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Chapter 1: Introduction, Definitional and Historical Considerations

What is Abnormal Behaviour?
➔ Statistical Infrequency
- The normal curve, or bell-shaped curve, places the majority of people in the middle as far
as any particular characteristic is concerned, very few people fall at either extreme.
- Statistical Infrequency is used explicitly in diagnosing mental retardation.

➔ Violation of Norms
Behaviour that violates social norms or threats or makes anxious

➔ Personal Suffering
Behaviour is abnormal if it creates great distress and torment in the person experiencing it.
- Personal distress fit many forms of abnormality

➔ Disability or Dysfunction
Disability – impairment in some important area of life
o Substance- use disorders are defined in apart of the social or occupational
disability created by substance abuse and addiction
o Phobia can produce distress and disability.

➔ Unexpectedness
Distress and disability are considered abnormal when they are unexpected responses to
environment stressors

The Mental Health Professions

- Clinical Psychologist; requires Ph.D or Psy.D degrees. Which entails for 4-7 years of
graduate study.
o Based on scientist-practitioner model
o Candidates in clinical psychology learn skills in two additional areas; assessment
and diagnosis and psychotherapy; primarily verbal means of helping troubled
individuals change their thoughts, feelings, and behaviour to reduce distress and
to achieve greater life satisfaction.

- Psychiatrist; holds an MD degree and has had postgraduate training; residency, in which
he or she has received supervision in the practice of diagnosis and psychotherapy. (they
can also function as physicians)
- Psychoanalyst; received specialized training at a psychoanalytic institute.
- Social Worker; obtains an M.S.W (master of social work) degree. Programs for
counselling psychologist are somewhat similar to graduate training in clinical psychology
- Counselling psychologist are similar to graduate training in clinical psychology but
usually have less emphasis on research and the more severe forms of psychopathology.

History of Psychopathology
→ Early Demonology ;The doctrine that an evil being, such as the devil, may dwell within a
person and control his or her mind and body is called demonology. This type of thinking are
found in the records of the early Chinese, Egyptians, Babylonians, and Greeks.

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It’s treatment was often exorcism, the casting out of evil spirits by ritualistic chanting or torture.
o This typically took the form of elaborate rites of prayer, noisemaking, forcing the
afflicted to drink terrible-tasting brews, and extreme measures such as flogging
and starvation, to render the body uninhabitable to devils.
o Trapanning of skulls (the making of surgical opening in a living skull by some
instrument) by Stone Age or Neolithic.
▪ It was presumed that the individual would return to a normal state by
creating an opening through which evils spirits could escape.
▪ One popular theory is that it was a way of treating conditions such as
epilepsy, headaches, and psychological disorders attributed to demons
within the cranium.
▪ This most common in Peru and Bolivia, 3 aboriginal specimens have been
found in Canada, all on the Pacific coast in British Columbia.

→ Somatogensis
- In the fifth century, Hippocrates rejected the prevailing Greek belief that gods sent
serious physical diseases and mental disturbance as punishment and insisted instead that
such illnesses had natural causes and hence should be treated like other, more common
maladies, such as colds and constipation.
- The brain is the organ of consciousness, of intellectual life and emotional; thus, he
thought that deviant thinking and behaviour were indications of some kind of brain
pathology
o Somatogenesis; the notion that something is wrong with the soma, or physical
body, disturbs thought and action
o Psychogensis; in contrast, is the belief that a disturbance has psychological
origins
- Hippocrates classified mental disorders into three categories: mania, melancholia and
phrenitis (of brain fever)
- Hippocrates’s physiology was rather crude, he conceived of normal brain functioning,
and therefore of mental health, as dependent on delicate balance among four humours:
blood, black bile, yellow bile and phlegm.

→ The Dark Ages and Demonology

- The monks cared for and nursed the sick.
- When monks cared for the mentally disordered, they prayed over them and touched them
with relics or they concocted fantastic potions for them to drink in the waning phase of
the mood.
- The families of the deranged might take them to shrines
- Many of the mentally ill roamed the countryside, becoming more and more disturbed.

→The Persecution of Witches

- Pope Innocent VIII exhorted the clergy of Europe to leave no stone unturned in the
search for witches.
o He sent 2 Dominican monks to northern Germany as inquisitors. They issued a
comprehensive and explicit manual, Malleus Maleficarum, to guide which hunts.

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o Those who were accused of witchcraft were to be tortured if they did not confess;
those convicted and penitent were to be imprisoned for life; and those convicted
and unrepentant were to be handed over to the law for execution.

→ Witchcraft and Mental Illness

- The mentally ill were generally considered witches.
- Many of the accused were not mentally ill.
- The delusion-like confessions were obtained during brutal torture; words were put on the
tongues of the tortured by these accusers and by the beliefs of the times.
- In England, where torture was not allowed, the confessions did not usually contain
descriptions indicative of delusions or hallucinations.
o In the dunking test, if the women did not drown, she was thought to be in league
with the devil. But if you drown, you weren’t but you end up dead.
o This indicates that witchcraft was not the primary interpretation of mental illness.
- “lunacy” trials to determine a person’s sanity were held in England.

Development of Asylums
→ Bethlehem and Other Early Asylums
- Bedlam; a contraction and popular name for this hospital, became a descriptive term for
a place of scene of wild uproar and confusion.
o This became one of London’s great tourist attractions, by the eighteenth century
rivalling both Westminster Abbey and the tower of London.
- In the Lunatics’ Tower constructed in Vienne in 1784, patients were confined in the
spaces between inner square rooms and the outer walls, where they could be viewed by
passersby.
- Medical treatment were often crude and painful.
- Benjamin Rush, who began practising medicine in Philadelphia in 1769, he believed that
mental disorder was caused by an excess of blood in the brain.
o He favoured treatment was to draw great quantities of blood
o He also believed that many “lunatics “could be cursed by being frightened.

→ Moral Treatment
- Philippe Pinel considered a primary figure in the movement for humanitarian treatment
of the asylums.
o He began to treat patients as sick human beings rather than beasts.
o Pinel did for people with mental illness, he was not a complete paragon of
enlightenment and egalitarianism. The more humanitarian treatment he reserved for
the upper classes; patients of the lower classes were still subjected to terror and
coercion as a means of control
- Quaker, William Tuke was shocked by the conditions at York Asylum in England,
proposed to the Society of Friends that it found its own institution.
o It was a country estate, providing mentally ill people with a quiet and religious
atmosphere in which to live, work and rest.
o Patients discussed the moral treatment offered at the York Retreat as a form of
affective conditioning informed by “benevolent theory” steeped in religious ethics.

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o He believed that a central aspect of moral treatment was restoring a patient’s sense
of self- esteem by letting her or him demonstrate self-restraint.
- This is known as the moral treatment, patients had close contact with the attendants, who
talked and read to them and encouraged them to engage in purpose activity residents led as
normal lives as possible and in general took responsibility for themselves within the
constraints of their disorders.
- Ironically, the efforts of the Dorothea Dix, a crusader for improved conditions for people
with mental illness, helped effect this change.

