Persistent or recurrent difficulties with at least one of the following:
 1) Inability to have vaginal/penetration during intercourse
 2) Marked vulvar, vaginal, or pelvic pain during vaginal penetration or intercourse
attempts
 3) Marked fear or anxiety about pain or penetration
 4) Marked tensing of the pelvic floor muscles during attempted vaginal penetration
o Vaginismus = involuntary muscle spasms o the outer third of the vagina, making intercourse
impossible
o Make sure pain is not caused by infection or lack of lubrication
o Can still have sexual arousal and reach orgasm from manual/oral stimulation
Etiology of Sexual Dysfunction
 2 causes: fears about performance and adoption of spectator role
 Fears about performance – concerns with how one is performing during sex
 Spectator role – being an observer rather than a participant in a sexual experience
Biological Factors
 Separate category for sexual dysfunctions caused by medical illness (diabetes, MS, spinal cord injury,
heavy alcohol use before sex, heavy cigarette smoking)
 Can be caused by low levels of testosterone/estrogen or high levels induced by anabolic steroids or
testosterone supplements
 SSRIs and antihypertensive drugs have effects on sexual function:
o Delayed orgasm, decreased libido, diminished lubrication
 Erectile symptoms often elated to incipient vascular disorder
Psychosocial Factors
 Some sexual dysfunctions can be traced to rape/sexual abuse
o Childhood sexual abused associated with diminished arousal/desire, and premature
ejaculation in men
 For women – concerns about partner’s affection correlated with sexual satisfaction
 Anxiety and anger, poor communication, embarrassment, fears
 Increased risk if have depression/anxiety and panic disorder
 Anxiety/depression comorbid with sexual pain
 Negative cognitions
 People who blame themselves for decreased sexual performance are more likely to develop
dysfunction symptoms
o Later experience diminished arousal
Treatment

lOMoARcPSD|2532716
 Begin by resolving any relationship problems – training in non-sexual communication skills and non-
sexual issues
o Difficulties with in-laws, child rearing
 Recommend planning romantic events together to restore closeness and intimacy
 Behavioural couples therapy especially effective for women
 Sensate focus – reestablish sexual intimacy through contact
Anxiety Reduction and Psychoeducation
 Systematic desensitization and in vivo desensitization (begin with psychoeducation, then using small
dilator, then larger)
 Psychoeducation – videos showing sexual techniques
 For premature ejaculation – expand repertoire of activities
Procedures to Change Attitudes and Thought
 Sensate-focus exercises
 Help focus on physical sensations
Communication Training
 Communicate likes and dislikes to one another
 Expressing sexual preferences
 **Used when dysfunction is specific to a given relationship and not a concern with previous partners
Directed Masturbation
 Developed to enhance a women’s comfort with and enjoyment of sexuality
 Women carefully examines her nude body, identify various areas, instructed to touch her genitals,
find areas that produce pleasure
 Increase intensity using erotic fantasies, if no orgasm, use vibrator, let her partner do for her as she
was doing
 Helpful for treating orgasmic disorders
Other Physical Treatments
 Learn sexual positions that increase clitoral stimulation (for female orgasmic disorder)
 Squeeze technique (premature ejaculation)
Medications
 Testosterone therapy (not approved by FDA for female) – sexual interest/arousal disorder
 Psychotherapy is helpful alongside medication
 Antidepressants:
o Helpful is depression contributes to diminished sex drive
o Particularly use SSRIs – also helpful in treatment of premature ejaculation
o Some actually interfere with sexual responsiveness, use 2nd medication e.g. buproprion
 PDE-5 inhibitors:
o Phosphodiesterase type 5 inhibitor *treatment for erectile disorder
o Relax smooth muscles and allow blow to flow into penis, creating erection during sexual
stimulation but not in its absence
o Taken 1 hour before sex, effects last 4 hours
o Side effects: headaches, indigestions
o May be dangerous with cardiovascular disease (often comorbid)
2. Paraphilic Disorders
 = Recurrent sexual attraction to unusual objects or sexual activities lasting at least 6 months
 1 category for people whose sexual attractions are focused on causing pain & another for those
focused on children

lOMoARcPSD|2532716
 When termed “disorder” – diagnoses are to be considered only when the sexual attractions cause
marked distress or impairment or when the person engages in sexual activities with a nonconsenting
person
 Objects of sexual attraction are described:
o Fetishistic disorder = an inanimate object or non-genital body part
o Transvestic disorder = cross-dressing
o Pedophilic disorder = children
o Voyeuristic disorder = watching unsuspecting others undress or have sex
o Exhibitionistic disorder = exposing one’s genitals to an unwilling stranger
o Frotteuristic disorder = sexual touching of an unsuspecting person
o Sexual sadism disorder = inflicting pain
o Sexual masochism disorder = receiving pain
 Lack of structured interviews to reliably assess these disorders
 Most people with Paraphilic disorders are heterosexual males
 Onset: adolescence (sadism and masochism in early adulthood)
 More than 2/3 meet mood disorder criteria, anxiety/substance disorders also common
I. Fetishistic Disorder
 1) For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviours
involving the use of nonliving objects or nongenital body parts
 2) Causes significant distress or impairment in functioning
 3) The sexually arousing objects are not limited to articles of clothing used in cross-dressing or to
devices designed to provide tactile genital stimulation, such as a vibrator
 Almost exclusively effects men, fetish sometimes necessary for sexual arousal
 Clothing (underwear), leather, articles related to feet (stockings, women’s shoes) are common
fetishes
o Hair, nails, hands, feet are sexually arousing
 Feel compulsive attraction to the object, involuntary and irresistible
II. Pedophilic Disorder and Incest
 1) For at least 6 months, recurrent and intense, sexually arousing fantasies, urges, or behaviours
involving sexual contact with a prepubescent child
 2) Person has acted on these urges or the urges and fantasies cause marked distress or interpersonal
problems
 3) Person is at least 16 years old and 5 years older than the child
 Generally molest children they know, most don’t engage in violence other than the sexual act
 Denies that he is forcing himself on the victim
 50% are adolescent males, most are heterosexual
 Incest = sexual relations between close relatives for whom marriage is forbidden (subtype of
pedophilic disorder)
o Most common between brother and sister, then father and daughter
o Children of incest can inherit too many recessive genes and lead to serious genetic defect
o Men who commit incest usually abuse their pubescent daughters (vs. pre-pubertal)
o Show greater penile arousal
III. Voyeuristic Disorder
 1) For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviours
involving the observation of unsuspecting others who are naked, disrobing, or engaged in sexual
activity

lOMoARcPSD|2532716
 2) Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause
marked distress or interpersonal problems
 These fantasies are quite common among men
 “Peeping” helps promote sexual arousal and is sometimes essential for it
 Does not find it exciting to watch a women who is undressing for his benefit
 Excited by anticipation of how the women would react is she knew he was watching
IV. Exhibitionistic Disorder
 1) For at least 6 months recurrent, intense, and sexually arousing fantasies, urges, or behaviours
involving showing one’s genitals to an unsuspecting person
 2) Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause
clinically significant distress or interpersonal problems
 Many masturbate during exposure
 Desire to shock or embarrass the observer
 Urge to expose triggered by anxiety and restlessness and well as by sexual arousal
 Symptoms of anxiety: headaches, palpitations and Derealization
 May be repeated often, same place, same time of day *compulsive
 Social and legal consequences are far off of mind
 Flee and feel remorseful after
V. Frotteuristic Disorder
 1) For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviours
involving touching or rubbing against a nonconsenting person
 2) Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause
clinically significant distress
 Typically occurs on a crowded bus or sidewalk that provide an easy means of escape
 Report doing so a dozen times
VI. Sexual Sadism and Masochism Disorders
Sadism Criteria
 1) For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviours
involving the physical or psychological suffering of another person
 2) Causes clinically significant distress or impairment in functioning or the person has acted on these
urges with a nonconsenting person
Masochism Criteria
 1) For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviours
involving the act of being humiliated, beaten, bound, or made to suffer
 2) Causes marked distress or impairments in functioning
 Manifestations of masochism: physical bondage, blindfolding, spanking, whipping, electric shocks,
cutting, humiliation (being urinated/defecated on, being forced to wear a collar and bark, being put
on display naked), and taking the role of slave and submitting to orders and commands
 Most sadists have relationships with masochists, or can take on both roles **masochists outnumber
sadists
 Behaviour becoming more acceptable over time
 Found in straight and gay relationships
 20-30% of sadomasochistic clubs are female
 Above average in income and educational status
 Alcohol abuse is common among sadists
Etiology of Paraphilic Disorders
 Most paraphilics are male, perhaps androgens (hormones like testosterone) play a role

lOMoARcPSD|2532716
 Androgens regulate sexual desire *high among sexual offenders with Paraphilic disorders
Childhood Sexual Abuse
 2/3 of sexual offenders reported a history of sexual abuse
 Succumbing to sexual urge thought of as impulsive act, often occur in context of alcohol use (unable
to inhibit impulses)
 Others report often occur in context of negative moods – sexual activity used as means to escape
 Heightened impulsivity and poor emotion regulation
 Cognitive distortions and attitudes, lack of empathy for women
 Distortion that a women who left her blinds up wants to be looked at, or women who dress
provocatively “ask for it”
 Men with pedophilia have lower IQ, higher rates of neurocognitive problems
Treatment
Strategies to Enhance Motivation
 Sexual offenders lack motivation to change illegal behaviour
 Deny their problem, minimize seriousness, feel confident that they can control it
 Blame the victim for being overly seductive
 Enhance motivation, bolster hope that client can gain control over urges through treatment,
highlight potential legal consequences
CBT
 Aversion therapy to reduce attraction to inappropriate object/activity
 Satiation – trained to pair Paraphilic fantasy with another aversive stimulus (masturbating for 55
minutes after orgasm)
 Covert sensitization – person imagines situations he finds inappropriately arousing and imagines
feeling sick/ashamed for feeling and acting this way *reduces deviant arousal
 Counter distorted thinking that the subjects aren’t really being harmed
 Social skills training, training in empathy towards others
 Sexual impulse control training
Biological Treatments
 Castration – removal of testes
 Medications used as supplement to psyc treatment – hormonal agents that reduce androgens
o Reduce arousal to deviant objects
o Long-term use associated with negative side effects
 SSRIs commonly used
Balancing Efforts to Protect Public Against Civil Liberties for Those with Paraphilias
 Unconstitutional to detain a person on basis of his/her potential for future crimes
 High risk for sexual crime can be detained if risk is related to psyc disorder that diminished ability to
control sexual behaviour
 Allowed to find out where sexual offenders are living
CHAPTER 13: Disorders of Childhood

 Number of children diagnosed/treated has increased over the years (ADHD diagnoses increased 41%
2003-2012)
 Controversial medication treatment
Classification and Diagnosis of Childhood Disorders
 Developmental psychopathology = focuses on the disorders of childhood within the context of life-
span development, enabling us to identify behaviours that are considered appropriate at one stage
but not at another

lOMoARcPSD|2532716
 Most childhood disorders fall under either: a) Neurodevelopmental disorders & b) Disruptive,
impulse-control, and conduct disorders
 Defined in 2 broad domains:
o Externalizing disorders = more outward-directed behaviours, such as aggressiveness,
noncompliance, over-activity, and impulsiveness
 Includes ADHD, conduct disorder, and oppositional defiant disorder
o Internalizing disorders = more inward-focused experiences and behaviours, such as
depression, social withdrawal, and anxiety
 Childhood anxiety, and mood disorders
I. Attention-Deficit/Hyperactivity Disorder (ADHD)
DSM-5 Criteria
 1) Either A or B:
o A) 6+ manifestations of inattention present for at least 6 months to a maladaptive degree and
greater than what would be expected given a person’s developmental level (e.g. careless
mistakes, not listening well, not following instructions, easily distracted, forgetful in daily
activities)
o B) 6+ manifestations of hyperactivity-impulsivity present for at least 6 months to a
maladaptive degree and greater than what would be expected given a person’s
developmental level, e.g. fidgeting, running about inappropriately (in adults, restlessness),
acting as if “driven by a motor”, interrupting or intruding, incessant talking
 2) Several of the above present before age 12
 3) Present in two or more settings
 4) Significant impairment in social, academic, or occupational functioning
 5) For people age 17 or older, only 5 signs of hyperactivity-impulsivity are needed to meet the
diagnosis
 Overestimate their ability to navigate social situations with peers
 Vicious cycles – 3 domains: poor social skills, aggressive behaviour, overestimation of one’s social
abilities – predict decline in these abilities at follow-up
 Age of onset was changed from under 7 to under 12 & adults only need to show symptoms in 5
domains = more diagnoses
 3 specifiers:
o 1) Predominantly inattentive = children whose problems are primarily those of poor
attention
 More difficulty with focused attention or speed of information processing
 Problems with DA and prefrontal cortex
o 2) Predominantly hyperactive-impulsive = children whose difficulties result primarily from
hyperactive/impulsive behaviour
o 3) Combined = children who have both sets of problems ***majority
 More likely to develop conduct problems & oppositional behaviour, be placed in
special classes and have difficulties interacting with peers
 Frequently comorbid with conduct disorder *ADHD associated more with off-task behaviour in
school, cognitive and achievement deficits, and a better long-term prognosis
 Also comorbid with anxiety and depression (30%), 15-30% have a learning disorder
 Hyperactive symptoms predict substance use
 8-11% prevalence *increase could be due to factors other than increase in the actual disorder
o Over diagnosis due to assessments that are too brief to properly judge & differing
educational policies

lOMoARcPSD|2532716
 3x as common in boys than girls

ADHD in Adulthood
 65-80% of children with ADHD still have symptoms associated with impairments in adolescence
 Most adults with ADHD are employed and financially independent (generally lower SES)
 15% still meet criteria at age 25, 60% still experience impairment from symptoms
Etiology
Genetic Factors
 Genetic component to ADHD, heritability estimate of 70-80%
 Number of candidate genes found as suggested to causing ADHD *related to NTM DA (DRD4, DRD5,
DAT1)
o Only associated with risk if have particular environmental factors **prenatal nicotine/alcohol
use
 SNAP-25 – gene that codes for protein that promotes plasticity of neuron synapses also associated
with ADHD
 Brain areas linked to DA may be different in structure/function/connectivity
 Dopaminergic areas: caudate nucleus, globus pallidus, frontal lobes *smaller in kids with ADHD *less
frontal activation
 Perform poorer on neuropsychological tests requiring frontal lobes
 Perinatal and Prenatal Factors:
o LBW is a predictor *less of an impact with maternal warmth
 Environmental Toxins:
o Additives and artificial colours in foods upset that nervous system of children who are
hyperactive
o View that refined sugar can cause ADHD is not supported by research
o Higher blood-lead levels may associate with hyperactivity symptoms and attention problems
o Maternal smoking *nicotine* may play a role in development of ADHD
Family Factors
 Parent-child relationship interacts with neurobiological factors to contribute to ADHD symptoms
 Many parents of ADHD children have ADHD themselves
Treatment
Stimulant Medications
 Examples: methylphenidate, Ritalin – prescribed since 1960s, others: Adderall, Concerta, Strattera
 80% of ADHD patients take stimulants, includes 10% of all adolescent boys
 Drugs reduce disruptive behaviours and impulsivity and improve ability to focus attention
 Short-term improvements in goal0directed activity, classroom behaviour, social interactions with
parents/teachers/peers, reductions in aggressiveness and impulsivity in 75%
 Drugs interact with DA system
 Combined treatment of medication and therapy is superior, followed by medication alone
o Combined treatment also didn’t require as high a dose of Ritalin & more social skills
improvement
 Medication more effective for children with ADHD
 Stimulant side effects: loss of appetite, weight loss, stomach pain, sleep problems, cardiovascular
risks
Psychological Treatment
 Parent training & changes in classroom management
 Children’s behaviour monitored at home and school, reinforced for behaving appropriately

lOMoARcPSD|2532716
o Point system and daily report cards

 Focus: improving academic work, completing household tasks, learning specific social skills
 May be as effective as Ritalin
II. Conduct Disorder
 Intermittent explosive disorder (IED) = recurrent verbal or physical aggressive outbursts that are far
out of proportion of the circumstances
o Aggression is impulsive and not preplanned toward other people
 Oppositional defiant disorder (ODD) = child does not meet criteria for conduct disorder, most
especially, extreme physical aggressiveness, but exhibits such behaviours as losing his/her temper,
arguing with adults, repeated refusing to comply with requests from adults, deliberately doing things
to annoy others, and being angry, spiteful, touchy or vindictive
o ODD and ADHD frequently occur together *different since defiant behaviours not thought to
arise from attentional deficits or impulsiveness
o Children with ODD are more deliberate