→ Asylums in Canada
- LaJeunesse documented how attempts at moral treatment in Alberta in the early twentieth
century were undercut by Primer Arthur Sfiton’s decision to focus on larger institutes ,
where patients were crowded into building with inadequate space
- Dr. Henry Hunt Stabb made heroic efforts to institute moral treatment and non- restraint
at the Lunatic Asylum in St, Johns Newfoundland.
- Mentally ill people were admitted to hospital in Quebec as early as 1714, but psychiatric
asylums emerged in the decade following 1840, and eventually there was a network of
asylums.
- The process began with humane intentions as part of a progressive and reformist
movement, which attempted to overcome neglect and suffering.
- Alberta was the last province to open an asylum for the insane
- Asylum superintends were British-trained physicians who modelled the asylums after
British Forms of structure, treatment, and administration, although Barlett,
- “Dangerously overcrowded” and lamented the fact that this overcrowding was responsible
for striking increase in the death list and for the impaired general health of the inmates.
- Almost 20% of the inmates died while in the institution, a large number due to the “general
paresis of the insane” and to a condition called “phthisis”.
- There are concerns that exist today that Canada has developed a two-tier medial system in
which the wealthy have more opportunity for, and quick access to, superior quality care.
o In 1853 the legislature passed the Private Lunatic Asylums Act to accommodate
the wealthy in alternatives to the public asylums.
- This history of development of institutions of the mentally disordered in Canada can be
characterized in terms of two distinctive trends
o Provincial psychiatric hospitals; is “tertiary” that is they provide specialized
treatment and rehabilitation services for individuals whose needs for are too
complex to be managed in the community.
o Community treatment orders; a legal tool issued by a medical practitioner that
establishes the conditioned under which a mentally ill person may live in the
community, including requirements for compliance with treatment.
o The consequence for a patient of failing to follow the CTO is being returned to a
psychiatric faculty for assessment.
- Transinsitutionalization; phenomena where inmates released from one therapeutic
community move into other institutions, either as planned move or as an unforeseen
consequence

The Beginning of Contemporary Thought

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→ An Early system or Classification

- Wilhelm Griesinger, was impressed by Sydenham’s approach, he insisted that any
diagnosis of mental disorder specify a biological cause
- Kraepelin discerned among mental disorders a tendency for a certain group of symptoms;
syndromes,
o He regarded each mental illness as distinct from all others, having its own genesis,
symptoms, course, and outcome.
o He proposed two major groups of severe mental diseases: dementia praecox, an
term for schizophrenia and manic-depressive psychosis (not called bipolar
disorder)
o He postulated a chemical imbalance as the cause of schizophrenia and an
irregularity in metabolism as the explanation of manic-depressive psychosis.

→ General Paresis and Syphilis

A steady deterioration of both physical and mental abilities and that these patients suffered
multiple impairments, including delusions of grandeur and progressive paralysis. This
deterioration in mental and physical health was designated a disease, general paresis.
o Although it was established that some patients with paresis had earlier syphilis,
there were many competing theories for the origin of paresis.
- Louis Pasteur established the germ theory of disease, which set forth the view that disease
is caused by infection of body by multiple organisms.
o This theory laid the groundwork for demonstrating the relation between syphilis
and general paresis.

→ Psychogenesis
- Some investigators considered mental illnesses to have an entirely different origin. Various
psychogenic points of view, which attributed mental disorders to psychological
malfunctions, were fashionable in France and Austria

→ Mesmer and Charcot

Franz Anton Mesmer
- He felt that one person could influence that fluid of another to bring about a change in the
other’s behaviour.
- He conducted meetings closed in mystery and mysticism at which afflicted patients sat
around savoured banquet, or tub.
o Iron rods protruded through the over of the banquet from bottles underneath that
contained various chemicals.
o He would enter a room, take various rods form the tub, and touch afflicted parts of
his patient’s bodies.
o The rods were believed to transmit animal magnetism and adjust the distribution of
the universal magnetic fluid, thereby removing the hysterical disorder.
Jean Martin Charcot
- He espoused a somatogenic point of view.
- Some of his students hypnotized a normal women ad prompted her to display certain
hysterical symptoms.

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- He changed his mind about hysteria and became interested in non-physiological

interpretations of these very puzzling phenomena.

→ Breur and the cathartic method

Josef Breuer treated a young woman who had become bedridden with a number of hysterical
symptoms.
o The experience of reliving an earlier emotional catastrophe and releasing the
mention tension caused by suppressed thoughts about the event was called
catharsis
o Breur’s method became known as the cathartic method.

Current Attitudes towards People with Psychological Disorders

→ The Public Perception
- People with psychological disorders are unstable and dangerous and psychological
disorders can never “cured
- A study found that the majority of Canadians believe that maintaining mental health is
“very important”. (95% of women and 88% of men) However, relative to a 1997 survey,
fewer Canadians were willing to tell their bosses of friends if they were receiving help for
their depression.

→ Anti-Stigma Campaigns
A preventive intervention developed by Stuart sought to reduce stigma in high school students
through a video-based about learning program (the schizophrenia society of Canada’s reaching out
program) that chronicled the challenges of actual people with schizophrenia.
o Exposure to the program results in increased knowledge of schizophrenia and its
treatment and less social distancing.
o Female students showed greater gains in understand than males.

→ Mental Health Literacy

The term mental health literacy has been created to refer to the accurate knowledge that a person
develops about mental illness and its causes and treatment.

Mental Health Problems and Their Treatment in Canada

➔ Regional Differences
There is obvious difference in certain parts of Canada.
Eg.
- In both newfoundland and Labrador and Prince Edward Island are have reported the most
happiness and least distress.
- Quebec is reported very high levels of self-esteem and mastery but the least happiness and
most distress.

Cost of Mental Health Problems

A study from Ontario estimated that the burden of mental illness and addictions is 1.5x greater
than the combined burden of all cancers.
o The five disorders with the highest amount of burden were depression, bipolar
disorder, alcohol use disorders, social phobia and schizophrenia.

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Transformations in Canada’s Mental Health System

→ Romanow Report
- The mandate was to engage Canadians in a national dialogue and to asses options for a
long-term, sustainable, universally accessible, publicly funded health care system.
- Two key policy weaknesses in the mental health area in Canada
o A fragmented constituency
o The lack of a comprehensive national plan
- Romannow proposed the establishment of an new program to provide direct support to
informal caregiver to allow them to be away from work to prove necessary home care
assistance at critical times.
- Numerous mental health professional and advocacy groups endorse these and other key
recommendations and urged the Minister of Health to include them to any proposed
implementations plans in order to offer hope to people with serious mental illnesses.
o This causes frustration because his recommendations had not been implemented.

→ The Senate Committee Final Report

The Senate committee put forward 118 specific recommendations for transforming Canada’s
mental health systems. Two recommendations were key
o Mental Health Commission of Canada: The commission would pave the way for
a national action plan. It would complement work being done by people and
existing structures at all government levels and be designed according to two key
principles:
▪ An independent not-for-profit organization at arm’s length from
governments
▪ Existing stakeholder organizations, and one with central focus on those
living with mental illness and their families.
o Mental Health Transition Fund: allow the federal government to make a time-
limited investment to per transition cost and to speed the process of developing a
community-based system.

Delivery of Psychotherapy: Issues and Challenges

→ Wait Times for Treatment
The national median wait time for those seeking psychiatric treatment in 2015 was 19.8 weeks.
Which far exceeds which specialist believe is appropriate. Most specific finding included that
- The short wait times were in Ontario (15.8), British Columbia (18.5) and Manitoba (19.5)
- The longest wait times were in Newfoundland and Labrador followed by New Brunswick.
Data were not available for P.E.I which tends to historically have one of the longest wait
times
- The median wait time to see a psychiatrist on a urgent basis was 2.0 weeks, whereas on an
elective basis it was 8.2 weeks.

A group called Wait Time Alliance concluded in 2014 that no significant progress has occurred
in terms of reducing wait times.
- Reports of wait times from at least 3 months to over a year have surfaced and seem far too
common.
-

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→ Help-Seeking and Perceived Need for Help

The problem of lengthy wait times would be substantially greater if everyone in Canada who
needed it asked for help.
- Comorbid is the present of three or more disorders if they exist simultaneously – was
associated with increased likelihood of seeking help, but it was still the case that 35% of
women with three or more disorders did not seek help.