DSM-5 Criteria:
 1) Repetitive and persistent behaviour pattern that violates the basic rights of others or conventional
social norms as manifested by he presence of 3+ of the following in the previous 12 months and at
least one of them in the previous 6 months:
o A. Aggression to people and animals (e.g. bullying, initiating physical fights, physical cruelty
to people or animals, forcing someone into a sexual activity)
o B. Destruction of property (e.g. fie-setting, vandalism)
o C. Deceitfulness or theft (e.g. breaking into another’s house or car, conning, shoplifting)
o D. Serious violation of rules (e.g. staying out at night before age 13 in defiance of parental
rules, truancy before age 13)
 2) Significant impairment in social, academic, or occupational functioning
 3-4x as common in boys than girls
 Behaviour marked by: callousness, viciousness, and lack of remorse
 Limited prosocial emotions – diagnostic specifier for children who have callous and unemotional
traits
o Lack of remorse/empathy/guilt and shallow emotions
o Traits associated with more severe course, more cognitive deficits, more antisocial behaviour,
poorer response to treatment
 Often comorbid with substance abuse and internalizing disorders (15-45% comorbidity with
anxiety/depression)
o Conduct disorder tends to precede anxiety/depression *except specific phobias and social
anxiety
 7% of preschoolers exhibit symptoms *important to assess early, not just manifestations of typical
developmentally disruptive behaviours
 2 courses:
o Life-course-persistent pattern of antisocial behaviour, begin to show conduct problems by
age 3 and continue to commit serious transgression into adulthood
o Adolescent-limited – typical childhoods, high levels of antisocial behaviour during
adolescence, typical, non-problematic adulthood
 Result of maturity gap between adolescent physical maturation and opportunity to
assume adult responsibilities and obtain rewards usually accorded such behaviour

lOMoARcPSD|2532716
 Continue to have substance use, impulsivity, crime and mental health problems in mid
20s
 6-9.5% prevalence, more common in boys
 Incidence and prevalence of serious law breaking peak at age 17, drop in young adulthood
Etiology
Genetic Factors
 Some genetic factors of conduct disorder are shared with other disorders (ADHD, depression) others
are specific to CD
 Criminal and antisocial behaviour is accounted for both by genetic and environmental factors
 40-50% of antisocial behaviour is heritable
 Aggressive behaviour is more heritable than other delinquent behaviour
 Age of onset is related to heritability
 MAOA gene – located on the X chromosome, releases MAO enzyme which metabolizes NTMs (DA, 5-
HT, NE)
o Maltreated children with low MAOA activity more likely to develop conduct disorder
Brain Function, Autonomic Nervous System, and Neuropsychological Factors
 Deficits in brain regions supporting emotions **empathetic responses
o Difficulty perceiving distress and happiness on others, no difficulty perceiving anger
 Reduced amygdala and prefrontal cortex activation
 Do not learn to associate behaviour with reward/punishment as easily as others (amygdala/ventral
striatum)
 ANS abnormalities associated with antisocial behaviour in adolescents
o Low levels of resting skin conductance and heart rate *lower arousal
o May not fear punishment as much
 Poor verbal skills, problems with executive functioning, problems with memory
 IQ 1 SD lower if developed at early age *not due to low SES or school failure
 Deficient in moral awareness, lacking remorse for wrongdoings *prominent in antisocial personality
disorder and psychopathy
 Interpret ambiguous acts as hostile intent (e.g. being bumped in line)
Peer Influences
 1) Acceptance or rejection by peers
o Rejection by peers is causally related to aggressive behaviour *specifically in combination
with ADHD
o Can predict later aggressive behaviour
 2) Affiliation with deviant peers
o Increases likelihood of delinquent behaviour
Treatment
Family Intervention
 Intervening early has an impact
 Family checkup treatment (FCU) = 3 meetings to get to know, assess, and provide feedback to
parents regarding their children and parenting practices
 Parent management training (PMT) = parents are taught to modify their response to their children
so that prosocial rather than antisocial behaviour is consistently rewarded
o Parents taught to use positive reinforcement, and time-outs and loss of privileges
o Most efficacious intervention
Multisystemic Treatment (MST)

lOMoARcPSD|2532716
 = Delivering intensive and comprehensive therapy services in the community, targeting the
adolescent, the family, the school, and in some cases, the peer group
 Conduct problems influenced by multiple factors
 Incorporates behavioural, cognitive, family-systems and case management techniques
 Emphasizes individual family strengths
Prevention Programs
 Fast Track – designed to help children academically, socially, and behaviourally, focusing on areas
that are problematic in CD including peer-relationships, aggressive and disruptive behaviour, social
information processing, and parent-child relationships
o Treatment for 10 years, more intensive in years 1-5
o Benefits dwindled as children got older
III. Depression and Anxiety in Children and Adolescents
A) Depression
 Ages 7-17 show following same symptoms as adults:
o Depressed mood, inability to experience pleasure, fatigue, concentration problems, suicidal
ideation
 Show more guilt, lower rates of early-morning wakefulness, early-morning depression, loss of
appetite & weight loss
 Recurrent symptoms
 Occurs in 2-3% of school-aged children under age 13
 By adolescence, rate rises to from 6-16% for girls and 4-7% for boys (2x as common among
adolescent girls)
o Less gender differences in symptoms *no gender difference until adolescence
 Comorbid with anxiety
 Role of genetic factors (with depressed parent, have 4x risk of developing depression)
 Gene-environment interactions predict onset: short-allele of serotonin gene & interpersonal stress
 Interpersonal factors especially important in predicting depression in girls
 Early adversity predicts depression for ages 15-20 or rejection by parents
 Cortisol in people with depression is associated with small volume of hippocampus
 Cognitive distortions and negative attributional style (consistent with Beck’s theory and hopelessness
theory)
 Attributional style doesn’t appear to be stable until early adolescence *does not predict child
depression
 Treatment:
o Treatment for Adolescents with Depression Study (TADS) – efficacy of antidepressants
(Prozac)
 Combined treatment of Prozac with CBT most effective, more than either alone
 Similar relapse rates for all 3 treatment groups
o Side effects: nausea, diarrhea, sleep problems, agitation, suicidality concerns
o Girls more likely to relapse than boys, especially with comorbid anxiety (both genders)
o CBT in school setting is more effective than family/supportive therapy
o CBT most effective for Caucasian adolescents, those with good coping skills
 Prevention:
o Selective – target particular youth based on family risk factors, environmental factors, or
personal factors
 More effective

lOMoARcPSD|2532716
o Universal – targeted toward large groups, typically in schools, seek to provide education and
information about depression
B) Anxiety
 Common fears that get outgrown: fear of the dark, imaginary creatures, fear of being separated from
parents
 Reported more often in girls than boys
 In order to meet criteria, functioning must be impaired *don’t need to regard fear as
excessive/unreasonable
 3-5% prevalence in children/adolescents *specific phobias and social anxiety disorder are most
common
 Separation anxiety disorder:
o Characterized by constant worry that some harm will befall their parents or themselves when
they are away from their parents
o Often first observed when children begin school
o 1) Excessive anxiety that is not developmentally appropriate about being away from people
to whom one is attached, with at least 3 symptoms that last for at least 4 weeks
 Repeated & excessive distress when separated, excessive worry that something bad
will happen to an attachment figure, refusal/reluctance to go to
school/work/elsewhere, refusal/reluctance to sleep away from home, nightmares
about separation from attachment figure, repeated physical complaints when
separated from attachment figure
o Changes: moved into anxiety chapter, age of onset prior to 18 was removed **can be
diagnosed in an adult
 Social Anxiety Disorder: 1-7% prevalence, higher rates in adolescents *care more what others think
of them
 5% meet criteria for PTSD
o 4 categories of symptoms for children older than 6:
o 1) Intrusively re-experiencing the traumatic event (nightmares, flashbacks, intrusive
thoughts)
o 2) Avoiding trauma-related situations or information and experiencing a general numbing of
responses (detachment)
o 3) Negative changes in cognitions or mood related to traumatic event
o 4) Increased arousal and reactivity, which can include irritability, sleep problems and
hypervigilance
o Separate criteria for younger than 6 *presented in more developmentally appropriate ways
 OCD prevalence: from less than 1-4%, similar symptoms as in adulthood
o Common obsessions in children: dirt/contamination, aggression, Adolescence: sex, religion
o More common in boys as children, more common in women as adults
 Etiology:
o Heritability estimate of 29-50%
o Parenting practices parental control and overprotectiveness, more than parental rejection
o Social anxiety: over-estimate danger in many situations, under-estimate ability to cope
 Anxiety interferes with social interactions, avoid social situations
 Behavioural inhibition is an important risk factor
o PTSD:
 Requires exposure to trauma (experienced or witnessed)

lOMoARcPSD|2532716
 Risk factors: level of family stress, coping styles of family, past experiences with
trauma
 Treatment:
o Major treatment focus is exposure *modified for children by including more modeling and
more reinforcement
o CBT is effective: Coping Cat – focuses on confrontation of fears, development of new ways to
think about fears, exposure to feared situations and relapse prevention
 Effective short-term and long-term
o Family CBT more effective than individual CBT when both parents have anxiety disorder, and
both are more effective than psychoeducation
o Combination of CBT and medication (Sertraline *Zoloft) more effective than either alone
*results are more immediate
o Group therapy effective for social anxiety disorder
o For OCD, CBT more effective than medication, and combination *unless severe, then
combination is best
o Other methods: bibliotherapy and computer-assisted therapy
 Bibliotherapy – parents given written materials and are the therapist with their
children
 Reduces anxiety, but not as effective as CBT
IV. Autism Spectrum Disorder
 Not formally included in DSM until 3rd edition, rates have been rising
 4 categories from DSM-IV-TR are combined into autism spectrum disorder (ASD)
o 1) Autistic disorder, 2) Asperger’s disorder, 3) Pervasive developmental disorder not
otherwise specified, 4) Childhood disintegrative disorder
o All shared similar clinical features and etiologies, only varied in severity
o DSM-5 – different clinical specifiers relating to severity and extent of language impairment
Social and Emotional Disturbances
 Rarely approach others, look through/past people, turn their backs on others, few initiate play,
usually unresponsive when being approached
CHAPTER 14: Late Life and Neurocognitive Disorders

1. Aging: Issues and Methods
 Social problems of aging are especially severe for women (wrinkles, sagging skin) *signs of aging not
valued in women
 Old defined as over 65 – set by social policies
 Young old = 65-74, old-old = 75-84, oldest-old = 85+
 Number of elderly population is growing
Myths About Late Life
 Psychologists must examine stereotypes about late life
 Common myths:
 1) Aging involves inexorable cognitive decline
o Severe cognitive problems do not occur for most
o Mild declines are common (processing speed & working memory)
 2) Late life is a sad time and most elderly are depressed
o Older individuals report less negative emotion than younger people, more skilled at
regulating emotions
o More brain activation in key areas when viewing positive images

lOMoARcPSD|2532716
 3) Late life is a lonely time

o Focus shifts away from seeking new social interactions, interested in a few close relationships
= social selectivity
 4) Older people lose interest in sex
o Sexual activity does not decrease from mid-to-late-life for most people
 Underreport somatic symptoms, no more likely to meet criteria for somatic symptom disorders than
young people
 Negative self-views about aging can predict earlier death
The Problems Experienced in Late Life
 80% of elderly have at least one major medical condition
 Quality and depth of sleep decline, sleep apnea rates increase, sleep deficits can worsen
physical/psyc/cognitive problems
 Polypharmacy = the prescribing of multiple drugs to a person
 1/3 are prescribed at least 5 medications *increased risk of side effects, prescribed more drugs to
combat side-effects
 Most psychoactive drugs are tested on younger people *difficult to estimate appropriate does for
elderly
Research Methods in the Study of Aging
 Age effects = consequences of being a certain chronological age
 Cohort effects = the consequences of growing up during a particular time period with its unique
challenges and opportunities
 Time-of-measurement effects = confounds that arise because events at a particular point in time
can have a specific effect on a variable that is being studied (e.g. post-earthquake)
 Cross-sectional studies = the investigator compares different age groups at the same moment in
time on the variable of interest
o Do not examine the same people over time, they do not provide clear information about how
people change as they age
 Longitudinal studies = researcher periodically retests one group of people using the same measure
over a number of years or decades (e.g. Baltimore longitudinal study of aging)
o Results may be biased due to attrition = participants drop out of the study due to death =
selective mortality, or other problems
2. Psychological Disorders in Late Life
 Same criteria used for older and younger adults
 No psyc diagnosis if symptoms are accounted for by medical condition/side-effects
o Thyroid problems, Addison’s disease, Cushing’s disease, Parkinson’s, Alzheimer’s,
hypoglycemia, anemia, testosterone deficiencies, vitamin deficiencies produce symptoms
that mimic side effects of schizophrenia, depression, anxiety
Estimating the Prevalence of Psychological Disorders in Late Life
 Those over 65 have lowest prevalence of psyc disorders of all age groups *National Comorbidity
Survey-Replication (NCS-R)
 No one 65+ met criteria for drug abuse/dependency disorder *NCS-R Study
 Most who experience disorder in late life are experiencing a recurrence of a disorder that started in
earlier life
 Aging relates to more positive emotionality in close-knit social circles *could enhance mental health
as we age
Methodological Issues in Estimating the Prevalence of Psychopathology
 Discomfort discussing symptoms may minimize prevalence rates
 Cohort effects – adults during drug-oriented era of 1960s, many continued using

lOMoARcPSD|2532716
 People with psyc disorders are at risk for dying before age 65
o Heavy drinkers: die from cirrhosis between 55-64 years old
o Anxiety/mood: cardiovascular disease
o Worsened immune function overall
3. Neurocognitive Disorders in Late Life
 Most elderly do not have cognitive disorders
 Dementia = deterioration of cognitive abilities
 Delirium = a state of mental confusion
I. Dementia
 = Deterioration of cognitive abilities to the point that functioning becomes impaired
o Impaired social and occupational functioning
 Most common symptom: difficulty remembering things, especially recent events
 Lose control of impulses, use coarse language, tell inappropriate jokes, shoplift, make sexually
inappropriate remarks
 Difficulty dealing with abstract ideas, emotional disturbances common (depression, flatness of
affect, sporadic outbursts)
 Delusions and hallucinations can occur
 Language disturbances – vague patterns of speech
 Become withdrawn and apathetic
 Course may be progressive, static or remitting *mostly develops slowly, can detect subtle
cognitive/behavioural defects before
 Mild cognitive impairment = the early signs of decline noted before functional impairment is
present
 1) DSM mild neurocognitive disorders are similar to mild cognitive impairment
 2) DSM major neurocognitive disorders are similar to dementia
 Difference based on ability to live independently
 Not all people with mild cognitive impairment develop dementia (10% will), 1% of adults develop
dementia w/o MCI
Criteria for Mild Neurocognitive Disorder (Mild cognitive impairment)
 1) Modest cognitive decline from previous levels in one or more domains based on the following:
o Concerns of the patient, a close other or clinician
o Modest neurocognitive decline (between the 3rd and 16th percentile) on formal testing or
equivalent clinical evaluation
 2) The cognitive deficits do not interfere with independence in everyday activities (e.g. paying bills or
managing medications), even though greater effort, compensatory strategies, or accommodation
may be required to maintain independence
 3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to
another psychological disorder
Criteria for Major Neurocognitive Disorder (Dementia)
 1) Significant cognitive decline from previous levels in one or more domains based on both of the
following:
o Concerns of the patient, a close other, or clinician
o Substantial neurocognitive impairments (below the 3rd percentile on formal testing) or
 2) The cognitive deficits interfere with independence in the everyday activities