→ The Human Costs of Deinstitutionalization and Limits Access to Service

- Unfortunately, the consequence of deinstitutionalization in an area of escalating needs for
services are multiple and include homelessness and a lack of supported housing, the jailing
of the mentally ill, the filature to achieve an ideal of community-focused care for people
with mental disorders, a lack of home is, insufficient intensive care management, too few
community-based crisis response system concerns about community treatment orders.
- The issue of incarcerating mentally ill people became an extremely salient one In Canada
was result of the case of Ashley Smith, who strangled herself in 2007 at the Grand Valley
Institution for Women in Kitchener, Ontario. There were staff that seeming in a position to
intervene but did not stop her.

→ Community Psychology and Prevention

- Community psychology in contrast, operates in “the seeking mode”. Rather than waiting
for people to initiate contact, community psychologist’s week out problem or even
potential problems
- Prevention, in contrast to the more usual situation of trying to reduce the severity or
duration of an existing problem.

→ New Beginning: Canada’s Mental Health Strategy

Direction, Chaining Lives is built on six key strategic direction
o Promote mental health across the lifespan in homes, schools and workplace and
prevent mental illness and suicide wherever possible
o Forster recovery and well-being for people of all ages living with mental health
problems and illness, and uphold their rights.
o Provide access to the right combinations of services, treatment, and supports, when
and where people need them.
o Reduce disparities in risk factors and access to mental health services, and
strengthen the response to the needs to diverse communities and Northern
o Work with first nations, Inuit and metis citizens to address their distinct mental
health needs, acknowledging their unique circumstances rights and cultures
o Mobilize leadership, improve knowledge and foster collaboration at all levels
▪ This plan will work only to the extent that public and private resources are
dedicated to the mental health and well-being of people in Canada

Chapter 2: Current Paradigms and the Integrative Approaches

- The Biological Paradigm(medical model or disease model)
The biological paradigm of abnormal behaviour is a continuation of the somatogenic hypothesis.
o Eg. Is its influence is Hall’s use of gynaecological procedures to treat “insanity”
in women from British Columbia.

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Contemporary Approaches to the Biological Paradigm

→ Behaviour Genetics
- Genotype is his or her unobservable genetic constitutions. This is fixed at birth, but it
should not be viewed as static entity
- Phenotype the totality of his or her observable, behavioural characterises, such as level of
anxiety. Phenotype changes over time and is viewed as the product of an interaction
between the genotype and the environment.
The study of behaviour genetics has relied on four basic methods to uncover whether a
predisposition for psychopathology is inherited: comparison of members of a family,
comparison of pairs twins, the investigation of adoptees, and linkage analysis.
- Family method can be used to study a genetic predisposition among members of family
because the average number of genes shared by two blood relatives is known.
- People who share 50% of their genes with a given individual are called first-degree
relatives of that person.
- Nephews and nieces share 25% of the genetic makeup of an uncle and are second-degree
relative.
- If a genetic predisposition to the disorder being studied is present, first-degree relatives of
the index cases should have the disorder at a rate higher than that found in the general
population.

In the twin method, both monozygotic (MZ) twins and dizygotic (DZ) twins are compared.
- MZ, or identical, twin develop from a single fertilized egg and typically they are genetically
the same. Always the same sex
o A growing number of studies have identified MZ twins who differ both genetically
and epigenetically in terms of developmental changes in gene expression.
- DZ, fraternal pairs develop from separate eggs and are on average only 50% alike
genetically, no more alike than any other two siblings. Can be either the same sex or
different.
- When the twins are similar diagnostically, they are said to be concordant. To the extent
that a predisposition for a mental disorder can be inherited, concordance for the disorder
should be greater in genetically identical MZ pairs than in DZ pairs.
- Research using the adoptees method study children with abnormal disorders who were
adopted and reared apart from their parents.

→ Molecular Genetics
It tries to specify the particular gene or genes involved and the precise functions of these genes
- Genetic Polymorphism is the variability that occurs among members of the species. It
involves differences in the DNA sequences that can manifest in very different forms among
members in the same habitat.
- Linkage analysis is a method in molecular genetics used to study people.
o They collect diagnostic information and blood samples from affected individuals
and their relatives and use the blood samples to study the inheritance pattern of
characteristics whose genetics are fully understood, referred to as genetic markers.

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o Researchers in this area often hypothesize gene-environment interactions. This is

the notion that a disorder or related symptoms are the joint product of a genetic
vulnerability and specific environmental experiences or conditions.
- One concern is that an exclusive focus on genetic factors promotes the notion that illness
and mental illness are predetermined.

→ Genetic Difference Reflected in temperament

Current research on temperament is based on the notion that individual differences among people
are largely attributable to genetically predetermined differences that are detectable almost as soon
as children are born.
- Temperament as constitutionally based differences in reactivity and self-regulation.
- Pioneering work by Thomas and Chess led to the identification of 3 temperament styles
o Difficult child
o Easy child
o Hard-to-warm-up child, who is more reserved
- Robins, John, Caspi, Moffitt, and Stouthamer-Loever analyzed data from 300
adolescent boys in the United states and found 3 types of categories
o Resilient type
These type of children cope well with adversity.
o Over controlling type
These children are overly inhibited and prone to distress.
o Undercontrolling type
These kids are prone to acting out and aggressive behaviours & impulsive and can seem out of
control at times.

→ Neuroscience and Biochemistry in the Nervous System

o Nerve impulse change in the electric potential of the cell, travels down the axon to
the terminal endings.
o Synapse; between the terminal endings of the sending axon and the cell membrane
of the receiving neuron, there is a small gap.
- For a nerve impulse to pass form one neuron to another and for communications to occur,
the impulse must have a way of bridging the synaptic gap
- The terminal ends of each axon contain synaptic vesicles, small structures that are filled
with neurotransmitters, chemical substance that allow a nerve impulse to cross the
synapse.
o When a neurotransmitter fits into a receptor site, a message can be sent to the
postsynaptic cell.
▪ Sometimes these messages are excitatory, leading to the creation of a nerve
impulse in the postsynaptic cell; at other times, the messages can be
inhibitory, making the postsynaptic cell less likely to fire.
▪ Inhibitory neurotransmitters act as mood stabilizers or balancers, while
excitatory neurotransmitters stimulate the brain.
- Several key neurotransmitter have been implicated in psychopathology.
o Norepinephrine, a neurotransmitter of the peripheral sympathetic nervous
system, is involved in producing stages of high arousal and is involved in anxiety
disorders.

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o Both serotonin and dopamine are neurotransmitters in the brain; serotonin may
be involved in depression, and dopamine in schizophrenia.
o Another important brain transmitter is GABA, which inhibits some nerve impulses
and is implicated in anxiety disorders.

Biological Approaches to Treatment

An important implication of the biological paradigm is that prevention or treatment of mental
disorders should be possible by altering bodily functioning.
o This practice involved planting battery-operated electrode in the brain that deliver
low-level electrical impulses.
▪ Unfortunately, only 3 of the 15 people in the deep brain stimulation group
had improved

Evaluating the Biological Paradigm

Reductionism is the view that whatever is being studied can be and should be reduced to its most
basic elements or constitutes,

The Cognitive-Behaviour Paradigm

→ The Rise of Behaviourism
John B. Watson is a key figure in the rise of behaviourism.
- As a response to the focus on introspection favoured by many others in the field of human
psychology, in 1913, Watson promoted a focus on behaviourism by extrapolating from the
work os psychologists who were investigating learning in animals
- Behaviourism can be defined as an approach that focuses on observable behaviour rather
than on consciousness.
- There are 3 types of learning have attracted the research efforts of psychologists

o Classical Conditioning
This was discovered by Ivan Pavlov (1849-1939).
- In this experiment, because the meat powder automatically elicits salivation with no prior
learning, the powder is termed an unconditioned stimulus and the response to it,
salivation, an unconditioned response.
- When the offering of meat powder is preceded several times by the ringing of a bell, a
neutral stimulus, the sound of the bell alone (the conditioned stimulus) is able to elicit the
salivary response (conditioned response)
- Extinction is what happens to the CR when the repeated sounding of the bell are later not
followed by meat powder; fewer and fewer salivations are elicited, and the CR gradually
disappears.
A famous experiment conducted by John Watson and Rosalie Rayner discovered that classical
condition could work with fear.
- Little Albert experiment. A loud noise would play in the presence of a rat.
- This study suggests the possible association between classical conditioning and the
development of certain emotional disorder, including phobias.
- Contemporary research in abnormal psychology has continued to implicate classical
conditioning in the development of anxiety disorders.