lOMoARcPSD|2532716
 0.4% prevalence of dementia in 2000

 Prevalence increases with age, 1-2% ages 60-69, increases to 20% in ages 85+
 Types:
o Alzheimer’s – most researched
o Frontotemporal dementia – affects frontal and temporal lobes
o Vascular dementia – caused by cerebrovascular disease
o Dementia with Lewy Bodies – presence of Lewy bodies
Alzheimer’s Disease
 Brain tissue irreversibly deteriorates, death usually occurs within 12 years
 6th leading cause of death in US
 Most common symptom is memory loss, may begin with absentmindedness and gaps in memory for
new material
 Interferes with daily living
 Apathy is a common symptom before cognitive symptoms are noticeable, 1/3 develop depression,
problems with language and word finding, visual-spatial abilities decline – disorientation = confusion
with respect to time, place or identity
 Unaware of own cognitive problems initially, become agitated
 Personality loses its sparkle/integrity “not him/herself anymore”
 Become oblivious to surroundings
 Plaques = small, round beta-amyloid protein deposits outside the neurons
o Mostly in frontal cortex, may be present 10-20 years before cognitive symptoms
o Measured using special PET scan
 Neurofibrillary tangles = twisted protein filaments composed largely of the protein tau in the axons
of neurons
o Measured in cerebrospinal fluid
o Most densely present in hippocampus
 Immune response to plaques leads to inflammation, triggers a series of brain changes
 Loss of acetylcholinergic (ACh) and gluateminergic neurons, neurons begin to die
 Entorhinal cortex and hippocampus shrink, followed by shrinking of frontal, temporal, and parietal
lobes
 Ventricles become enlarged
 Cerebellum, spinal cord and motor/sensory areas less affected *do not appear to have anything
physically wrong at first
 25% eventually experience motor deficits
 Heritability estimate of 79%, 21% due to environmental factors
 A set of 10 genes explains 20% of the risk for AD among white non-Hispanic samples
 Polymorphism of gene on chromosome 19 called apolipoprotein (ApoE-4 allele)
o Having 1 allele increases risk by 20%
o Interferes with clearing excess beta-amyloid from brain
o 2 alleles – overproduction of beta-amyloid plaques, loss of neurons in hippocampus and low
glucose metabolism BEFORE AD
 Immune process and high cholesterol can trigger inflammation, related to greater risk of AD (e.g.
type II diabetes)
 Brain trauma from accident/injury increases risk
 Lifestyle variables: smoking, being single, obesity, depression, low social support = higher risk
o Lower risk: Mediterranean diet, exercise, education, engagement in cognitive activities
 Exercise may predict fewer memory problems, less decline in cognitive function

lOMoARcPSD|2532716
o Low levels of plaques in brain

 Frequent cognitive activity related to 46% decrease in risk, protects against cognitive decline
 Cognitive reserve = the idea that some people may be able to compensate for the disease by using
alternative brain networks or cognitive strategies such that cognitive symptoms are less pronounced
 Depression can be a consequence of dementia, opposite effect occurs as well
Frontotemporal Dementia
 = Caused be a loss of neurons in the frontal and temporal regions of the brain (anterior temporal and
prefrontal)
 Begins in mid-to-late 50s, progresses rapidly, death occurs in 5-10 years, less than 1% prevalence
 Memory is not severely impaired
 There are multiple subtypes, most common = behavioural variant FTD
o Deterioration in at least 3 areas at a level that leads to functional impairment:
 Empathy, executive function, ability to inhibit behaviour, compulsive/perseverative
behaviour, hyperorality (= tendencies to put nonfood objects in the mouth) and
apathy
 Changes in personality and judgment, emotional regulation
 Often misdiagnosed as a midlife crisis (begin chain smoking, over eating, drinking alcohol) or
depression/bipolar/schizophrenia
 Affects emotion more than AD, damages social relationships, inability to properly express emotions
 May violate social conventions
 Affects marital satisfaction more than AD
 Caused by different molecular processes: Pick’s disease = presence of Pick bodies within neurons
 Some have high levels of tau = protein filaments that contribute to neurofibrillary tangles
 Strong genetic component
Vascular Dementia
 = Caused by cerebrovascular disease
 Stroke causes blood clot, impairs circulation, results in death of neurons
 7% develop dementia in year after stroke, risk increases with recurrent strokes
 Similar risks as for cardiovascular disease: high levels of bad cholesterol (LDL), smoking, elevated
blood pressure
 More common in African American than Caucasian
 Symptoms vary depending on where stroke occurred
 Onset usually more rapid, can co-occur with AD
Dementia with Lewy Bodies (DLB)
 = Protein deposits (Lewy bodies) form in the brain and cause cognitive decline
 2 subtypes depending on whether it occurs in context of Parkinson’s
 80% with PD develop DLB
 Hard to distinguish symptoms from PD (shuffling gait) and AD (loss of memory)
 More likely than AD to include visual hallucinations and fluctuating cognitive symptoms
 Extremely sensitive to physical side effects of antipsychotic medications
 Experience intense dreams with levels of movement/vocalizing (acting out dreams)
Dementias Caused by Disease and Injury
 Encephalitis – inflammation of brain tissue caused by viruses that enter the brain
 Meningitis – inflammation of membranes covering the outer brain, caused by bacterial infection
 Organism that produces syphilis can invade brain and cause dementia
 HIV, head trauma, brain tumor, nutritional deficiencies (B-complex vitamin), kidney/liver failure,
endocrine problems (hyperthyroidism), exposure to toxins (mercury/lead)
Treatments

lOMoARcPSD|2532716
 No cure, some medications used to treat symptoms

Medications
 No medications address cognitive symptoms of FTD
 Most treatment research focused on AD and memory decline, medications can slow the decline but
cannot restore memory
 Cholinesterase inhibitors used – interfere with breakdown of ACh *donepezil and rivastigmine
o Vitamin E, statins, nonsteroidal anti-inflammatory drugs
o Slow memory decline compared to placebo
 Memantine – drug that affects glutamate receptors involved in memory
 Preventative work focuses on processes involved in the creation of amyloid from its precursor
protein
 Aversive side effects – nausea
 Use medical treatments to address psyc symptoms: depression, agitation that co-occur
 Depression produces more cognitive impairment in elderly than younger patients
 Antipsychotics can relieve agitation, increase risk of death
 Cognitive deficits continued/worsened after destroying the plaques
 Focus mostly on prevention
Psychological/Lifestyle Treatments
 Supportive psychotherapy to help patients and family deal with effects of disease
o Discuss illness, learn about it, learn how to care for family member, encourages realistic
attitude in dealing with specific challenges
 Increase exercise to improve cognitive function
 Cognitive training programs – focus on improving memory, reasoning, cognitive processing speed
o Try to teach meta-cognitive skills (thinking about thinking, strategies for enhancing memory)
o Training in multi-tasking helps memory as well
 Behavioural approaches to compensate for memory loss & reduce depression/disruptive behaviour
of early AD
o External memory aids (shopping lists, calendars, labels)
o Pleasant/encouraging activities to decrease depression
o Identify triggers for disruptive behaviour and decrease them
o Music can help reduce agitation
II. Delirium
 1) Disturbances in attention and awareness
 2) A change in cognition, such as disturbance in orientation, language, memory, perception, or
visuospatial ability, not better accounted for by a dementia
 3) Rapid onset (hours/days) and fluctuation during the course of a day
 4) Symptoms are caused by a medical condition, substance intoxication or withdrawal, or toxin
 “Out of track”, deviating from usual state, clouded state of consciousness
 Two most common symptoms: extreme trouble focusing attention, profound disturbances in
sleep/wake cycle
 Cannot maintain coherent stream of thought, trouble answering questions
 Become drowsy during the day, awake/agitated at night
 Vivid dreams and nightmares
 Speech is rambling and incoherent
 Lose track of what day it is, where they are, who they are
 Memory impairment for recent events is common

lOMoARcPSD|2532716
 Perceptual disturbances are frequent, mistake unfamiliar for familiar, visual hallucinations, delusions
in 25% of older adults (poorly worked out, fleeting and changeable)
 Mood/activity swings, disordered thoughts, erratic, shift between emotions
 Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, incontinence
of urine and feces
 Become lethargic/unresponsive
 Have lucid intervals – alter and coherent *daily fluctuations help distinguish from AD
 Symptoms worsen during sleepless nights
 More common among young children and older adults (nursing homes and hospitals)
 6-12% nursing home residents developed delirium in 1 year
 Often misdiagnosed, especially if lethargy is present or if person has dementia
 High mortality rate if left untreated, 1/3 die within a year
 Increased risk for further cognitive decline
Etiology
 Caused by medical conditions: drug intoxications, withdrawal reactions, metabolic and nutritional
imbalances (diabetes, thyroid dysfunction, kidney/liver failure, congestive heart failure,
malnutrition), dehydration, infections, fevers, neurological disorders, stress of major injury
 One of most common triggers is hip surgery
 Usually has more than one cause
 Physical declines of late life, increased susceptibility to chronic diseases, many medication
prescribed, greater sensitivity to drugs = increased vulnerability for elderly
Treatment
 Recovery if underlying cause is treated promptly
 Atypical antipsychotic medication
 Treatment takes 1-4 weeks for condition to clear, longer in older people
 Preventative strategies:
o Clocks of hospital patients in field of vision, helps stay oriented
o Shades open during the day, lights turned off at night
o Minimal sleep disruptions
o Stress-free, hydration
 Risk factors: sleep deprivation, immobility, dehydration, visual/hearing impairment
 High risk of delirium among those with dementia
CHAPTER 15: Personality Disorders

 Defined by enduring problems with forming a stably positive identity and with sustaining close and
constructive relationships
 Extreme and inflexible traits, 10 different disorders, highly heterogeneous
o Paranoid – chronic tendencies to be mistrustful and suspicious
o Antisocial – patterns of irresponsibility and callous disregard for rights of others
o Dependent – overreliance on others
 Persistent, pervasive and maladaptive ways in which the traits are expressed
 Unstable, positive sense of self
1. The DSM-5 Approach to Classification
 10 different personality disorders, in 3 clusters:
 A) Odd/eccentric  paranoid, schizoid, schizotypal, B) Dramatic/erratic  antisocial, borderline, C)
Anxious/fearful  avoidant, dependent, obsessive-compulsive
 1/10 meet diagnostic criteria

lOMoARcPSD|2532716
 More common among those with a psychological disorder (MDD, anxiety)

 People with PD 7x more likely to have anxiety/mood disorder, and 4x as likely to have a substance
disorder *especially cluster B
 More severe, poorer social functioning and worse treatment outcome when comorbid PDs are
present
o Doubles the risk of depression
Assessment of DSM-5 Personality Disorders
 List of criteria and structured interviews for each PD *most clinicians do not used the structured
interviews
 Low Interrater reliability for schizoid PD
 Low agreement rates in diagnoses and often miss diagnoses
 Interviews with people who know the patient will improve the accuracy of diagnosis *rarely occurs
Problems with the DSM-5 Approach to Personality Disorders
 PDs are Not Stable over Time:
o Half patients diagnosed with a PD at one point in time achieved remission after 2 years
o 99% remitted 16 years later
o Symptoms most common during adolescence *PDs may not be as enduring, decline in 20s
and late life
o Many people still have some symptoms after remission
o After remission many problems in functioning still persist
o Risk of relapse still remains high, years after remission *symptoms wax and wane over time
 Personality Disorders are Highly Comorbid:
o More than 50% with PD meet diagnosis for another PD
o DSM system may not be ideal for classifying PDs, lack of test-retest stability and high
comorbidity
 Some PDs are extremely rare (< 2%)
 People with PD can vary a good deal from one another in the nature of their personality traits &
severity of condition
2. Alternative DSM-5 Model for Personality Disorders
 Recommend reducing the number of PDs, incorporating personality trait dimensions, and diagnosing
PDs on the basis of extreme scores on personality trait dimensions ***Found in appendix of DSM-5
 Includes only 6 of the 10 PDs: schizoid, histrionic, dependent were excluded because they are rare,
paranoid was excluded because it overlaps with other PDs
 Diagnosis based on personality traits
 5 personality trait domains and 25 more specific personality trait facets, rated using self-report
*related to 5-factor model
 Diagnosed is person shows persistent and pervasive impairments in self and interpersonal aspects of
functioning from early adulthood
 Provides richer detail for diagnosis, individuals diagnosed with same PD can vary lots in personality
traits from another
 Personality trait ratings tend to be stable over time, more than PD diagnoses
 Personality trait dimensions are related to many aspects of psychological adjustment
 Captures subsyndromal symptoms better
3. Common Risk Factors Across the Personality Disorders
 Psychoanalytic and behavioural theory placed emphasis on parenting and early developmental
influences
 Recent evidence of strong biological component

lOMoARcPSD|2532716
 Children in the Community Study:

o Assessed links between childhood adversity and PDs
o Assessed 2 aspects of parenting style: aversive parental behaviour and lack of parental
affection
o Kept track of child maltreatment, assessed with clinical interview for diagnosing PDs
o Findings suggested that PDs were strongly related to early adversity
o Parenting style also predicted certain PDs
 Norwegian Birth Registry – sample of twins:
o High heritability estimates for all PDs (.55-.77)
4. Clinical Description and Etiology of the Odd/Eccentric Cluster
 Similar bizarre thinking/experiences seen in schizophrenia *less severe
I. Paranoid PD
 Presence of 4+ of the following signs of distrust and suspiciousness from early adulthood across
many contexts:
o 1) Unjustified suspiciousness of being harmed, deceived, or exploited
o 2) Unwarranted doubts about the loyalty or trustworthiness of friends or associates
o 3) Reluctance to confide in others because of suspiciousness
o 4) Tendency to read hidden meanings into the benign actions of others
o 5) Bears grudges for perceived wrongs
o 6) Angry reactions to perceived attacks on character or reputation
o 7) Unwarranted suspiciousness of the partner’s fidelity
 Expect to be mistreated/exploited, are very secretive and continually on the lookout for signs of
trickery/abuse
 Hostile and angry in response to perceived insults, seen as difficult and critical
 Other symptoms of schizophrenia are not present (hallucinations), less impairment in
social/occupational functioning, no cognitive disorganization
 Full-blown delusions are not present
 Co-occurs most often with schizotypal, borderline and avoidant PD
II. Schizoid PD
 Presence of 4+ of the following signs of aloofness and flat affect from early adulthood across many
contexts:
o 1) Lack of desire for or enjoyment of close relationships
o 2) Almost always prefers solitude to companionship
o 3) Little interest in sex
o 4) Few or no pleasurable activities
o 5) Lack of friends
o 6) Indifference to praise or criticism
o 7) Flat affect, emotional detachment, or coldness
 Appear dull, bland, aloof, no warm feelings for others
 Rarely experience strong emotions
III. Schizotypal PD
 Presence of 5+ of the following signs of unusual thinking, eccentric behaviour, and interpersonal
deficits from early adulthood across many contexts:
o 1) Ideas of reference
o 2) Odd beliefs or magical thinking e.g. beliefs in extrasensory perception
o 3) Unusual perceptions
o 4) Odd thought and speech

lOMoARcPSD|2532716
o 5) Suspiciousness or paranoia
o 6) Inappropriate or restricted affect
o 7) Odd or eccentric behaviour or appearance
o 8) Lack of close friends
o 9) Social anxiety and interpersonal fears that do not diminish with familiarity
 Recurrent illusions (inaccurate sensory perceptions), flat/constricted affect, aloof from others
 Most do not develop delusions or schizophrenia (some do)
 Similar genetic vulnerability as for schizophrenia – enlarged ventricles, less temporal grey matter
(also cognitive and neuropsychological deficits)
 60% heritable
5. Clinical Description and Etiology of the Dramatic/Erratic Cluster
 Highly inconsistent behaviour, inflated self-esteem, rule breaking behaviour, exaggerated emotional
displays
 Most well-known
IV. Antisocial PD (APD) and Psychopathy
 1) Age at least 18
 2) Evidence of conduct disorder before age 15
 3) Pervasive pattern of disregard for the rights of others since the age of 15 as sown by at least 3 of
the following:
o Repeated law breaking, deceitfulness/lying, impulsivity, irritability/aggressiveness, reckless
disregard for own safety & that of others, irresponsibility as seen in unreliable
employment/financial history, lack of remorse
 Used interchangeably with psychopathy by public *antisocial behaviour is important for both, but
they differ in important ways
 Psychopathy is not included in DSM-5
 Antisocial PD:
o Core feature: pervasive pattern of disregard for the rights of others
o Presence of conduct disorder, little regard for truth, lack of remorse for misdeeds
o Men are 5x more likely to meet criteria, ¾ meet criteria for another disorder *substance
abuse is common
o ¾ convicted felons meet criteria
o Poverty of emotion:
 Negative – lack of shame/remorse/anxiety, doesn’t learn from mistakes
 Positive – merely an act to manipulate others, superficially charming
 Psychopathy:
o Predates APD diagnostic criteria
o “Mask of Sanity” – Hervey Cleckley
o Criteria focuses on person’s thoughts and feelings *poverty of emotions (positive and
negative)
o No sense of shame, positive feelings for others is an act
o Superficially charming
o Impossible to learn from mistakes due to lack of anxiety
o Impulsive rule-breaking behaviour
o Boldness, meanness, and impulsivity
o Assessed using Psychopathy Checklist-Revised (PCL-R)
o Symptoms do not need to show before age 15 *will not obtain high scores on PCL-R if have
APD

lOMoARcPSD|2532716
Etiology
 Most research done on those convicted as criminals, use different measures (APD vs. psychopathy)
 Interactions of Genes and the Social Environment:
o Role of social environment is key in APD: parenting qualities of negativity, inconsistency and
low in warmth
o Poverty and exposure to violence also predict antisocial behaviour
o Those with CD, if impoverished, 2x more likely to develop APD
o Polymorphism of MAO-A gene predicts psychopathy in males who had experienced
childhood abuse or maternal rejection
o Anti-social behaviour is 40-50% heritable
 Psychological Risk: Insensitivity to Threat and to Others’ Emotions:
o Psychopaths are unable to learn from experience, immune to anxiety that keeps us from
breaking the law/lying
o Deficits in experience of fear and threat, lower than normal levels of skin conductance
o Deficits in developing conditioned fear responses *no increased amygdala activity for CS
o Even more unresponsive to threat when trying to obtain a reward
o Inattentiveness to threats when pursing a goal – deficits in regions of prefrontal cortex
involve in attending to negative information during goal pursuit
o Lack of empathy – especially difficult to recognize fear in others
V. Borderline PD (BPD)
 Presence of 5+ of the following signs of instability in relationships, self-image, and impulsivity from
early adulthood across many contexts:
o 1) Frantic efforts to avoid abandonment
o 2) Unstable interpersonal relationships in which others are either idealized or devalued
o 3) Unstable sense of self
o 4) Self-damaging, impulsive behaviours in at least two areas, such as spending, sex, substance
abuse, reckless driving, and binge eating
o 5) Recurrent suicidal behaviour, gestures or self-injurious behaviour
o 6) Marked mood reactivity
o 7) Chronic feelings of emptiness
o 8) Recurrent bouts of intense or poorly controlled anger
o 9) Curing stress, a tendency to experience transient paranoid thoughts and dissociative
symptoms
 Very common in clinical settings, very hard to treat, associated with recurrent periods of suicidality
 Core features: impulsivity and instability in relationships and mood, emotional reactivity
 Emotions are intense, erratic, shift abruptly *passionate idealization to contemptuous anger
 Overly sensitive to small signs of emotions in others
 No clear/coherent sense of self
 Cannot bear to be alone (fear of abandonment), chronic depression and emptiness
 Psychotic and dissociative symptoms when stressed
 2/3 engage in self-mutilation
 Likely to have comorbid PTSD, mood disorders, substance related disorders, eating disorders = more
likely to last longer
Etiology
o Highly heritable (60%)
o Lower serotonin function – general dysregulation

lOMoARcPSD|2532716
o Increased activation of amygdala to emotional pictures – emotion dysregulation

o Deficits in prefrontal cortex – impulsivity
o Disrupted connectivity between prefrontal cortex and amygdala
 Social Factors: Childhood Abuse in the Context of Genetic Vulnerability:
o Parental separation, verbal & emotional abuse during childhood
o Tied to high rates of childhood abuse/neglect and high heritability
o Childhood abuse doesn’t predict BPD after genetic risk is controlled
o Childhood trauma accounts for less than 1% in variance
o Genetically driven impulsivity, emotionality and risk-seeking in parents could increase risk of
abusing children
 Linehan’s Diathesis-Stress Theory:
o BPD develops when people who have difficulty controlling their emotions because of a
biological diathesis are raised in a family environment that is invalidating
o Emotional regulation diathesis interactions with experiences of invalidation = BPD
development
 Biological diathesis: Emotional dysregulation in the child  great demands on the
family  invalidation by parents through punishing/ignoring  emotional outbursts
by child to which parents attend  emotional dysregulation of child
VI. Histrionic Personality Disorder (HPD)
 Presence of 5+ of the following signs of excessive emotionality and attention seeking from early
adulthood across many contexts:
o 1) Strong need to be the centre of attention
o 2) Inappropriate sexually seductive behaviour
o 3) Rapidly shifting and shallow expression of emotions
o 4) Use of physical appearance to draw attention to self
o 5) Speech that is excessively impressionistic and lacking in detail
o 6) Exaggerated, theatrical emotional expression
o 7) Overly suggestible
o 8) Misreads relationships are more intimate than they are
 Key feature: overly dramatic and attention-seeking behaviour
 Use physical appearance to draw attention to themselves
 Emotionally shallow, overly concerned with physical attractiveness, uncomfortable when not the
centre of attention
 Easily influenced by others
VII. Narcissistic Personality Disorder
 Presence of 5+ of the following signs of grandiosity, need for admiration, and lack of empathy from
o 1) Grandiose view of one’s importance
o 2) Preoccupation with one’s success, brilliance, beauty
o 3) Belief that one is special and can be understood only by other high-status people
o 4) Extreme need for admiration
o 5) Strong sense of entitlement
o 6) Tendency to exploit others
o 7) Lack of empathy
o 8) Envious of others
o 9) Arrogant behaviour or attitudes
 Interpersonal relationships disturbed by lack of empathy, arrogance and envy, self-centeredness

lOMoARcPSD|2532716
 Overly reactive to criticism

 Seeks out higher-status partner
Etiology
 Parenting:
o Parents who are overly indulgent foster children’s belief that they are special and behavioural
expressions of their specialness will be tolerated by others
 Self-Psychology:
o Variant of psychodynamic theory (Heinz Kohut)
o Characteristics mask low SE (parent & patient)
o In childhood, narcissist valued as a means to increase parent’s own SE
 Not valued for his/her own self-worth and competencies
o Parental emotional coldness & overemphasis on child’s achievement reported by narcissist
o Person with NPD projects self-importance, self-absorption, and fantasies of limitless success
o Fragile self-esteem
 Social-Cognitive Model:
o 1) People with NPD have fragile self-esteem, in part because they are trying to maintain the
belief that they are special
o 2) Interpersonal interactions are important to them for bolstering SE rather than for gaining
closeness or warmth
o Overestimate attractiveness to others and contributions in group activities
o Attribute success to abilities rather than to chance/luck ***cognitive biases
o Show more reactivity when falsely told they have done poorly on an IQ test (also when told
they have succeeded)
o Primary goal in interactions is to bolster their own self-esteem brag a lot, denigrate others
who perform better
6. Clinical Description and Etiology of the Anxious/Fearful Cluster
 Prone to worry and distress
IIX. Avoidant Personality Disorder
 A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as
shown by 4+ of the following from early adulthood across many contexts:
o 1) Avoidance of occupational activities that involve significant interpersonal contact, because
of fears of criticism or disapproval
o 2) Unwilling to get involved with people unless certain of being liked
o 3) Restrained in intimate relationships because of the fear of being shamed or ridiculed
o 4) Preoccupation with being criticized or rejected
o 5) Inhibited in new interpersonal situations because of feelings of inadequacy
o 6) Views self as socially inept, unappealing or inferior
o 7) Unusually reluctant to try new activities (taking risks) because they may prove
embarrassing
 Often co-occurs with social anxiety disorder – similar diagnostic criteria and genetic vulnerability
overlaps *maybe a more chronic variant of social anxiety disorder
 80% have comorbid major depression, alcohol abuse is also common
IX. Dependent Personality Disorder
 An excessive need to be taken care of, as shown by the presence of at least 5 of the following from
o 1) Difficulty making decisions without excessive advice and reassurance from others
o 2) Need for others to take responsibility for most major areas of life

lOMoARcPSD|2532716
o 3) Difficulty disagreeing with others for fear of losing their support

o 4) Difficulty doing things on own or starting projects because of lack of self-confidence
o 5) Doing unpleasant things as a way to obtain the approval and support of others
o 6) Feelings of helplessness when alone because of fears of being unable to care for self
o 7) Urgently seeking new relationships when one ends
o 8) Preoccupation with fears of having to take care of oneself
 See themselves as weak, fear being alone
 Very passive
 Can do what is necessary to maintain a close relationship
 Men with higher levels of dependency are at elevated risk of perpetrating domestic violence
 Likely to develop depression after interpersonal losses, show high suicidality when depressed
 Elevated risk of developing anxiety disorders and bulimia
 Overprotective parents may reinforce children for dependency
 Authoritarian discipline may limit opportunities for children to develop feelings of self-efficacy
X. Obsessive-Compulsive Personality Disorder
 Intense need for order, perfection, and control as shown by the presence of at least 4 of the
following from early adulthood across many contexts:
o 1) Preoccupation with rules, details, and organization to the extent that the point of an
activity is lost
o 2) Extreme perfectionism interferes with task completion
o 3) Excessive devotion to work to the exclusion of leisure and friendships
o 4) Inflexibility about morals and values
o 5) Difficulty discarding worthless items
o 6) Reluctance to delegate unless others conform to one’s standards
o 7) Miserliness
o 8) Rigidity and stubbornness
 More oriented towards work than pleasure *causes social relationships to suffer, little time for
leisure, family, friends
 Difficulty making decisions and allocating time
 Serious, rigid, formal, and inflexible
 Does not include obsessions and compulsions of OCD, often co-occurs with OCD, some overlapping
genetic variability
7. Treatment of Personality Disorders
 Many enter treatment for condition other than PD (e.g. substance abuse, anxiety, depression)
General Approaches to the Treatment of PDs
 Psychotherapy is the treatment of choice – small but positive effects, often supplemented with
medication
 Weekly sessions, or day-treatment programs (several hours/day), occupational therapy provided
 Psychodynamic theory – childhood problems are at the root of PDs, help patient reconsider those
early experiences, become more aware of how they drive current behaviour and reconsider
beliefs/responses to early events
 Cognitive theory – negative cognitive beliefs are at the heart of PDs, help person become aware of
those beliefs and challenge maladaptive cognitions
o Explore biases in thinking
o Look for dysfunctional schemas/assumptions the underline person’s thoughts/feelings
 Cannot change underlying traits of PD, but can change disorder into a style or more adaptive way of
approaching life

lOMoARcPSD|2532716
Treatment of Schizotypal Disorder and Avoidant Personality Disorder

 Antipsychotic drugs (risperidone) for schizotypal, reduces unusual thinking
 Avoidant PD responds to same treatments as social anxiety disorder – antidepressant medications
and cognitive behavioural treatment
o Help person challenge negative beliefs about social interactions, teach behavioural strategies
for dealing with social situations, exposure treatment
 Psychopathy – psychotherapy, either CBT or psychodynamic
Treatment of Borderline Personality Disorder
 ***Difficult to treat
 Show interpersonal problems in therapeutic relationship
 Client finds it difficult to trust others, idealize and vilify the therapist
 Difficult to tell if call at 2:00 from patient is call for help or a manipulative gesture to test the
therapist
 Medications – anti-depressants, mood stabilizers
 Hospitalization is often necessary to protect against suicide
 Many therapist consult with others due to high stress of treatment
 Metallization based therapy – fail to think about their own and other’s feelings
 Schema-focused cognitive therapy – identify maladaptive assumptions that underlie cognitions
 Dialectical behaviour therapy – combines client-centered empathy and acceptance with cognitive
behavioural problem solving, emotion-regulation techniques and social skills training
o Constant tension between any phenomenon and its opposite is resolved by creating a new
phenomenon (the synthesis) *term dialectical used on 2 main ways:
 1) Seemingly opposite strategies that the therapist must use when treating BPD –
accepting them as they are and yet helping them change
 2) The patient’s realization that splitting the world into good and bad is not necessary;
instead one can achieve a synthesis of these apparent opposites
o 4 stages:
 1) Dangerously impulsive behaviours are addressed with the goal of promoting
greater control
 2) Learning to modulate the extreme emotionality – learn to tolerate emotional
distress
 3) Improving relationships and self-esteem
 4) Designed to promote connectedness and happiness
 Learn more effective and socially acceptable ways to handle day-to-day problems
CHAPTER 16: Legal and Ethical Issues

 Bill of rights: first 10 amendments to the constitution
 Maximize degree of liberty consistent with preserving order in the community at large
 Criminal commitment = a procedure that confines a person in a mental or forensic hospital either
for determination of competency to stand trial or after acquittal by reason of insanity
o For someone with a psychological disorder who has broken the law/alleged to have done so
 Civil commitment = a set of procedures by which a person who is deemed mentally ill and
dangerous but has not broken a law can be deprived of liberty and placed in a hospital
1. Criminal Commitment
 Insanity = a disordered mind *may be regarded as unable to formulate and carry out a criminal
purpose
o Cannot be a guilty mind

lOMoARcPSD|2532716
o Defined in court proceedings

The Insanity Defense
 Insanity defense = the legal argument that a defendant should not be held responsible for an illegal
act if it is attributable to a psychological disorder or intellectual disability that interferes with
rationality or that results form some other excusing circumstance, such as not knowing right from
wrong
 Pleaded in less than 1% of all cases that reach trial
 Rarely successful when pleaded, only 7% success rate
 Based on accused’s mental condition at the time crime was committed
 Insanity defense has been around since the 7th century BCE
Landmark Cases and Laws
 Irresistible Impulse:
o = If a pathological impulse or uncontrollable drive compelled the person to commit the
criminal act, an insanity defense is legitimate
o Test was confirmed in 2 court cases: Parsons v. State and Davis v. United States
 The M’Naghten Rule:
o Formulated in the aftermath of a murder trial in England, defendant has set out to kill the
Prime Minister, but had mistaken his secretary for the PM, claimed he had been instructed to
kill the PM by the voice of God
o To establish defense of insanity, must be proved that at time of crime, accused party was
under a defect of reasoning (disease of mind), and did not know nature/quality of act he was
doing
 If he had known what he was doing, he didn’t know it was wrong
 The Durham Test:
o Durham v. United States
o A person is not responsible for a crime if it was “the product of mental disease or mental
defect”
o Definition of mental disease/defect open to jurisdictions and mental health professionals to
decide
o Only used by New Hampshire
 American Law Institute Guidelines:
o ALI proposed its own guidelines, intended to be more specific and informative
o Aka “Moral penal code”
 1) A person is not responsible for criminal conduct if at the time of such conduct as a
result of mental disease or defect he lacks substantial capacity either to appreciate
the criminality of his conduct or conform his conduct to the requirements of law
 2) The terms “mental disease/defect” do not include an abnormality manifested only
by repeated criminal or otherwise antisocial conduct
o First guideline combines M’Naghten rule and irresistible impulse
 Insanity Defense Reform Act:
o John Hinckley Jr. found not guilty by reason of insanity (NGRI) for assassination attempt
against President Ronald Reagan
o Many committed to mental hospital stay there longer than would have stayed in prison
o As a consequence of political pressures to get tough on criminal, congress enacted the
Insanity Defense Reform Act
 Addressed insanity defense at federal level for the first time
 1) Eliminates irresistible-impulse component of the ALI rules