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o Operant Conditioning
It applied to behaviour that operates on the environment.
- B.F. Skinner reformulated the law of effect by shifting the focus form the linking of
stimuli and responses to the relationships between responses and their consequences or
contingencies.
- Skinner distinguished two types of reinforcement that influence behaviour.
o Positive reinforcement is the strengthening of a tendency to respond by virtue of
the presentation of a pleasant event, called a positive reinforcer.
o Negative reinforcement also strengthens a response, but it does so via the removal
of an aversive event, such as the cessation of electric shock.called such
consequences negative reinforcers.
- He was responsible for the study of operant behaviour and the extension of this approach
to education, psychotherapy, and society as a whole.
o Modelling
We learn by watching and imitating others
- Experimental work by Albert Bandura and others
- They used a modelling treatment to reduce the fear of dogs in children. After witnessing a
fearless model engage in various activities with a dog, initially fearful children became
more willing to approach and handle a dog.
- Modelling may explain the acquisition of abnormal behaviour.
- Children of parents with phobias or substance-abuse problems may acquire similar
behaviour patterns, in part through modelling.

Albert Bandura developed social learning and cognitive self-regulation theories that influenced
the development of both learning and cognitive paradigms.
- Research on Social Learning is about children who witnessed an adult being aggressive
with a plastic Bobo doll.
- These variations led Bandura to conclude that there are four key processes in observational
learning; attention (noticing the model’s behaviour); retention (remembering the model’s
behaviour); reproduction (personally exhibiting the behaviour); and motivation
(repeating imitated behaviours if they received positive consequences)
- His more recent work is a cognitive self-regulation theory known as social cognitive
theory that focuses on the concept of human agency and self-efficacy, an individual’s
perceived sense of being capable.
o Self-Regulation is a multi-stage process that involved self- observation, self-
judgment by comparing personal achievements and behaviours with standards and
goals, and self-response in the form of self-reinforcement and praise or self-
punishment and criticism.

- Behaviour Therapy (behaviour modification0

In its initial form, this therapy applied procedures based on classical and operant conditioning to
alter clinical problems. This is an attempt to change abnormal behaviour, thoughts and feelings by
applying in a clinical context the methods used and the discoveries made by experimental
psychologist in their study of both normal and abnormal behaviour.
o Cognitive behaviour therapy is often considered a fourth aspect of behaviour
therapy,

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▪ Counterconditioning and exposure

Counterconditioning is relearning achieved by electing a new response in the presence of a
particular stimulus.

- The counterconditioning principles is behind an important behaviour therapy technique,

systematic desensitization, developed by Joesph Wolp.

- An other type of counterconditioning, aversive conditioning, In this, a stimulus attractive

to the client is paired with an unpleasant event, such as a drug that produces nausea, In the
hope of endowing it with negative properties.

The Cognitive Perspective

- Cognition term that groups together the mental processes of perceiving, recognizing,
conceiving, judging, and reasoning.
- Cognitive Paradigm focuses on how people (and animals) structure their experiences,
how they make sense of them, and how they relate their current experiences to past ones
that have been stores in memory.

- The Basics of Cognitive Theory

The learner fits new information into a organized network of already accumulated knowledge,
often referred to as a schema, or cognitive set.

- Beck’s Cognitive Therapy

The psychiatrist Aaron Beck developed a cognitive therapy (CT) for depression based on the idea
that a depressed mood is caused by distortions in the way people perceive life experiences.

- The general goal of Beck’s therapy is to provide clients with experiences, both inside and
outside the consulting room, that will alter their negative schemas and dysfunctional beliefs
and attitudes.
Because this approach focused on the role of dysfunctional thoughts and beliefs, the main emphasis
of therapy is replacing these thoughts with more adaptive thoughts.

Rational-Emotive Behaviour Therapy

- Theory of rational-emotive behaviour therapy
Albert Ellis was another leading cognitive therapist. His principal thesis was that sustained
emotional reaction are caused by internal sentences that people repeat to themselves, and these
self-statements reflect sometimes unspoken assumptions
- Elli’s rational-emotive therapy (RET) – rational-emotive behaviour therapy (REBT),
the aim is to eliminate self-defeating beliefs through a rational examination of them.
o Clinical Implementation of REBT
Once a client verbalizes a different belief or self-statement during a therapy session, it must be
made part of everyday thinking.
- Ellis emphasizes the importance of getting the client to behave differently, both to test out
new belief and learn to cope with life’s disappointments.
- This is how this approach becomes both cognitive and behavioural

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Cognitive Behaviour Therapy

- The Cognitive-Behaviour Integrated Approach
Classical behavioural therapies emphasize the direct manipulation of overt behaviour and
occasionally of covert behaviour, with thoughts and feelings being construed as internal
behaviours.
o Cognitive- behavioural therapy (CBT) does incorporate theory and research on
cognitive and behavioural processes and represents a blend of cognitive and
learning principals
o Cognitive restructuring is a general term for changing a pattern of thought that is
presumed to be causing a disturbed emotion or behaviour

The Psychoanalytic Paradigm

→ Classical Psychoanalytic Theory
This refers to the original view of Freud. His theories encompassed both the structure of the mind
itself and the development and dynamics of personality.
- Structure of the Mind
He divided the mind, or the psyche, into 3 parts; id, ego, and superego.
o Id – present at birth and is part of the mind that accounts for all the energy needed
to run the psyche. He saw the source of all the id’s energy as biological. This energy
called libido, converted into psychic energy, all of it unconscious, below the level
of awareness.
▪ This seeks immediate gratification and operates according to the pleasure
principle.
▪ When the id is not satisfied, tension is produced, and the id strives to
eliminate this tension.
• Eg. The infant feels hunger, an aversive drive, and is impelled to
move about, sucking, to reduce the tension
o Ego – primarily conscious and begins to develop from the id during the second six
months of life.
▪ Though its planning and decision-making functions, called secondary
process thinking, the ego realizes that operating on the pleasure principle
at all times is not the most effective way of maintaining life.
o Superego – operates roughly as the conscience and develops throughout childhood.
- Psychodynamics- the behaviour of human being, as conceptualized by Freud, is a complex
interplay of these three parts of the psyche.

Neurotic Anxiety
When one’s life is in jeopardy, one fells objective (realistic) anxiety – the ego’s reaction,
according to Freud, to danger in the external world.
- neurotic anxiety a feeling of fear that is not connected to reality or to any real threat.
- Moral Anxiety that drives the supergo – namely the perfection principle.

→ Defences Mechanisms: Coping with Anxiety

A defence mechanism is a strategy, unconsciously need, to protect the ego form anxiety.
- Repression which pushes unacceptable impulses and thoughts into the unconscious.