lOMoARcPSD|2532716
 2) Changes the ALI’s “lacks substantial capacity…to appreciate” to “unable to

appreciate” *tightens the grounds for an insanity defense, making criteria for
impairment judgment more stringent
 3) Stipulates that mental disease/defect must be severe
 No longer can use defense “diminished capacity” or “diminished
responsibility” based on mitigating circumstances as extreme passion or
temporary insanity
 4) Shifts the burden of proof from prosecution to defense *defense must prove the
defendant insane, with clear and convincing evidence
 5) Person may remain committed longer than the ordinary sentence, released only
when deemed by professionals to be no longer dangerous and no longer mentally ill
 Current Insanity Pleas:
o Not guilty by reason of insanity (NGRI) = there is no dispute over whether the person
actually committed the crime – both sides agree that the person committed the crime
 Due to the person’s insanity at the time, the defense argues that the person should
not be held responsible for and thus should be acquitted of the crime
 Successful: person not held responsible due to psychological disorder
 Committed indefinitely to forensic hospital, released only when deemed no longer
dangerous and no longer mentally ill
 Forensic hospital perimeter is secure with gates, barbed wires, or electric fences,
doors to different units may be locked, bars may be placed on windows, security
doesn’t carry weapons or wear uniforms
 Someone found NGRI could not remain committed if no longer mentally ill, even if still
considered dangerous
o Guilty but mentally ill (GBMI) = allows an accused person to be found legally guilty of a crime
– thus maximizing the chances of incarceration – but also allows for psychiatric judgment on
how to deal with the convicted person if he/she is considered to have been mentally ill at
time of crime
 Usually put in general prison population, may or may not receive treatment
 May be committed to mental hospital if still considered dangerous/mentally ill after
sentence is over
 E.g. Jeffery Dahmer – accused of and admitted to butchering, cannibalizing and having
sex with the corpses of 15 boys and young men, entered plea of guilty, attorneys
argued disorder should be considered during sentencing
 Critics argue that it doesn’t benefit criminals with psychological disorders, and doesn’t
result in appropriate treatment
 Some believe GMBI is not as tough as a guilty verdict, but people receiving GBMI
verdict often spend more time incarcerated
 Standards of Proof (table 16.2)
o Beyond a reasonable doubt – 95% certainty needed to convict
o Clear and convincing evidence – 75%
o Beyond a preponderance of the evidence – 51%
Competency to Stand Trial
 Insanity defense concerns accused’s mental state at the time of the crime
 Competency to stand trial = whether the defendant has sufficient present ability to consult with his
lawyer with a reasonable degree of rational understanding, and whether he has a rational as well as
a factual understanding of the proceedings against him

lOMoARcPSD|2532716
 Must be decided before it can be determined whether a person is responsible for the crime which
he/she is accused
 Pate v. Robinson – the defense attorney, prosecutor, or judge may raise the question of the
psychological disorder whenever there is reason to believe that the accused person’s mental
condition might interfere with his/her upcoming trial
 In absentia “not present” = a centuries old principle of English common law that refers to the
person’s mental state, not his/her physical presence
o Trial can be delayed, accused person placed in hospital with hopes of restoring adequate
mental function
 Being deemed mentally ill doesn’t necessarily mean cannot stand trial
 Being judged incompetent to stand trial has consequences for individual:
o Bail is automatically denied, person usually kept in hospital for pretrial examination
(supposed to receive treatment to become competent to stand trial), person may lose
employment, undergo trauma from being separated from family/friends/familiar
surroundings
 Jackson v. Yates – deaf and mute man with intellectual disability, deemed unlikely to ever be
competent to stand trial
o If deemed not ever competent, state must either institute civil commitment or release the
defendant
o Cannot be committed to process of determining competency that exceeds longest possible
sentence
o Most people deemed competent in about 6 months
 Can proceed in trial with “synthetic sanity” due to medication
 Cannot forced defendant to take medication, until 2003***new ruling, can be used only if
alternative treatments had failed
 Medications are often the most effective means of restoring competency
Insanity, Intellectual Disability, and Capital Punishment
 Should someone who is sentenced to death have to be legally sane at the time of the execution?
 Daryl Atkins – intellectual disability and capital punishment – lacked understanding of consequences
of actions, not morally culpable for acts as a person of normal intelligence *capital punishment
would be unconstitutional
o Ruled that capital punishment of those with intellectual disability constitutes cruel and
unusual punishment (8th amendment prohibits)
o State of Virginia defined intellectual disability as IQ of 70 or less along with difficulties in self-
care and social interaction ***varies from state-to-state
 Supreme Court 2014 – intellectual disability cannot be determined solely on the basis of IQ score,
must also include assessments of adaptive functioning over the lifetime
2. Civil Commitment
 Governments have a duty to protect their citizens from harm
 Right and obligation to protect us both from ourselves, parens patriae, “power of the state” & from
others, the police power of the state
 A person can be committed to a hospital against his/her will if judgment is made that he/she is:
o 1) Mentally ill and, 2) A danger to self (suicidal or unable to provide for basic physical needs)
or to others
o Dangerousness to others is more often the principle criterion in court rulings
 Civil commitment is supposed to last only as long as the person remains dangerous
 Formal and informal commitment procedures:

lOMoARcPSD|2532716
o Formal (judicial) commitment is by order of a court, can be requested by any responsible

citizen
 Judge will order mental health examination if believes there is a good reason to
 Person has the right to object the these attempts, court hearing scheduled to allow
person to present evidence against commitment
o Informal (emergency) commitment can be accomplished without involving the courts initially
 If hospital board believes a person requesting discharge is too mentally ill and
dangerous, can detain the person with a temporary, informal commitment order
 Police can take any person acting out-of-control or in a dangerous manner to a
psychiatric hospital
 Most common is the Physician’s Certificate (PC) – physician can sign a certificate that
allows a person to be hospitalized for some period between 24 hours to 20 days
 Affects more people than criminal commitment
Preventative Detention and Problems in the Prediction of Dangerousness
 Not the case that people with psychological disorders account for a significant proportion of the
violence that besets society
 3% of US violence is linked to psychological disorders
 Over 90% diagnosed with psychotic disorders (mostly schizophrenia) are not violent
 MacArthur Violence Risk Assessment Study – large prospective study of violent behaviour in persons
recently discharged from psychiatric hospitals
o People with psyc disorders who did not also abuse substances were no more likely to engage
in violence that are people without psyc disorders and substance abuse
o When people with psyc disorders do act aggressively, usually against family/friends, and at
home
o People with psyc disorders report more violent thoughts in hospital
o People with psyc disorder more likely to be aggressive if have positive or disorganization
symptoms of schizophrenia or also abusing drugs
o Issues of substance abuse rather than psychotic disorders are the main contributory factors
to violence
 The Prediction of Dangerousness:
o Mental health professionals are poor at making a judgment of whether or not a person will
commit a dangerous act
o Historical-Clinical-Risk Management-20 (HCR-20) – identifies and measures violence risk
factors based on clinical judgment
o Most accurate under the following conditions:
 1) If a person has been repeatedly violent in the recent past, it is reasonable to
predict that he/she will be violent in future unless there are major changes in person’s
attitude/environment
 2) If violence is in the person’s distant past, and if it was a single and very serious act,
and if that person has been incarcerated for a period, violence can be expected on
release if there is reason to believe that the person’ pre-detention personality and
physical abilities have not changes, and returning to same environment
 3) With no history of violence, violence can be predicted if person is judged to be on
brink of violent act
o Violence with psychological disorder more likely if not being treated
o Assisted outpatient treatment (AOT) = an arrangement whereby a person is mandated by
the court to receive treatment on an outpatient basis

lOMoARcPSD|2532716
 Can expect violence to be reduced and increases compliance with medication

Protection of the Rights of People with Psychological Disorders
 1970 Supreme Court: Addington v. Texas  state must produce clear and convincing evidence that a
person is mentally ill and dangerous before he or she can be involuntarily committed to a psychiatric
hospital
 Least Restrictive Alternative:
o Least restrictive alternative to freedom – provided when treating people with psyc disorders
and protecting them form harming themselves and others
o Only those who cannot be adequately looked after in less restrictive settings be placed in
hospitals
o Restrict the person’s liberty to the least possible degree while remaining workable
o Unconstitutional to confine a person who is non-dangerous and who is capable of living on
his/her own or with help of willing family/friend
 Right to Treatment:
o If a person is deprived of liberty because he or she is mentally ill and is a danger to self or
others, is the state not required to provide treatment?
o Wyatt v. Stickney – treatment is the only justification for the civil commitment of people with
a psyc disorder to a psychiatric hospital *ensures protection of people confined by civil
commitment
o O’Connor v. Donaldson – civilly committed man sued 2 state hospital doctors for his release &
for monetary damages on the grounds that he had been kept against his will for 14 years
without being treated & w/o being dangerous
o A civilly committed person’s status must be periodically reviewed
 Right to Refuse Treatment:
o As many as 1/3 of individuals who take medications do not benefit from them
o Can refuse treatment due to protection of freedom from physical invasion, freedom of
thought & right to privacy
o Government cannot force antipsychotic drugs on a person on the supposition that at some
future time he or she might become dangerous
o Must be a very good reason to deprive a person of liberty and force medication – threat to
others
Deinstitutionalization, Civil Liberties, and Mental Health
 Deinstitutionalization = discharging as many peoples as possible from hospitals and discouraging
admissions
 2010 – about 14 psychiatric hospital beds for every 100,000 people in the US (compared to 350 in
1955)
 We need about 50/100,000 to meet the needs of people with psychological disorders
 Transinstitutionalization – declines in number of psychiatric hospital beds have lead to increases in
presence of people with psyc disorders in nursing homes, mental health departments of non-psyc
hospitals and prisons
o These settings are not equipped to handle to particular need of these people
 2007 – 17-30% of people in prison had serious psyc disorder
 Police officers are often the first to come in contact with person with psyc disorder, make decision of
hospital or jail
 Mobile crisis units consisting of trained mental health professionals who work in junction with police
to find the best option for a person with a psyc disorder
 Funding to properly train police – Mentally Ill Offender Treatment and Crime Reduction Act

lOMoARcPSD|2532716
 Mental health courts in local communities

 Consensus Project – increases awareness of number of people with psyc disorders who are housed
in jails rather than treatment facilities
3. Ethical Dilemmas in Therapy and Research
 Ethics statements designed to provide an ideal, to review moral issues of right and wrong that
may/may not be reflected in the law
 APA has a code of ethics – includes ethical standards that constrain research and practice in
psychology
Ethical Restraints on Research
 Citizens who participate in research experiments must be protected from unnecessary harm, risk,
humiliation and invasion of privacy
 Nuremberg trials conducted by allies following WWII put German physicians on trial who ran cruel
experiments on concentration camp inhabitants
 Nuremberg Code (1947), Declaration of Helsinki (1964)
Informed Consent
 Informed consent = investigator must provide enough information to enable people to decide
whether they want to be in a study
 Must describe the study clearly, including any risks involved
 Must be no coercion in obtaining informed consent
 Must understand that have the right to not take part in the study or to withdraw at any point,
without fear of penalty
 A health professional can assess whether or not an individual is able to give informed consent
 If a guardian gives consent on behalf on an individual, guardian’s ability to provide that consent
should be assessed
 People with psyc disorders are not necessarily incapable of giving informed consent
Confidentiality and Privileged Communication
 Confidentiality = nothing will be revealed to a third party except for other professionals and those
intimately involved in the treatment
 Privileged communication = communication between parties in a confidential relationship that is
protected by law
 Recipient cannot be legally compelled to disclose it as a witness
o Applies to relationships between husbands/wives, physician/patient, pastor/penitent,
attorney/client, psychologist/patient
o Only he or she may release the other person to disclose confidential information in a legal
proceeding
 There are limits:
o If person has accused the therapist of malpractice – can divulge info about therapy in self-
defense
o If the person is less than 16 years old and therapist has reason to believe that the child has
been a victim of a crime (e.g. child abuse) *psychologist is required to report to police to
child welfare within 36 hours any suspicion
o If the person initiated therapy in hopes of evading the law for having committed a crime or
for planning on doing so
o If the therapist judges that the person is a danger to self or others and disclosure of info is
necessary to ward off danger
CHAPTER 14: Late Life and Neurocognitive Disorders

lOMoARcPSD|2532716
1. Aging: Issues and Methods

 Social problems of aging are especially severe for women (wrinkles, sagging skin) *signs of aging not
valued in women
 Old defined as over 65 – set by social policies
 Young old = 65-74, old-old = 75-84, oldest-old = 85+
 Number of elderly population is growing
Myths About Late Life
 Psychologists must examine stereotypes about late life
 Common myths:
 1) Aging involves inexorable cognitive decline
o Severe cognitive problems do not occur for most
o Mild declines are common (processing speed & working memory)
 2) Late life is a sad time and most elderly are depressed
o Older individuals report less negative emotion than younger people, more skilled at
regulating emotions
o More brain activation in key areas when viewing positive images
 3) Late life is a lonely time
o Focus shifts away from seeking new social interactions, interested in a few close relationships
= social selectivity
 4) Older people lose interest in sex
o Sexual activity does not decrease from mid-to-late-life for most people
 Underreport somatic symptoms, no more likely to meet criteria for somatic symptom disorders than
young people
 Negative self-views about aging can predict earlier death
The Problems Experienced in Late Life
 80% of elderly have at least one major medical condition
 Quality and depth of sleep decline, sleep apnea rates increase, sleep deficits can worsen
physical/psyc/cognitive problems
 Polypharmacy = the prescribing of multiple drugs to a person
 1/3 are prescribed at least 5 medications *increased risk of side effects, prescribed more drugs to
combat side-effects
 Most psychoactive drugs are tested on younger people *difficult to estimate appropriate does for
elderly
Research Methods in the Study of Aging
 Age effects = consequences of being a certain chronological age
 Cohort effects = the consequences of growing up during a particular time period with its unique
challenges and opportunities
 Time-of-measurement effects = confounds that arise because events at a particular point in time
can have a specific effect on a variable that is being studied (e.g. post-earthquake)
 Cross-sectional studies = the investigator compares different age groups at the same moment in
time on the variable of interest
o Do not examine the same people over time, they do not provide clear information about how
people change as they age
 Longitudinal studies = researcher periodically retests one group of people using the same measure
over a number of years or decades (e.g. Baltimore longitudinal study of aging)
o Results may be biased due to attrition = participants drop out of the study due to death =
selective mortality, or other problems