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o By remaining repressed, these infantile memories and desires cannot be corrected

by adult experiences and therefore retain their original intensity and immaturity.
- Denial - entails disavowing a traumatic experience, such as being raped, and pushing it
into the unconscious
- Projection attributes to external agents characteristics or desires that an individual
possesses but cannot accept in his or her conscious awareness.
o Eg. A woman who unconsciously is averse to regarding herself as angry at others
may instead see others as angry with her.
- Displacement- redirecting emotional responses from a dangerous object to a substitute
- Reaction Formation - converting one into its opposite
- Regression - retreating to the behavioural patterns of an earlier age
- Rationalization, inventing a reason for an unreasonable action or attitude
- Sublimation- converting sexual or aggressive impulses into socially valued behaviours,
especially creative activity

→ Psychoanalytic Therapy
Classical psychoanalysis is based on Freud’s second theory of neurotic anxiety is the reaction of
the ego when a previously punished and repressed id impulse presses for expression.
- Psychoanalytic therapy is an insight therapy. It attempts to remove the earlier repression
and help the client face the childhood conflict, gain insight into it, and resolve it in the light
of adult reality.
- Psychotherapy is a social interaction in which a trained professional try to help another
person, the client or patient, behave and feel differently.
- London categorized psychotherapies as insight therapies or action (behavioural)
therapies.
o Insight therapies assume the behaviour, emotions and thoughts become disordered
because people do not understand what motivates them, especially when their needs
nad drives conflict.

- Dream analysis, in sleep, ego defences are relaxed, allowing normally repressed material
to enter the sleeper’s consciousness.

- Transference; the client’s responses to the analyst are not in keeping with the analyst-
client relationship but seem instead to reflect relationships with important people in the
client’s past.

- Countertransference; is the analyst’s feeling towards the client. Analyst must be away of
their own feelings so that they can see the client clearly.

- Interpretation; repressed material begins to appear in therapy.

Ego analysis
→ Brief psychodynamic therapy
- This shorter form was developed to meet the expectations of the many clients who prefer
therapy to be fairly short term and targeted to specific problems in their every lives.

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o Contemporary psychoanalytic thought

Lerner has provided a contemporary assessment of psychoanalysis and current psychodynamic
perspectives. He has identified five conceptual approaches that are predominant in contemporary
psychoanalytic thought
- Modern structural theory, Self-psychology, Object relations theory, Interpersonal-
relational and Attachment theory

o Interpersonal therapy
This a contemporary variation of brief psychodynamic therapy that has grown in popularity and
impact.
- an important goal is to examine these past influences in terms of how they have an impact
on and contribute to current relationships.

The Humanistic Paradigm

- Humanistic therapies, like psychoanalytic therapies, are insight-focused, based on the
assumption that disordered behaviour results from a lack of insight, and can best treated by
increasing the individual’s awareness of motivations and needs.
- Humanistic paradigm places greater emphasis on the person’s freedom of choice, regarding
free will as the person’s most important characteristic.

→ Carl Rogers’ Client- Centered Therapy

Rogers’ client-centred therapy is based on several assumptions about human nature and the way
we can try to understand it.
- When people are not concerned with the evaluations, demands, and preferences of others,
their lives are guided by an innate tendency towards self- actualization

o Rogers’ Therapeutic Intervention

- The client is to take the lead and direct the course of the conversation and the session
- The therapist’s job is to create the condition that, during the session, help the client return
to this or her basic nature and judge which course of life is intrinsically gratifying.
- People must take responsibility for themselves, even when they are troubled.
- Empathy is so important in Rogerian therapy and in all other kinds of therapy.
o Primary empathy is the therapist’s understand, accepting, and communicating to
the client what the client is thinking of feelings. The therapist conveys primary by
restating the client’s thoughts ad feelings, pretty much in the client’s own words.
o Advanced empathy entails an inference by the therapist of the thoughts and
feelings that lie behind what the client is saying, and of which the client may only
be dimly, it at all, aware.
▪ At the advanced or interpretive level, the therapist offers something new, a
perspective that he or she hopes is better, more productive, and that implies
new modes of action.
- Client-centred therapy- and all other phenomenological therapies – concentrates on client
adopting frameworks different from those they had upon beginning treatment

Consequences of Adopting a Paradigm

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→ Different Perspective on a Clinical Problem: Cathy – A Case of Trichotillomania

- A behavioural theorist would focus on the reinforcement of the relief of tension provided
by chronic hair pulling
o A psychoanalytic theorist would focus on the interpersonal dynamics and early.
o The trichotillomania could be attributed to a sense of anxiety reflecting the
unconscious interplay of the id and the superego, with this conflict distracting the
ego from the conscious need to study and do well in school.
o As it turned out, this person suffered from extreme levels of perfectionism and
concern over mistakes and this became a central focus of treatment.

→ Eclecticism in Psychotherapy: Practice Makes Imperfect

Eclecticism, employing ideas that therapeutic techniques from a variety of school.
- Those who engage in eclectic therapy prefer the term “integrative” rather than “eclectic”,
and most common integration is cognitive therapy
- Therapist often behave in ways not entirely consistent with the theories they hot.
- Behavioural theories do no prescribe such a procedure, but on the basis of clinical
experience, and perhaps through their own humanity, behaviour therapist have realized that
empathic listening helps them establish rapport, determine what is really bothering the
client, and plan a sensible therapy programs.

Psychosocial Influences on Mental Health

→ Familial Factors
Classic psychoanalytic theory places great importance on a child’s early experiences with her or
his parents.
- Parenting Styles
Diana Baumrind identified three parents styles: authoritarian parenting, permissive
parenting, and authoritative parenting
o The authoritarian and permissive styles lead to negative outcomes in children,
but for different reasons.
▪ Authoritarian parents tend to be restrictive, punitive, and over controlling.
▪ Exposure to authoritarian parenting also leads to poorer intellectual and
social development.
▪ authoritarian parents are overinvolved with their children, permissive
parents show little involvement and may seem disinterested in their
children.
▪ This type of parenting style is also associated with internalizing and
externalizing symptoms in children.
o Authoritative approach
▪ They use discipline in conjunction with reason and warmth
- Affluenza
Soniya Luthar and her colleagues has helped us to understand that coming from an affluent home
is not necessarily protective when it is companied by a destructive parental orientation.

- Parental Marital Discord

Conflict in the family is also implicated in poor mental health

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- Parental Mental Illness

One of the most pernicious risk factors is exposure to mental illness in one of both parents.
o Children with a mentally ill parent describe the delicate balancing act of trying to
cope with the parental mental health problems while trying to maintain their own
relationships.

→ Peers and the Broader Social Environment

Research on the role of peer influences on psychopathology tends to emphasize two elements:
peer status and peer victimization.
- Contemporary research on peer status is focusing on the feeling exclusion and how it
relates to a personality style known as rejection sensitivity, with some people being
hypersensitive to whether they are accepted or rejected by others.
- Peer influences are not independent of parental factors; for instance, rejection sensitivity is
linked with a reported history of low parental acceptance and perceived parental rejection.
- The tireless efforts of the members of PREVnet have resulted in substantial improvements
focused on four themes: education, assessment, intervention and policy.
- A key feature of PREVNet is its annual international conference on bullying, which
provides a forum for the latest research

The Cultural Context

- Cultural Diversity is important to highly heterogeneous countries such as Canada, since
most of our discussion of psychopathology is presented within the context and constraints
of Western European society.
- Theories of multicultural counselling and therapy attempt to incorporate these revisions
into an integrated perspective.

→ Psychiatric Problems in Minority Groups

Research on the mental health of immigrants to Canada has found additional evidence for what is
known as the healthy immigrant effect and this has been attributed in part to pre-screening
processes that limit entry to potential immigrants with health problems.
- The healthy immigrant effect is more evident among adults, and less detectable among
children who immigrated at a relatively early age had a comparatively higher risk for mood
disorders.
- Cultural diversity has implications of the assessment and diagnosis of psychological
disorders.
o In terms of clinical assessment, it is problematic that clinicians often interact with
clients who have difficulty conversing in one of the official languages of Canada.