lOMoARcPSD|2532716
2. Psychological Disorders in Late Life

 Same criteria used for older and younger adults
 No psyc diagnosis if symptoms are accounted for by medical condition/side-effects
o Thyroid problems, Addison’s disease, Cushing’s disease, Parkinson’s, Alzheimer’s,
hypoglycemia, anemia, testosterone deficiencies, vitamin deficiencies produce symptoms
that mimic side effects of schizophrenia, depression, anxiety
Estimating the Prevalence of Psychological Disorders in Late Life
 Those over 65 have lowest prevalence of psyc disorders of all age groups *National Comorbidity
Survey-Replication (NCS-R)
 No one 65+ met criteria for drug abuse/dependency disorder *NCS-R Study
 Most who experience disorder in late life are experiencing a recurrence of a disorder that started in
earlier life
 Aging relates to more positive emotionality in close-knit social circles *could enhance mental health
as we age
Methodological Issues in Estimating the Prevalence of Psychopathology
 Discomfort discussing symptoms may minimize prevalence rates
 Cohort effects – adults during drug-oriented era of 1960s, many continued using
 People with psyc disorders are at risk for dying before age 65
o Heavy drinkers: die from cirrhosis between 55-64 years old
o Anxiety/mood: cardiovascular disease
o Worsened immune function overall
3. Neurocognitive Disorders in Late Life
 Most elderly do not have cognitive disorders
 Dementia = deterioration of cognitive abilities
 Delirium = a state of mental confusion
I. Dementia
 = Deterioration of cognitive abilities to the point that functioning becomes impaired
o Impaired social and occupational functioning
 Most common symptom: difficulty remembering things, especially recent events
 Lose control of impulses, use coarse language, tell inappropriate jokes, shoplift, make sexually
inappropriate remarks
 Difficulty dealing with abstract ideas, emotional disturbances common (depression, flatness of
affect, sporadic outbursts)
 Delusions and hallucinations can occur
 Language disturbances – vague patterns of speech
 Become withdrawn and apathetic
 Course may be progressive, static or remitting *mostly develops slowly, can detect subtle
cognitive/behavioural defects before
 Mild cognitive impairment = the early signs of decline noted before functional impairment is
present
 1) DSM mild neurocognitive disorders are similar to mild cognitive impairment
 2) DSM major neurocognitive disorders are similar to dementia
 Difference based on ability to live independently
 Not all people with mild cognitive impairment develop dementia (10% will), 1% of adults develop
dementia w/o MCI
Criteria for Mild Neurocognitive Disorder (Mild cognitive impairment)
 1) Modest cognitive decline from previous levels in one or more domains based on the following:
o Concerns of the patient, a close other or clinician

lOMoARcPSD|2532716
o Modest neurocognitive decline (between the 3rd and 16th percentile) on formal testing or
 2) The cognitive deficits do not interfere with independence in everyday activities (e.g. paying bills or
managing medications), even though greater effort, compensatory strategies, or accommodation
may be required to maintain independence
Criteria for Major Neurocognitive Disorder (Dementia)
 1) Significant cognitive decline from previous levels in one or more domains based on both of the
following:
o Concerns of the patient, a close other, or clinician
o Substantial neurocognitive impairments (below the 3rd percentile on formal testing) or
 2) The cognitive deficits interfere with independence in the everyday activities
 0.4% prevalence of dementia in 2000
 Prevalence increases with age, 1-2% ages 60-69, increases to 20% in ages 85+
 Types:
o Alzheimer’s – most researched
o Frontotemporal dementia – affects frontal and temporal lobes
o Vascular dementia – caused by cerebrovascular disease
o Dementia with Lewy Bodies – presence of Lewy bodies
Alzheimer’s Disease
 Brain tissue irreversibly deteriorates, death usually occurs within 12 years
 6th leading cause of death in US
 Most common symptom is memory loss, may begin with absentmindedness and gaps in memory for
new material
 Interferes with daily living
 Apathy is a common symptom before cognitive symptoms are noticeable, 1/3 develop depression,
problems with language and word finding, visual-spatial abilities decline – disorientation = confusion
with respect to time, place or identity
 Unaware of own cognitive problems initially, become agitated
 Personality loses its sparkle/integrity “not him/herself anymore”
 Become oblivious to surroundings
 Plaques = small, round beta-amyloid protein deposits outside the neurons
o Mostly in frontal cortex, may be present 10-20 years before cognitive symptoms
o Measured using special PET scan
 Neurofibrillary tangles = twisted protein filaments composed largely of the protein tau in the axons
of neurons
o Measured in cerebrospinal fluid
o Most densely present in hippocampus
 Immune response to plaques leads to inflammation, triggers a series of brain changes
 Loss of acetylcholinergic (ACh) and gluateminergic neurons, neurons begin to die
 Entorhinal cortex and hippocampus shrink, followed by shrinking of frontal, temporal, and parietal
lobes
 Ventricles become enlarged

lOMoARcPSD|2532716
 Cerebellum, spinal cord and motor/sensory areas less affected *do not appear to have anything
physically wrong at first
 25% eventually experience motor deficits
 Heritability estimate of 79%, 21% due to environmental factors
 A set of 10 genes explains 20% of the risk for AD among white non-Hispanic samples
 Polymorphism of gene on chromosome 19 called apolipoprotein (ApoE-4 allele)
o Having 1 allele increases risk by 20%
o Interferes with clearing excess beta-amyloid from brain
o 2 alleles – overproduction of beta-amyloid plaques, loss of neurons in hippocampus and low
glucose metabolism BEFORE AD
 Immune process and high cholesterol can trigger inflammation, related to greater risk of AD (e.g.
type II diabetes)
 Brain trauma from accident/injury increases risk
 Lifestyle variables: smoking, being single, obesity, depression, low social support = higher risk
o Lower risk: Mediterranean diet, exercise, education, engagement in cognitive activities
 Exercise may predict fewer memory problems, less decline in cognitive function
o Low levels of plaques in brain
 Frequent cognitive activity related to 46% decrease in risk, protects against cognitive decline
 Cognitive reserve = the idea that some people may be able to compensate for the disease by using
alternative brain networks or cognitive strategies such that cognitive symptoms are less pronounced
 Depression can be a consequence of dementia, opposite effect occurs as well
Frontotemporal Dementia
 = Caused be a loss of neurons in the frontal and temporal regions of the brain (anterior temporal and
prefrontal)
 Begins in mid-to-late 50s, progresses rapidly, death occurs in 5-10 years, less than 1% prevalence
 Memory is not severely impaired
 There are multiple subtypes, most common = behavioural variant FTD
o Deterioration in at least 3 areas at a level that leads to functional impairment:
 Empathy, executive function, ability to inhibit behaviour, compulsive/perseverative
behaviour, hyperorality (= tendencies to put nonfood objects in the mouth) and
apathy
 Changes in personality and judgment, emotional regulation
 Often misdiagnosed as a midlife crisis (begin chain smoking, over eating, drinking alcohol) or
depression/bipolar/schizophrenia
 Affects emotion more than AD, damages social relationships, inability to properly express emotions
 May violate social conventions
 Affects marital satisfaction more than AD
 Caused by different molecular processes: Pick’s disease = presence of Pick bodies within neurons
 Some have high levels of tau = protein filaments that contribute to neurofibrillary tangles
 Strong genetic component
Vascular Dementia
 = Caused by cerebrovascular disease
 Stroke causes blood clot, impairs circulation, results in death of neurons
 7% develop dementia in year after stroke, risk increases with recurrent strokes
 Similar risks as for cardiovascular disease: high levels of bad cholesterol (LDL), smoking, elevated
blood pressure
 More common in African American than Caucasian
 Symptoms vary depending on where stroke occurred

lOMoARcPSD|2532716
 Onset usually more rapid, can co-occur with AD

Dementia with Lewy Bodies (DLB)
 = Protein deposits (Lewy bodies) form in the brain and cause cognitive decline
 2 subtypes depending on whether it occurs in context of Parkinson’s
 80% with PD develop DLB
 Hard to distinguish symptoms from PD (shuffling gait) and AD (loss of memory)
 More likely than AD to include visual hallucinations and fluctuating cognitive symptoms
 Extremely sensitive to physical side effects of antipsychotic medications
 Experience intense dreams with levels of movement/vocalizing (acting out dreams)
Dementias Caused by Disease and Injury
 Encephalitis – inflammation of brain tissue caused by viruses that enter the brain
 Meningitis – inflammation of membranes covering the outer brain, caused by bacterial infection
 Organism that produces syphilis can invade brain and cause dementia
 HIV, head trauma, brain tumor, nutritional deficiencies (B-complex vitamin), kidney/liver failure,
endocrine problems (hyperthyroidism), exposure to toxins (mercury/lead)
Treatments
 No cure, some medications used to treat symptoms
Medications
 No medications address cognitive symptoms of FTD
 Most treatment research focused on AD and memory decline, medications can slow the decline but
cannot restore memory
 Cholinesterase inhibitors used – interfere with breakdown of ACh *donepezil and rivastigmine
o Vitamin E, statins, nonsteroidal anti-inflammatory drugs
o Slow memory decline compared to placebo
 Memantine – drug that affects glutamate receptors involved in memory
 Preventative work focuses on processes involved in the creation of amyloid from its precursor
protein
 Aversive side effects – nausea
 Use medical treatments to address psyc symptoms: depression, agitation that co-occur
 Depression produces more cognitive impairment in elderly than younger patients
 Antipsychotics can relieve agitation, increase risk of death
 Cognitive deficits continued/worsened after destroying the plaques
 Focus mostly on prevention
Psychological/Lifestyle Treatments
 Supportive psychotherapy to help patients and family deal with effects of disease
o Discuss illness, learn about it, learn how to care for family member, encourages realistic
attitude in dealing with specific challenges
 Increase exercise to improve cognitive function
 Cognitive training programs – focus on improving memory, reasoning, cognitive processing speed
o Try to teach meta-cognitive skills (thinking about thinking, strategies for enhancing memory)
o Training in multi-tasking helps memory as well
 Behavioural approaches to compensate for memory loss & reduce depression/disruptive behaviour
of early AD
o External memory aids (shopping lists, calendars, labels)
o Pleasant/encouraging activities to decrease depression
o Identify triggers for disruptive behaviour and decrease them
o Music can help reduce agitation

lOMoARcPSD|2532716
II. Delirium
 1) Disturbances in attention and awareness
 2) A change in cognition, such as disturbance in orientation, language, memory, perception, or
visuospatial ability, not better accounted for by a dementia
 3) Rapid onset (hours/days) and fluctuation during the course of a day
 4) Symptoms are caused by a medical condition, substance intoxication or withdrawal, or toxin
 “Out of track”, deviating from usual state, clouded state of consciousness
 Two most common symptoms: extreme trouble focusing attention, profound disturbances in
sleep/wake cycle
 Cannot maintain coherent stream of thought, trouble answering questions
 Become drowsy during the day, awake/agitated at night
 Vivid dreams and nightmares
 Speech is rambling and incoherent
 Lose track of what day it is, where they are, who they are
 Memory impairment for recent events is common
 Perceptual disturbances are frequent, mistake unfamiliar for familiar, visual hallucinations, delusions
in 25% of older adults (poorly worked out, fleeting and changeable)
 Mood/activity swings, disordered thoughts, erratic, shift between emotions
 Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, incontinence
of urine and feces
 Become lethargic/unresponsive
 Have lucid intervals – alter and coherent *daily fluctuations help distinguish from AD
 Symptoms worsen during sleepless nights
 More common among young children and older adults (nursing homes and hospitals)
 6-12% nursing home residents developed delirium in 1 year
 Often misdiagnosed, especially if lethargy is present or if person has dementia
 High mortality rate if left untreated, 1/3 die within a year
 Increased risk for further cognitive decline
Etiology
 Caused by medical conditions: drug intoxications, withdrawal reactions, metabolic and nutritional
imbalances (diabetes, thyroid dysfunction, kidney/liver failure, congestive heart failure,
malnutrition), dehydration, infections, fevers, neurological disorders, stress of major injury
 One of most common triggers is hip surgery
 Usually has more than one cause
 Physical declines of late life, increased susceptibility to chronic diseases, many medication
prescribed, greater sensitivity to drugs = increased vulnerability for elderly
Treatment
 Recovery if underlying cause is treated promptly
 Atypical antipsychotic medication
 Treatment takes 1-4 weeks for condition to clear, longer in older people
 Preventative strategies:
o Clocks of hospital patients in field of vision, helps stay oriented
o Shades open during the day, lights turned off at night
o Minimal sleep disruptions
o Stress-free, hydration
 Risk factors: sleep deprivation, immobility, dehydration, visual/hearing impairment
 High risk of delirium among those with dementia

lOMoARcPSD|2532716
CHAPTER 15: Personality Disorders (PD)

 Defined by enduring problems with forming a stably positive identity and with sustaining close and
constructive relationships
 Extreme and inflexible traits, 10 different disorders, highly heterogeneous
o Paranoid – chronic tendencies to be mistrustful and suspicious
o Antisocial – patterns of irresponsibility and callous disregard for rights of others
o Dependent – overreliance on others
 Persistent, pervasive and maladaptive ways in which the traits are expressed
 Unstable, positive sense of self
1. The DSM-5 Approach to Classification
 10 different personality disorders, in 3 clusters:
 A) Odd/eccentric  paranoid, schizoid, schizotypal, B) Dramatic/erratic  antisocial, borderline, C)
Anxious/fearful  avoidant, dependent, obsessive-compulsive
 1/10 meet diagnostic criteria
 More common among those with a psychological disorder (MDD, anxiety)
 People with PD 7x more likely to have anxiety/mood disorder, and 4x as likely to have a substance
disorder *especially cluster B
 More severe, poorer social functioning and worse treatment outcome when comorbid PDs are
present
o Doubles the risk of depression
Assessment of DSM-5 Personality Disorders
 List of criteria and structured interviews for each PD *most clinicians do not used the structured
interviews
 Low Interrater reliability for schizoid PD
 Low agreement rates in diagnoses and often miss diagnoses
 Interviews with people who know the patient will improve the accuracy of diagnosis *rarely occurs
Problems with the DSM-5 Approach to Personality Disorders
 PDs are Not Stable over Time:
o Half patients diagnosed with a PD at one point in time achieved remission after 2 years
o 99% remitted 16 years later
o Symptoms most common during adolescence *PDs may not be as enduring, decline in 20s
and late life
o Many people still have some symptoms after remission
o After remission many problems in functioning still persist
o Risk of relapse still remains high, years after remission *symptoms wax and wane over time
 Personality Disorders are Highly Comorbid:
o More than 50% with PD meet diagnosis for another PD
o DSM system may not be ideal for classifying PDs, lack of test-retest stability and high
comorbidity
 Some PDs are extremely rare (< 2%)
 People with PD can vary a good deal from one another in the nature of their personality traits &
severity of condition
2. Alternative DSM-5 Model for Personality Disorders
 Recommend reducing the number of PDs, incorporating personality trait dimensions, and diagnosing
PDs on the basis of extreme scores on personality trait dimensions ***Found in appendix of DSM-5
 Includes only 6 of the 10 PDs: schizoid, histrionic, dependent were excluded because they are rare,
paranoid was excluded because it overlaps with other PDs

lOMoARcPSD|2532716
 Diagnosis based on personality traits

 5 personality trait domains and 25 more specific personality trait facets, rated using self-report
*related to 5-factor model
 Diagnosed is person shows persistent and pervasive impairments in self and interpersonal aspects of
functioning from early adulthood
 Provides richer detail for diagnosis, individuals diagnosed with same PD can vary lots in personality
traits from another
 Personality trait ratings tend to be stable over time, more than PD diagnoses
 Personality trait dimensions are related to many aspects of psychological adjustment
 Captures subsyndromal symptoms better
3. Common Risk Factors Across the Personality Disorders
 Psychoanalytic and behavioural theory placed emphasis on parenting and early developmental
influences
 Recent evidence of strong biological component
 Children in the Community Study:
o Assessed links between childhood adversity and PDs
o Assessed 2 aspects of parenting style: aversive parental behaviour and lack of parental
affection
o Kept track of child maltreatment, assessed with clinical interview for diagnosing PDs
o Findings suggested that PDs were strongly related to early adversity
o Parenting style also predicted certain PDs
 Norwegian Birth Registry – sample of twins:
o High heritability estimates for all PDs (.55-.77)
4. Clinical Description and Etiology of the Odd/Eccentric Cluster
 Similar bizarre thinking/experiences seen in schizophrenia *less severe
I. Paranoid PD
 Presence of 4+ of the following signs of distrust and suspiciousness from early adulthood across
many contexts:
o 1) Unjustified suspiciousness of being harmed, deceived, or exploited
o 2) Unwarranted doubts about the loyalty or trustworthiness of friends or associates
o 3) Reluctance to confide in others because of suspiciousness
o 4) Tendency to read hidden meanings into the benign actions of others
o 5) Bears grudges for perceived wrongs
o 6) Angry reactions to perceived attacks on character or reputation
o 7) Unwarranted suspiciousness of the partner’s fidelity
 Expect to be mistreated/exploited, are very secretive and continually on the lookout for signs of
trickery/abuse
 Hostile and angry in response to perceived insults, seen as difficult and critical
 Other symptoms of schizophrenia are not present (hallucinations), less impairment in
social/occupational functioning, no cognitive disorganization
 Full-blown delusions are not present
 Co-occurs most often with schizotypal, borderline and avoidant PD
II. Schizoid PD
 Presence of 4+ of the following signs of aloofness and flat affect from early adulthood across many
contexts:
o 1) Lack of desire for or enjoyment of close relationships
o 2) Almost always prefers solitude to companionship

lOMoARcPSD|2532716
o 3) Little interest in sex

o 4) Few or no pleasurable activities
o 5) Lack of friends
o 6) Indifference to praise or criticism
o 7) Flat affect, emotional detachment, or coldness
 Appear dull, bland, aloof, no warm feelings for others
 Rarely experience strong emotions
III. Schizotypal PD
 Presence of 5+ of the following signs of unusual thinking, eccentric behaviour, and interpersonal
deficits from early adulthood across many contexts:
o 1) Ideas of reference
o 2) Odd beliefs or magical thinking e.g. beliefs in extrasensory perception
o 3) Unusual perceptions
o 4) Odd thought and speech
o 5) Suspiciousness or paranoia
o 6) Inappropriate or restricted affect
o 7) Odd or eccentric behaviour or appearance
o 8) Lack of close friends
o 9) Social anxiety and interpersonal fears that do not diminish with familiarity
 Recurrent illusions (inaccurate sensory perceptions), flat/constricted affect, aloof from others
 Most do not develop delusions or schizophrenia (some do)
 Similar genetic vulnerability as for schizophrenia – enlarged ventricles, less temporal grey matter
(also cognitive and neuropsychological deficits)
 60% heritable
5. Clinical Description and Etiology of the Dramatic/Erratic Cluster
 Highly inconsistent behaviour, inflated self-esteem, rule breaking behaviour, exaggerated emotional
displays
 Most well-known
IV. Antisocial PD (APD) and Psychopathy
 1) Age at least 18
 2) Evidence of conduct disorder before age 15
 3) Pervasive pattern of disregard for the rights of others since the age of 15 as sown by at least 3 of
the following:
o Repeated law breaking, deceitfulness/lying, impulsivity, irritability/aggressiveness, reckless
disregard for own safety & that of others, irresponsibility as seen in unreliable
employment/financial history, lack of remorse
 Used interchangeably with psychopathy by public *antisocial behaviour is important for both, but
they differ in important ways
 Psychopathy is not included in DSM-5
 Antisocial PD:
o Core feature: pervasive pattern of disregard for the rights of others
o Presence of conduct disorder, little regard for truth, lack of remorse for misdeeds
o Men are 5x more likely to meet criteria, ¾ meet criteria for another disorder *substance
abuse is common
o ¾ convicted felons meet criteria
o Poverty of emotion:
 Negative – lack of shame/remorse/anxiety, doesn’t learn from mistakes

lOMoARcPSD|2532716
 Positive – merely an act to manipulate others, superficially charming

 Psychopathy:
o Predates APD diagnostic criteria
o “Mask of Sanity” – Hervey Cleckley
o Criteria focuses on person’s thoughts and feelings *poverty of emotions (positive and
negative)
o No sense of shame, positive feelings for others is an act
o Superficially charming
o Impossible to learn from mistakes due to lack of anxiety
o Impulsive rule-breaking behaviour
o Boldness, meanness, and impulsivity
o Assessed using Psychopathy Checklist-Revised (PCL-R)
o Symptoms do not need to show before age 15 *will not obtain high scores on PCL-R if have
APD
Etiology
 Most research done on those convicted as criminals, use different measures (APD vs. psychopathy)
 Interactions of Genes and the Social Environment:
o Role of social environment is key in APD: parenting qualities of negativity, inconsistency and
low in warmth
o Poverty and exposure to violence also predict antisocial behaviour
o Those with CD, if impoverished, 2x more likely to develop APD
o Polymorphism of MAO-A gene predicts psychopathy in males who had experienced
childhood abuse or maternal rejection
o Anti-social behaviour is 40-50% heritable
 Psychological Risk: Insensitivity to Threat and to Others’ Emotions:
o Psychopaths are unable to learn from experience, immune to anxiety that keeps us from
breaking the law/lying
o Deficits in experience of fear and threat, lower than normal levels of skin conductance
o Deficits in developing conditioned fear responses *no increased amygdala activity for CS
o Even more unresponsive to threat when trying to obtain a reward
o Inattentiveness to threats when pursing a goal – deficits in regions of prefrontal cortex
involve in attending to negative information during goal pursuit
o Lack of empathy – especially difficult to recognize fear in others
V. Borderline PD (BPD)
 Presence of 5+ of the following signs of instability in relationships, self-image, and impulsivity from
o 1) Frantic efforts to avoid abandonment
o 2) Unstable interpersonal relationships in which others are either idealized or devalued
o 3) Unstable sense of self
o 4) Self-damaging, impulsive behaviours in at least two areas, such as spending, sex, substance
abuse, reckless driving, and binge eating
o 5) Recurrent suicidal behaviour, gestures or self-injurious behaviour
o 6) Marked mood reactivity
o 7) Chronic feelings of emptiness
o 8) Recurrent bouts of intense or poorly controlled anger
o 9) Curing stress, a tendency to experience transient paranoid thoughts and dissociative
symptoms

lOMoARcPSD|2532716
 Very common in clinical settings, very hard to treat, associated with recurrent periods of suicidality
 Core features: impulsivity and instability in relationships and mood, emotional reactivity
 Emotions are intense, erratic, shift abruptly *passionate idealization to contemptuous anger
 Overly sensitive to small signs of emotions in others
 No clear/coherent sense of self
 Cannot bear to be alone (fear of abandonment), chronic depression and emptiness
 Psychotic and dissociative symptoms when stressed
 2/3 engage in self-mutilation
 Likely to have comorbid PTSD, mood disorders, substance related disorders, eating disorders = more
likely to last longer
Etiology
o Highly heritable (60%)
o Lower serotonin function – general dysregulation
o Increased activation of amygdala to emotional pictures – emotion dysregulation
o Deficits in prefrontal cortex – impulsivity
o Disrupted connectivity between prefrontal cortex and amygdala
 Social Factors: Childhood Abuse in the Context of Genetic Vulnerability:
o Parental separation, verbal & emotional abuse during childhood
o Tied to high rates of childhood abuse/neglect and high heritability
o Childhood abuse doesn’t predict BPD after genetic risk is controlled
o Childhood trauma accounts for less than 1% in variance
o Genetically driven impulsivity, emotionality and risk-seeking in parents could increase risk of
abusing children
 Linehan’s Diathesis-Stress Theory:
o BPD develops when people who have difficulty controlling their emotions because of a
biological diathesis are raised in a family environment that is invalidating
o Emotional regulation diathesis interactions with experiences of invalidation = BPD
development
 Biological diathesis: Emotional dysregulation in the child  great demands on the
family  invalidation by parents through punishing/ignoring  emotional outbursts
by child to which parents attend  emotional dysregulation of child
VI. Histrionic Personality Disorder (HPD)
 Presence of 5+ of the following signs of excessive emotionality and attention seeking from early
adulthood across many contexts:
o 1) Strong need to be the centre of attention
o 2) Inappropriate sexually seductive behaviour
o 3) Rapidly shifting and shallow expression of emotions
o 4) Use of physical appearance to draw attention to self
o 5) Speech that is excessively impressionistic and lacking in detail
o 6) Exaggerated, theatrical emotional expression
o 7) Overly suggestible
o 8) Misreads relationships are more intimate than they are
 Key feature: overly dramatic and attention-seeking behaviour
 Use physical appearance to draw attention to themselves
 Emotionally shallow, overly concerned with physical attractiveness, uncomfortable when not the
centre of attention

lOMoARcPSD|2532716
 Easily influenced by others

VII. Narcissistic Personality Disorder
 Presence of 5+ of the following signs of grandiosity, need for admiration, and lack of empathy from
o 1) Grandiose view of one’s importance
o 2) Preoccupation with one’s success, brilliance, beauty
o 3) Belief that one is special and can be understood only by other high-status people
o 4) Extreme need for admiration
o 5) Strong sense of entitlement
o 6) Tendency to exploit others
o 7) Lack of empathy
o 8) Envious of others
o 9) Arrogant behaviour or attitudes
 Interpersonal relationships disturbed by lack of empathy, arrogance and envy, self-centeredness
 Overly reactive to criticism
 Seeks out higher-status partner
Etiology
 Parenting:
o Parents who are overly indulgent foster children’s belief that they are special and behavioural
expressions of their specialness will be tolerated by others
 Self-Psychology:
o Variant of psychodynamic theory (Heinz Kohut)
o Characteristics mask low SE (parent & patient)
o In childhood, narcissist valued as a means to increase parent’s own SE
 Not valued for his/her own self-worth and competencies
o Parental emotional coldness & overemphasis on child’s achievement reported by narcissist
o Person with NPD projects self-importance, self-absorption, and fantasies of limitless success
o Fragile self-esteem
 Social-Cognitive Model:
o 1) People with NPD have fragile self-esteem, in part because they are trying to maintain the
belief that they are special
o 2) Interpersonal interactions are important to them for bolstering SE rather than for gaining
closeness or warmth
o Overestimate attractiveness to others and contributions in group activities
o Attribute success to abilities rather than to chance/luck ***cognitive biases
o Show more reactivity when falsely told they have done poorly on an IQ test (also when told
they have succeeded)
o Primary goal in interactions is to bolster their own self-esteem brag a lot, denigrate others
who perform better
6. Clinical Description and Etiology of the Anxious/Fearful Cluster
 Prone to worry and distress
IIX. Avoidant Personality Disorder
 A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as
shown by 4+ of the following from early adulthood across many contexts:
o 1) Avoidance of occupational activities that involve significant interpersonal contact, because
of fears of criticism or disapproval
o 2) Unwilling to get involved with people unless certain of being liked

lOMoARcPSD|2532716
o 3) Restrained in intimate relationships because of the fear of being shamed or ridiculed

o 4) Preoccupation with being criticized or rejected
o 5) Inhibited in new interpersonal situations because of feelings of inadequacy
o 6) Views self as socially inept, unappealing or inferior
o 7) Unusually reluctant to try new activities (taking risks) because they may prove
embarrassing
 Often co-occurs with social anxiety disorder – similar diagnostic criteria and genetic vulnerability
overlaps *maybe a more chronic variant of social anxiety disorder
 80% have comorbid major depression, alcohol abuse is also common
IX. Dependent Personality Disorder
 An excessive need to be taken care of, as shown by the presence of at least 5 of the following from
o 1) Difficulty making decisions without excessive advice and reassurance from others
o 2) Need for others to take responsibility for most major areas of life
o 3) Difficulty disagreeing with others for fear of losing their support
o 4) Difficulty doing things on own or starting projects because of lack of self-confidence
o 5) Doing unpleasant things as a way to obtain the approval and support of others
o 6) Feelings of helplessness when alone because of fears of being unable to care for self
o 7) Urgently seeking new relationships when one ends
o 8) Preoccupation with fears of having to take care of oneself
 See themselves as weak, fear being alone
 Very passive
 Can do what is necessary to maintain a close relationship
 Men with higher levels of dependency are at elevated risk of perpetrating domestic violence
 Likely to develop depression after interpersonal losses, show high suicidality when depressed
 Elevated risk of developing anxiety disorders and bulimia
 Overprotective parents may reinforce children for dependency
 Authoritarian discipline may limit opportunities for children to develop feelings of self-efficacy
X. Obsessive-Compulsive Personality Disorder
 Intense need for order, perfection, and control as shown by the presence of at least 4 of the
following from early adulthood across many contexts:
o 1) Preoccupation with rules, details, and organization to the extent that the point of an
activity is lost
o 2) Extreme perfectionism interferes with task completion
o 3) Excessive devotion to work to the exclusion of leisure and friendships
o 4) Inflexibility about morals and values
o 5) Difficulty discarding worthless items
o 6) Reluctance to delegate unless others conform to one’s standards
o 7) Miserliness
o 8) Rigidity and stubbornness
 More oriented towards work than pleasure *causes social relationships to suffer, little time for
leisure, family, friends
 Difficulty making decisions and allocating time
 Serious, rigid, formal, and inflexible
 Does not include obsessions and compulsions of OCD, often co-occurs with OCD, some overlapping
genetic variability
7. Treatment of Personality Disorders

lOMoARcPSD|2532716
 Many enter treatment for condition other than PD (e.g. substance abuse, anxiety, depression)
General Approaches to the Treatment of PDs
 Psychotherapy is the treatment of choice – small but positive effects, often supplemented with
medication
 Weekly sessions, or day-treatment programs (several hours/day), occupational therapy provided
 Psychodynamic theory – childhood problems are at the root of PDs, help patient reconsider those
early experiences, become more aware of how they drive current behaviour and reconsider
beliefs/responses to early events
 Cognitive theory – negative cognitive beliefs are at the heart of PDs, help person become aware of
those beliefs and challenge maladaptive cognitions
o Explore biases in thinking
o Look for dysfunctional schemas/assumptions the underline person’s thoughts/feelings
 Cannot change underlying traits of PD, but can change disorder into a style or more adaptive way of
approaching life
Treatment of Schizotypal Disorder and Avoidant Personality Disorder
 Antipsychotic drugs (risperidone) for schizotypal, reduces unusual thinking
 Avoidant PD responds to same treatments as social anxiety disorder – antidepressant medications
and cognitive behavioural treatment
o Help person challenge negative beliefs about social interactions, teach behavioural strategies
for dealing with social situations, exposure treatment
 Psychopathy – psychotherapy, either CBT or psychodynamic
Treatment of Borderline Personality Disorder
 ***Difficult to treat
 Show interpersonal problems in therapeutic relationship
 Client finds it difficult to trust others, idealize and vilify the therapist
 Difficult to tell if call at 2:00 from patient is call for help or a manipulative gesture to test the
therapist
 Medications – anti-depressants, mood stabilizers
 Hospitalization is often necessary to protect against suicide
 Many therapist consult with others due to high stress of treatment
 Metallization based therapy – fail to think about their own and other’s feelings
 Schema-focused cognitive therapy – identify maladaptive assumptions that underlie cognitions
 Dialectical behaviour therapy – combines client-centered empathy and acceptance with cognitive
behavioural problem solving, emotion-regulation techniques and social skills training
o Constant tension between any phenomenon and its opposite is resolved by creating a new
phenomenon (the synthesis) *term dialectical used on 2 main ways:
 1) Seemingly opposite strategies that the therapist must use when treating BPD –
accepting them as they are and yet helping them change
 2) The patient’s realization that splitting the world into good and bad is not necessary;
instead one can achieve a synthesis of these apparent opposites
o 4 stages:
 1) Dangerously impulsive behaviours are addressed with the goal of promoting
greater control
 2) Learning to modulate the extreme emotionality – learn to tolerate emotional
distress
 3) Improving relationships and self-esteem
 4) Designed to promote connectedness and happiness
 Learn more effective and socially acceptable ways to handle day-to-day problems