Diathesis – Stress and Biopsychosocial Integrative Paradigms

→ The Diathesis – Stress Paradigm
- Diathesis refers most precisely to a constitutional predisposition towards illness, but the
term may be extended to any characteristic or set of characteristics that increase a person’s
change of developing a disorder
- Differential susceptibility – suggested and showed that some factors that are considered
diatheses should actually be considered differential susceptibility factors because they

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involved the expected adverse reaction to negative experience by also positive reaction to
positive experiences.

→ The Biopsychosocial Paradigm

- The key point about the biopsychosocial paradigm is that explanations for the causes of
disorders typically involved complex interactions among many biological, psychological
and socio-environmental and soico-cultural factors.
- Protection from risk factors, or the ability to bounce back in the face of adversity is ferred
to as resilience.

▪ An Example: Soico-Economic Status and Poverty

The key factor for those with low SES was chronic maternal stress during the child’s infancy.
- The key factor for those from a high SES background was a parental history
- An important caveat about SEs is that many of its effect are actually due to living in an
impoverished neighbourhood.
- The negative impact of being poor is amplified when the person lives in a poor
neighbourhood

Chapter 3: Clinical Assessment, Classification and Diagnosis

Reliability and Validity in Assessment
→ Reliability
Consistency of measurement
- Inter-rater reliability measures the degree to which two independent observers of judges
agree.
- Test-retest reliability measure the extent to which people being observed twice or taking
the same test twice, perhaps several weeks or months apart, score in generally the same
way. This kind of reliability makes sense only when the theory assumes that people will
not change appreciably between testings on the variable being measured.
o Eg. Evaluating intelligence test
- Alternate-form reliability; psychologist use two different forms of test rather than giving
the same test twice because participants may remember their answers from last time.
- Internal consistency reliability assesses whether the items on attest are related to one
another.
In each of these types of reliability, a correlation- a measure of how closely two variables are
related – is calculated between rater or sets of items.

→ Validity
The extent to which a measure fulfills its intended purpose.
o Eg. If a questionnaire is intended to measure a person’s hostility.
It is important to note that validly is related to reliability: unreliable measure will not have good
validity because unreliable measure does not yield consistent results, an unreliable measure will
not relate very strongly to other measure.
o Eg. Unreliable measure of coping is not likely to relate well to how a person adjusts
to a stressful life experience.
- Content validity is the extent to which a measure adequately samples the domain of
interest.

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- Criterion validity evaluated by determining whether a measure is associated in an

expected way with some other measure.
- Construct validity relevant when we want to interpret a test as a measure of some
characteristic or construct that is not simple.
- Case Validity; has been suggested recently by Teglasi, Nebbergall, and Newman. This
unique because the focus here is on validity of the interpretations and decision made with
respect to a particular person. Case validity would be demonstrated when the person is
accurately assessed in their life context in a way that takes into account interactions
between the person and situations as well as interactions of the person’s schemas.

Psychological Assessment
→ Clinical Interviews
Pays attention to how the respondent answer – or does not answer – questions.
- Both reliability and validity may indeed be low for a single clinical interview that is
conducted in an unstructured fashion.

→ Structured Interviews
Questions are set out in a prescribed fashion for the interviewers.
- SCID is a branching interview; that is, the client’s response to one question determine the
next questions that is asked.
- There are many other structured interviews and the use of such interviews is a major factor
in the improvement of diagnostic reliability.

- Evidence – Base Assessment

Hunsley and Mash are pioneers who have advocated for evidence – base assessment are a way
of paralleling developments in evidence- based treatments.
- Evidence-based assessment selects assessment measures based on extensive criteria
including the reliability and validity of the measure and reading level required.
- Numerous problems undermining clinical assessment in actual setting were identified
including.
o Suggestions that very low numbers of clinicians adhere to best practice assessment
guidelines

→ Psychological Tests
Standardized procedures designed to measure a person’s performance on a particular task or to
assess his or her personality, or thought, feelings and behaviour.
o Standardization- statistical norms for the test can thereby be established as soon
as sufficient data have been collected.
o Test Norms are standards that are used to interpret an individual’s score because
the score by itself of an individual is meaningless without a comparison context.
▪ These are usually expressed in terms of the mean score obtained by specific
groups and the distribution or variability of score within a population.

- Personality Inventories
The person is asked to complete a self-report questionnaire indicating whether statements
assessing habitual tendencies apply to him or her.

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o Minnesota Multiphasic Personality Inventory (MMPI) was developed bin the

early 1940s by Hathaway and McKinley and revised in 1989 as the MMPI-2.
▪ It’s intent was to serve as an inexpensive means of detecting
psychopathology, the MMPI is called multiphasic because it was designed
to detect a number of psychological problems
o The MMPI-2 has several noteworthy changes designed to improve its validity and
acceptability.
▪ MMPI-2 is quite similar to the original, having the same formal, yielding
the same scale scores and profiles, and providing continuity with vast
literature already existing on the original MMPI.
▪ Less- Haley Fake Bad Scale– this scale was created to primarily identify
people in personal litigation lawsuits who claim to have been injured by
who are actually malingering and faking bad

- Projective Personality Tests

Projective test- psychological assessment device in which a set of standard stimuli – inkblot or
drawing – ambiguous enough to allow variation in responses in present to the individual.
- The assumption is that because the stimulus materials are unstructured, the client’s
response will be determined primarily by unconscious processes and will reveal his or her
true attitude, motivation and modes of behaviours. (projective hypothesis)
Rorschach Ink Blot test – best known projective technique. Half the inkblot are in black, white
and shades of grey, two also have red splots and three are in pastel colours. This test has been
matter of controversy and public debate.
- The test is considered more as a perceptual- cognitive task, and the person’s response are
viewed as a sample of how he or she perceptually and cognitively organizes real-life
situations.
Thematic Apperception Test (TAT) - a person is shown a series of black- and –white picture
one by one and asked to tell a story related to each.

→ Intelligence Tests
Alfred Binet, a French psychologist, originally constructed mental tests to help the Parisian school
board predict which children were in need to special schooling.
An intelligence test, referred as an IQ test, is a standardized means of assessing a person’s current
mental ability.
- Individually administered test, such as the Wechsler Adult Intelligence Scale (WAIS),
the Wechsler Intelligence Scale of Children (WISC), and the Standford-Binet, are all
based on the assumption that a detailed sample of an individual’s current intellectual
functioning can predict how well he or she will preform in school.
o As part of neuropsychological evaluations.
- IQ tests are highly reliable and have a good criterion validity.
- Race norms – one solutions that is used to rely, revised norms for various racial or
cultural groups

→ Behavioural and Cognitive Assessment and Case Formulation

Cognitive assessment focuses on the person’s perception of a situations, since the same event can
be perceived differently by different people

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→ Summary of Psychological Assessment Methods

Major Psychological Assessment Methods

Biological Assessment
→ Brain Imaging “seeing” The Brain
- Types of Brain Imaging
o Computerized axial tomography, the CT scan, helps to assess structural brain
abnormalities. A mobbing beam of X-rays passes into a horizontal cross-section of
the client’s brain, scanning it through 360 degrees; the moving X-ray detector on
the other side measure the amount of radioactivity that penetrates, thus detecting
subtle differences in tissue density.
▪ A computer used the information to construct a two-dimensional. Detailed
image of the cross-section, giving it optimal contrast.
o Newer computer-based devices for seeing the living brain include magnetic
resonance imaging, has been developed that allows researchers to take MRI
pictures so quickly that metabolic changes can be measured, providing a picture of
the brain at work rather than of its structure alone.
o Functional magnetic resonance imaging (fMRI) has been developed that allows
researchers to take MRI pictures so quickly that metabolic changes can be
measured, providing a picture of the brain at work rather than of its structure alone.
o PET scan, more expensive and invasive procedure, allows measurement of brain
function.