lOMoARcPSD|2532716
CHAPTER 16: Legal and Ethical Issues

 Bill of rights: first 10 amendments to the constitution
 Maximize degree of liberty consistent with preserving order in the community at large
 Criminal commitment = a procedure that confines a person in a mental or forensic hospital either
for determination of competency to stand trial or after acquittal by reason of insanity
o For someone with a psychological disorder who has broken the law/alleged to have done so
 Civil commitment = a set of procedures by which a person who is deemed mentally ill and
dangerous but has not broken a law can be deprived of liberty and placed in a hospital
1. Criminal Commitment
 Insanity = a disordered mind *may be regarded as unable to formulate and carry out a criminal
purpose
o Cannot be a guilty mind
o Defined in court proceedings
The Insanity Defense
 Insanity defense = the legal argument that a defendant should not be held responsible for an illegal
act if it is attributable to a psychological disorder or intellectual disability that interferes with
rationality or that results form some other excusing circumstance, such as not knowing right from
wrong
 Pleaded in less than 1% of all cases that reach trial
 Rarely successful when pleaded, only 7% success rate
 Based on accused’s mental condition at the time crime was committed
 Insanity defense has been around since the 7th century BCE
Landmark Cases and Laws
 Irresistible Impulse:
o = If a pathological impulse or uncontrollable drive compelled the person to commit the
criminal act, an insanity defense is legitimate
o Test was confirmed in 2 court cases: Parsons v. State and Davis v. United States
 The M’Naghten Rule:
o Formulated in the aftermath of a murder trial in England, defendant has set out to kill the
Prime Minister, but had mistaken his secretary for the PM, claimed he had been instructed to
kill the PM by the voice of God
o To establish defense of insanity, must be proved that at time of crime, accused party was
under a defect of reasoning (disease of mind), and did not know nature/quality of act he was
doing
 If he had known what he was doing, he didn’t know it was wrong
 The Durham Test:
o Durham v. United States
o A person is not responsible for a crime if it was “the product of mental disease or mental
defect”
o Definition of mental disease/defect open to jurisdictions and mental health professionals to
decide
o Only used by New Hampshire
 American Law Institute Guidelines:
o ALI proposed its own guidelines, intended to be more specific and informative
o Aka “Moral penal code”

lOMoARcPSD|2532716
 1) A person is not responsible for criminal conduct if at the time of such conduct as a
result of mental disease or defect he lacks substantial capacity either to appreciate
the criminality of his conduct or conform his conduct to the requirements of law
 2) The terms “mental disease/defect” do not include an abnormality manifested only
by repeated criminal or otherwise antisocial conduct
o First guideline combines M’Naghten rule and irresistible impulse
 Insanity Defense Reform Act:
o John Hinckley Jr. found not guilty by reason of insanity (NGRI) for assassination attempt
against President Ronald Reagan
o Many committed to mental hospital stay there longer than would have stayed in prison
o As a consequence of political pressures to get tough on criminal, congress enacted the
Insanity Defense Reform Act
 Addressed insanity defense at federal level for the first time
 1) Eliminates irresistible-impulse component of the ALI rules
 2) Changes the ALI’s “lacks substantial capacity…to appreciate” to “unable to
appreciate” *tightens the grounds for an insanity defense, making criteria for
impairment judgment more stringent
 3) Stipulates that mental disease/defect must be severe
 No longer can use defense “diminished capacity” or “diminished
responsibility” based on mitigating circumstances as extreme passion or
temporary insanity
 4) Shifts the burden of proof from prosecution to defense *defense must prove the
defendant insane, with clear and convincing evidence
 5) Person may remain committed longer than the ordinary sentence, released only
when deemed by professionals to be no longer dangerous and no longer mentally ill
 Current Insanity Pleas:
o Not guilty by reason of insanity (NGRI) = there is no dispute over whether the person
actually committed the crime – both sides agree that the person committed the crime
 Due to the person’s insanity at the time, the defense argues that the person should
not be held responsible for and thus should be acquitted of the crime
 Successful: person not held responsible due to psychological disorder
 Committed indefinitely to forensic hospital, released only when deemed no longer
dangerous and no longer mentally ill
 Forensic hospital perimeter is secure with gates, barbed wires, or electric fences,
doors to different units may be locked, bars may be placed on windows, security
doesn’t carry weapons or wear uniforms
 Someone found NGRI could not remain committed if no longer mentally ill, even if still
considered dangerous
o Guilty but mentally ill (GBMI) = allows an accused person to be found legally guilty of a crime
– thus maximizing the chances of incarceration – but also allows for psychiatric judgment on
how to deal with the convicted person if he/she is considered to have been mentally ill at
time of crime
 Usually put in general prison population, may or may not receive treatment
 May be committed to mental hospital if still considered dangerous/mentally ill after
sentence is over
 E.g. Jeffery Dahmer – accused of and admitted to butchering, cannibalizing and having
sex with the corpses of 15 boys and young men, entered plea of guilty, attorneys
argued disorder should be considered during sentencing

lOMoARcPSD|2532716
 Critics argue that it doesn’t benefit criminals with psychological disorders, and doesn’t
result in appropriate treatment
 Some believe GMBI is not as tough as a guilty verdict, but people receiving GBMI
verdict often spend more time incarcerated
 Standards of Proof (table 16.2)
o Beyond a reasonable doubt – 95% certainty needed to convict
o Clear and convincing evidence – 75%
o Beyond a preponderance of the evidence – 51%
Competency to Stand Trial
 Insanity defense concerns accused’s mental state at the time of the crime
 Competency to stand trial = whether the defendant has sufficient present ability to consult with his
lawyer with a reasonable degree of rational understanding, and whether he has a rational as well as
a factual understanding of the proceedings against him
 Must be decided before it can be determined whether a person is responsible for the crime which
he/she is accused
 Pate v. Robinson – the defense attorney, prosecutor, or judge may raise the question of the
psychological disorder whenever there is reason to believe that the accused person’s mental
condition might interfere with his/her upcoming trial
 In absentia “not present” = a centuries old principle of English common law that refers to the
person’s mental state, not his/her physical presence
o Trial can be delayed, accused person placed in hospital with hopes of restoring adequate
mental function
 Being deemed mentally ill doesn’t necessarily mean cannot stand trial
 Being judged incompetent to stand trial has consequences for individual:
o Bail is automatically denied, person usually kept in hospital for pretrial examination
(supposed to receive treatment to become competent to stand trial), person may lose
employment, undergo trauma from being separated from family/friends/familiar
surroundings
 Jackson v. Yates – deaf and mute man with intellectual disability, deemed unlikely to ever be
competent to stand trial
o If deemed not ever competent, state must either institute civil commitment or release the
defendant
o Cannot be committed to process of determining competency that exceeds longest possible
sentence
o Most people deemed competent in about 6 months
 Can proceed in trial with “synthetic sanity” due to medication
 Cannot forced defendant to take medication, until 2003***new ruling, can be used only if
alternative treatments had failed
 Medications are often the most effective means of restoring competency
Insanity, Intellectual Disability, and Capital Punishment
 Should someone who is sentenced to death have to be legally sane at the time of the execution?
 Daryl Atkins – intellectual disability and capital punishment – lacked understanding of consequences
of actions, not morally culpable for acts as a person of normal intelligence *capital punishment
would be unconstitutional
o Ruled that capital punishment of those with intellectual disability constitutes cruel and
unusual punishment (8th amendment prohibits)

lOMoARcPSD|2532716
o State of Virginia defined intellectual disability as IQ of 70 or less along with difficulties in self-
care and social interaction ***varies from state-to-state
 Supreme Court 2014 – intellectual disability cannot be determined solely on the basis of IQ score,
must also include assessments of adaptive functioning over the lifetime
2. Civil Commitment
 Governments have a duty to protect their citizens from harm
 Right and obligation to protect us both from ourselves, parens patriae, “power of the state” & from
others, the police power of the state
 A person can be committed to a hospital against his/her will if judgment is made that he/she is:
o 1) Mentally ill and, 2) A danger to self (suicidal or unable to provide for basic physical needs)
or to others
o Dangerousness to others is more often the principle criterion in court rulings
 Civil commitment is supposed to last only as long as the person remains dangerous
 Formal and informal commitment procedures:
o Formal (judicial) commitment is by order of a court, can be requested by any responsible
citizen
 Judge will order mental health examination if believes there is a good reason to
 Person has the right to object the these attempts, court hearing scheduled to allow
person to present evidence against commitment
o Informal (emergency) commitment can be accomplished without involving the courts initially
 If hospital board believes a person requesting discharge is too mentally ill and
dangerous, can detain the person with a temporary, informal commitment order
 Police can take any person acting out-of-control or in a dangerous manner to a
psychiatric hospital
 Most common is the Physician’s Certificate (PC) – physician can sign a certificate that
allows a person to be hospitalized for some period between 24 hours to 20 days
 Affects more people than criminal commitment
Preventative Detention and Problems in the Prediction of Dangerousness
 Not the case that people with psychological disorders account for a significant proportion of the
violence that besets society
 3% of US violence is linked to psychological disorders
 Over 90% diagnosed with psychotic disorders (mostly schizophrenia) are not violent
 MacArthur Violence Risk Assessment Study – large prospective study of violent behaviour in persons
recently discharged from psychiatric hospitals
o People with psyc disorders who did not also abuse substances were no more likely to engage
in violence that are people without psyc disorders and substance abuse
o When people with psyc disorders do act aggressively, usually against family/friends, and at
home
o People with psyc disorders report more violent thoughts in hospital
o People with psyc disorder more likely to be aggressive if have positive or disorganization
symptoms of schizophrenia or also abusing drugs
o Issues of substance abuse rather than psychotic disorders are the main contributory factors
to violence
 The Prediction of Dangerousness:
o Mental health professionals are poor at making a judgment of whether or not a person will
commit a dangerous act

lOMoARcPSD|2532716
o Historical-Clinical-Risk Management-20 (HCR-20) – identifies and measures violence risk

factors based on clinical judgment
o Most accurate under the following conditions:
 1) If a person has been repeatedly violent in the recent past, it is reasonable to
predict that he/she will be violent in future unless there are major changes in person’s
attitude/environment
 2) If violence is in the person’s distant past, and if it was a single and very serious act,
and if that person has been incarcerated for a period, violence can be expected on
release if there is reason to believe that the person’ pre-detention personality and
physical abilities have not changes, and returning to same environment
 3) With no history of violence, violence can be predicted if person is judged to be on
brink of violent act
o Violence with psychological disorder more likely if not being treated
o Assisted outpatient treatment (AOT) = an arrangement whereby a person is mandated by
the court to receive treatment on an outpatient basis
 Can expect violence to be reduced and increases compliance with medication
Protection of the Rights of People with Psychological Disorders
 1970 Supreme Court: Addington v. Texas  state must produce clear and convincing evidence that a
person is mentally ill and dangerous before he or she can be involuntarily committed to a psychiatric
hospital
 Least Restrictive Alternative:
o Least restrictive alternative to freedom – provided when treating people with psyc disorders
and protecting them form harming themselves and others
o Only those who cannot be adequately looked after in less restrictive settings be placed in
hospitals
o Restrict the person’s liberty to the least possible degree while remaining workable
o Unconstitutional to confine a person who is non-dangerous and who is capable of living on
his/her own or with help of willing family/friend
 Right to Treatment:
o If a person is deprived of liberty because he or she is mentally ill and is a danger to self or
others, is the state not required to provide treatment?
o Wyatt v. Stickney – treatment is the only justification for the civil commitment of people with
a psyc disorder to a psychiatric hospital *ensures protection of people confined by civil
commitment
o O’Connor v. Donaldson – civilly committed man sued 2 state hospital doctors for his release &
for monetary damages on the grounds that he had been kept against his will for 14 years
without being treated & w/o being dangerous
o A civilly committed person’s status must be periodically reviewed
 Right to Refuse Treatment:
o As many as 1/3 of individuals who take medications do not benefit from them
o Can refuse treatment due to protection of freedom from physical invasion, freedom of
thought & right to privacy
o Government cannot force antipsychotic drugs on a person on the supposition that at some
future time he or she might become dangerous
o Must be a very good reason to deprive a person of liberty and force medication – threat to
others
Deinstitutionalization, Civil Liberties, and Mental Health

lOMoARcPSD|2532716
 Deinstitutionalization = discharging as many peoples as possible from hospitals and discouraging

admissions
 2010 – about 14 psychiatric hospital beds for every 100,000 people in the US (compared to 350 in
1955)
 We need about 50/100,000 to meet the needs of people with psychological disorders
 Transinstitutionalization – declines in number of psychiatric hospital beds have lead to increases in
presence of people with psyc disorders in nursing homes, mental health departments of non-psyc
hospitals and prisons
o These settings are not equipped to handle to particular need of these people
 2007 – 17-30% of people in prison had serious psyc disorder
 Police officers are often the first to come in contact with person with psyc disorder, make decision of
hospital or jail
 Mobile crisis units consisting of trained mental health professionals who work in junction with police
to find the best option for a person with a psyc disorder
 Funding to properly train police – Mentally Ill Offender Treatment and Crime Reduction Act
 Mental health courts in local communities
 Consensus Project – increases awareness of number of people with psyc disorders who are housed
in jails rather than treatment facilities
3. Ethical Dilemmas in Therapy and Research
 Ethics statements designed to provide an ideal, to review moral issues of right and wrong that
may/may not be reflected in the law
 APA has a code of ethics – includes ethical standards that constrain research and practice in
psychology
Ethical Restraints on Research
 Citizens who participate in research experiments must be protected from unnecessary harm, risk,
humiliation and invasion of privacy
 Nuremberg trials conducted by allies following WWII put German physicians on trial who ran cruel
experiments on concentration camp inhabitants
 Nuremberg Code (1947), Declaration of Helsinki (1964)
Informed Consent
 Informed consent = investigator must provide enough information to enable people to decide
whether they want to be in a study
 Must describe the study clearly, including any risks involved
 Must be no coercion in obtaining informed consent
 Must understand that have the right to not take part in the study or to withdraw at any point,
without fear of penalty
 A health professional can assess whether or not an individual is able to give informed consent
 If a guardian gives consent on behalf on an individual, guardian’s ability to provide that consent
should be assessed
 People with psyc disorders are not necessarily incapable of giving informed consent
Confidentiality and Privileged Communication
 Confidentiality = nothing will be revealed to a third party except for other professionals and those
intimately involved in the treatment
 Privileged communication = communication between parties in a confidential relationship that is
protected by law
 Recipient cannot be legally compelled to disclose it as a witness
o Applies to relationships between husbands/wives, physician/patient, pastor/penitent,
attorney/client, psychologist/patient

lOMoARcPSD|2532716
o Only he or she may release the other person to disclose confidential information in a legal
proceeding
 There are limits:
o If person has accused the therapist of malpractice – can divulge info about therapy in self-
defense
o If the person is less than 16 years old and therapist has reason to believe that the child has
been a victim of a crime (e.g. child abuse) *psychologist is required to report to police to
child welfare within 36 hours any suspicion
o If the person initiated therapy in hopes of evading the law for having committed a crime or
for planning on doing so
o If the therapist judges that the person is a danger to self or others and disclosure of info is
necessary to ward off danger

Abpsych Summary

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Abpsych Summary

Uploaded by

Copyright:

Available Formats

lOMoARcPSD|2532716

Summary - book "Abnormal Psychology" - Textbook notes

Abnormal Psychology (University Of Manitoba)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

CHAPTER 1: Introduction and Historical Overview

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Coined the terms nature and nurture (genetics vs. environment)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

CHAPTER 2: Current Paradigms in Psychopathology

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

The Neuroscience Paradigm

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

o Increase neural transmission in neurons that use serotonin as a neurotransmitter by

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Interpersonal Therapy (IPT):

CHAPTER 3: Diagnosis and Assessment

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Criterion validity = evaluated by determining whether a measure is associated in an expected way

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 How Valid Are Diagnostic Categories?

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

o Identify intellectually gifted children

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

o Radioactive isotope injected into bloodstream, binds to glucose

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

CHAPTER 4: Research Methods in Psychopathology

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Rely on correlational method when cannot do an experiment for ethical reasons

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 1) Comparison of members of a family, 2) comparison of pairs of twins, 3)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

CHAPTER 5: Mood Disorders

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 4) Bipolar disorders are not present

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

o Symptoms must be present of at least 2 years among adults (1 year in children)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

o Triggers of depression in bipolar disorder are similar to those of MDD

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Behavioural Activation Therapy (BA):

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

o Many individuals with mood disorders have suicidal thoughts

CHAPTER 6: Anxiety Disorders

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Depersonalization = a feeling of being outside one’s body

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

 Highly comorbid with other disorders (75%)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)

Distributing prohibited | Downloaded by Alyanna de Leon (alyaaannaaaa@gmail.com)