Neuropsychological Assessment
- Neurologist is a physician who specializes in medical diseases that affect the nervous
system
- Neuropsychologist is a psychologist who studies how dysfunctions of the brain affect the
way we think, feel, and behave .
o They are trained as a psychologist – as such is interested in thought, emotion, and
behaviour – but one with a focus on how abnormalities of the brain affect behaviour
in deleterious ways.
Seidman and Bruder summarized the goals of neuropsychological testing as follows:
1. To measure as reliably, validly, and completely as possible the behavioural correlates of
brain functions
2. to identify the characteristic profile associated in the neurobehavioral syndrome

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3. to establish possible localization, lateralization, and etiology of a brain lesion

4. to determine whether neuropsychological deficits are present
5. to describe neuropsychological strength, weaknesses, and strategy of problems solving
6. to assess the patient’s feelings about his or her syndrome
7. to provide treatment recommendations

Neuropsychologists have developed tests to assess behavioural disturbances caused by brain

dysfunctions.
- Neuropsychological tests -The weight of the evidence does indicate that psychological
tests have some validity in the assessment of brain damage, and they are often used in
conjunction with the brain-scanning techniques just described.
o Tactile Performance test – Time
When blindfolded, the client tries to fit variously shaped blocks into spaces of a form board, first
using the preferred hand, then the other, and finally both
o Tactile Performance Test – Memory
After completing the times test, the participant is asked to draw the form board from memory,
showing the blocks in their proper locations. Both this and the times test are sensitive to damage
in the right parietal lobe.
o Category Test
The client, seeing an image on a screen that suggest on of the numbers from one to four, presses a
button to show which number he or she thinks it is. A bell indicate that the choice is correct, a
buzzer that it is incorrect. The client must keep track of these images and signals in order to figure
out the rules for making the correct choice.
o Speech Sound Perception Test
Participants listen to a series of nonsense words, each comprising two consonants with a long “e”
sound in the middle. They then select the “word” they heard from a set of alternatives. This test
measure left-hemisphere function, especially temporal and parietal areas.

Psychophysiological Assessment
- Psychophysiology is concerned with the bodily changes the accompany psychological
events or that are associated with a person’s psychological characteristics.
- Each heartbeat generates spreading changes in electrical potential, which can be recorded
by an electrocardiograph, or on a suitably tuned polygraph, and graphically depicted in an
electrocardiogram.
- A second measure of autonomic nervous system activity is electro dermal responding, or
skin conductance.
o Conductance is typically measured by determining the current that flows through
the skin when a known small voltage derived from an external source is passed
between two electrodes on the hand.

A Brief History of Classification

→ Early Efforts at Classification

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- Statistical Committee of the Royal Medico-Psychological Association produced a

classification scheme; however, even through it was revised several times, it was never
adopted by the association’s members.
- In the United States, the association of Medical Superintendents of American
Institutions of the Insane, adopted a somewhat revised version of the British system in
1886.

→ Development of the WHO and DSM Systems

- The World Health Organization (WHO) added mental disorders to the International List
of Causes of Death.
o Multiaxial classification, whereby each individual is rated on five separate
dimensions, or axes.
▪ This prevailed until it was removed recently in the DSM-5.
o It is important to highlight that the DSM is controversial and, as noted earlier, this
is certainly the case with the DSM-5. To many clinical scientists and practitioners,
it is not “the book of truth” about psychological problems, nor is it universally
embraced by psychiatrist, psychologists, and others in the field.
▪ It was developed originally by physicians who applied a medical model to
the diagnosis of presumed psychiatric illnesses and who assumed that
categorical diagnoses correspond to actual underlying disease entities with
specific symptoms, treatments and prognoses.
- The term mental disorder is problematic and that “no definition adequately specifies
precise boundaries for the concept”, DSM-5 provides.

Issues in the Classification of Abnormal Behaviour

→ The Value of Classification and Diagnoses
- Forming categories furthers knowledge, for once a category is formed, additional
information may be ascertained about it.
- Even through the category is only an asserted, and not a proven, entity, it may still be
heuristically useful in that it facilitates the acquisition of new information.

→ Criticisms of Classification
- Some information must inevitably be lost. What matters is whether the information lost is
relevant, the relevance depends on the purposes of the classification system
- Any classification is designed to group together objects sharing a common property and to
ignore differences in the objects that are not relevant to the purposes at hand.

→ Categorical vs. Dimensional Classification

- The DSM represents a categorical classification, a yes-no approach to classification.
- In contrast, in dimensional classification, the entities or objects being classified must be
ranked on a quantitative dimension.

→ Reliability: The Cornerstone of a Diagnostic System

The components of reliability – agreeing on who is a member of a class and who is not – are
sensitivity and specific.
o Sensitivity is agreement regarding the presence of a specific diagnosis

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o Specificity is agreement concerning the absence of a diagnosis.

o Kappa measures the proportion of agreement over and above what would be
expected by chance.
▪ Generally, kappa over .70 are considered good. It was found that 14
diagnoses were in the good or every good range in terms of agreement, but
six were in questionable range, and three were in the unacceptable range.

→ How Valid are Diagnostic Categories?

- Construct validity is determining by evaluating the extent to which accurate statement are
predictions can be made about a category once it has been formed.

→ The DSM and Criticisms and Diagnosis

Beginning with DSM-III, an effort was made to create more reliable and valid diagnostic
categories. Major improvements include. (in comparison to DSM-III)
1. The characteristics and symptoms of each diagnostic category were described much more
extensively than they were in DSM–II
2. Much more attention was paid to how the symptoms of a given disorder may differ
depending on the culture in which it appears.
3. Specific diagnostic criteria- the symptoms and other facts that much be present to justify
the diagnosis- were spelled out more precisely, and the clinical symptoms that constituted
a diagnosis were defined in a glossary.
- DSM-5 introduced two key changes that should result in much greater consideration of
cultural issues
- Psychosocial stressors and cultural features of both vulnerability and resilience
- In addition, the American Psychiatric Association has not developed the Cultural
Formulation Interview (CFI) .
o The cultural definition of the problem
o Cultural perceptions of cause, context and support and cultural factors affecting
current help-seeking
- The improved explicitness of the DSM criteria has reduced the descriptive inadequacies
that were major course of diagnostic unreliability and thus has led improved reliability.

The Diagnostic System of the American Psychiatric Association (DSM-5)

→ Development of the DSM-5
- Planning for the DSM-5 began in 1999 with a collaboration between the American
Psychiatric Association and the US National Institute of Mental Health (NIMH)
designed to stimulate research to address key issues in psychiatric nosology.
- Goal of reducing the proportion of diagnoses falling in the “not otherwise specified”
diagnostic category by making changes to symptom criteria where necessary.
- Goal to supplement the categorical approach with greater number of dimensional ratings.
- A key overarching goal was to streamline and simplify the DSM-5 in order to increase its
clinical usefulness when used by doctors in primary care. This is a key objective since the
family doctor is often the first point of contact for people needing psychological help

→ Overview of Changes in DSM-5

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→ Controversial Changes in DSM-5

- The creation of the autism spectrum disorder category, which combines various disorders
and does away with disorders such as Asperger’s syndrome, which is a milder form of
autism

- The second contentious issue is the inclusion of a new disorder for children called
disruptive mood dysregulation disorder. This criteria for this new disorder involved
displays three or more times a week of severe temper tantrums that are out of proportion
with the situations and not in keeping the child’s developmental level.
- The third contentious issue with DSM-5 is the removal of the bereavement exclusion from
the diagnostic criteria for major depressive disorder.
- The fourth issue is that last-minute decision of the DSM-5 group examining personality
disorders to revert to a categorical approach when it appeared that a dimensional approach
was about to be implemented.
o The four categories are identifying, self-direction, empathy, and intimacy.
o Five personality trait domains are evaluated
Negative affectivity vs. emotional stability
▪ Detachment vs. extroversion
▪ Antagonism vs. agreeableness
▪ Disinhibition vs. conscientiousness
▪ Psychoticism vs. lucidity
- Allen Frances chaired the process of creating the DSM-IV and has argued that the changes
in DSM-5 will medicalise and pathologies normal behaviours
o He has argued for a return to the cautious approach used in DSM-IV, and he
contended that proposed changes will result in many conditions being classified as
abnormal when they merely reflect normal or typical behaviour.
Chapter 4: Research Methods in the Study of Abnormal Behaviour

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- Theory is a set of propositions meant to explain a class of phenomena.

o A primary goal of science is to advance theories to account for data, often by
proposing cause – effect relationships.
o The results of empirical research allow the adequacy of theories to be evaluated.
- Hypotheses – expectations about what should occur if a theory is true – to be tested in
research.
- A theoretical concept, such as acquired fear, is useful in accounting for the fact that some
earlier experience can have an effect on current behaviour.

Case Study, Qualitative, and Epidemiological Research Methods

→ The Case Study
- Clinicians prepare a case study by collecting historical and biographical information on a
single individual, often including experiences during therapy sessions.
- A comprehensive case study would cover family history and background, medical history,
educational background, jobs held, marital history, and details concerning development,
adjustment, personality, life course and current situation.
- Case studies from practising clinicians may lack the degree of control and objectivity of
research using other methods, but these descriptive accounts have played an important role
in the study of abnormal behaviour.
o Providing Detailed Description
The case study can include much more detail than is typically included with other research
methods.
▪ Eg. The Three Faces of Eve (Brief Case)
o The Case study as Evidence
Case histories are especially useful when they negate an assumed universal relationship or law.
o Generating Hypotheses
The case study plays a unique and important role in generating hypotheses. Through exposure to
the life histories of a great number of clients, clinicians gain experience in understanding and
interpreting them.
- Theory-building case studies and the notion that an adequate theory must be able to
account for commonalities across case studies as well as the distinct and unique elements
of a particular base.
- Some case studies are so unique that it seems impossible to generalize to other individuals,
including other people with the same disorder.
- Case studies such as these are primarily informative in terms of the specific and unique
manifestations of a disorder. However, when similar case studies begin to surface, it may
result in the authors getting new insights into the nature of the phenomenon being
considered and point to necessary changes in theoretical understanding.
- The case study is an excellent way of examining the behaviour of a single individual in
great detail and of generating hypotheses that can later be evaluated by controlled research.
o The Case Study for Psychotherapy Training
Although a single case study may not suffice as evidence in support of a theory, there is a place
for case studies for practitioners who are new to psychotherapy or new to a particular therapeutic
orientation. The use of multiple research methods, with the case study approach as one method,
has gained popularity.
→ The Rise of Qualitative Research

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- Qualitative research - similar to case study research in that the focus is on the unique and
rich experiences of a small group of people who are studied in depth.
o Subject to some of the same criticisms that apply to case study accounts, but well-
done qualitative research can illuminate important phenomena that seem to reflect
issues and themes that matter to people and are central to understanding them.
o A study led by Christine Kurtz Landy from the School of Nursing at York
University examines the life experience of socio-economically disadvantaged post-
partum women
▪ Themes that emerged were
• The significant struggles associated with becoming a mother and
feeling out of control during the instance period right after giving
birth
• The sense of burden superimpose on this life transition due to the
context of living a life of poverty.
- Quantitative research – subjective emphasis on the individual are the focus.

→ Epidemiological Research
Epidemiological research focuses on determining three features of a disorder
1. Prevalence – the proportion of a population that has the disorder at a given point of
period of time (often lifetime)
2. Incidence – the number of new cases of the disorder that occur in some period, usually
a year
3. Risk Factor – conditions or variable that, it present, increase the likelihood of
developing the disorder

The Correlational Method

This method established whether there is a relationship between or among two or more variables.
It is often employed in epidemiological research, as well as in other studies.

→ Measuring Correlation
The first step in determining a correlation is to obtain pairs of observations of the variables in
question, such as height and weight, for each member of a group of participants.
- Correlation coefficient – denoted by the symbol r.

→ Statistical Significance
A statistically significant correlation is one that is not likely to have occurred by chance.
- In psychological research, a correlation is considered statistically significant if the
likelihood or probability that it is a chance finding is 5 or less in 100.

→ Applications to Psychopathology
When the correlational method is used in research on psychopathology, one of the variables is
typically diagnosis.
o Eg. Whether the participant is diagnosed as having an anxiety disorder or not.
- Variables such as having an anxiety disorder or not are called classificatory variables.

→ Problems of Causality

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- The Directionality Problem

“Correlation does not imply causation.”
o According to this idea, studies investigating the hypothesize causes of
psychopathology would use a prospective, longitudinal design in which the
hypothesize causes are studied before a disorder has developed.
o High-risk method overcome this problem. With this approach, only individuals
with greater than average risk developing schizophrenia in adulthood would be
selected for study.

- The Third-Variable Problem

Correlation may have been produced by a third, unforeseen factor.

- Longitudinal Modelling and Group Trajectories

Nomothetic research – nonos meaning law
Idiographic research – idios meaning private
o It involved typically measuring a group of people on a number of variables and then
focuses on the relationships among these variables with the goal of making
generalizations that apply to the population. (also known as variable-centered
research)
Developmental trajectories – level of a particular behaviour over time.
Group-based trajectory models – This is based on evidence that it is impossible to distinguish
clear subgroups of participants in a sample and it is important to distinguish these groups both
when considering the contribution of developmental factors and the best treatment options for
these people.
Latent class growth analysis- complicated topic and it is easiest to illustrate it with a research
example form the depression field.
- Found latent trajectory classes were identified among the group men based on yearly
assessments of depression: very low depression, moderate-decreasing depression, high-
decreasing depression, and high persistent depression.
o Not surprisingly, the high persistent group seemed to differ qualitatively form the
other three groups based on analyses of associated factors and outcomes.

The Experiment
→ Basic Features of Experimental Design for Groups of Participants
1. The researcher typically begins with an experimental hypothesis
2. The investigatory chooses an independent variable that can be manipulated
3. Participants are assigned to two conditions by random assignment so that each participant
has an equal chance of being in each condition
4. The researcher arranges for the measurement of depend variable, something that is
expected to depend on or vary with manipulations of the independent variable.
5. When differences between groups are found to be a function of variations in the
independent variable, the researcher is said to have produced an experimental effect.
o The placebo effect is an improvement in a physical or psychological condition that
is attributable to a client’s expectations of help rather than to any specific active
ingredient in a treatment.

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o The double-blind procedure is when neither the research or the clients are aware
of who has been placed in the treatment and placebo controls.

- Internal Validity
In contrast research has internal validity when the effect can be confidently attributed to the
manipulation of the independent variable.

- External Validity
The extent to which results can be generalized beyond the immediate study. If investigators have
demonstrated that a particular treatment helps a group of clients, they will undoubtedly want to
conclude that their treatment will be effective in administering to their clients, at other times, and
in other places.
o Determining the external validity of the results of a psychological experiment is
difficult.

- Analogue Experiments
Investigators attempt to bring a related phenomenon – that is, an analogue – into the laboratory for
more intensive study.

- Single-Subject Experimental Research

o Reversal of ABAB design, some aspect of the participant’s behaviour is carefully
measured in a specific sequence.
▪ During an initial time period the baseline
▪ During a period when a treatment is introduced
▪ During a reinstatement of the conditions that prevailed in the baseline period
▪ During a reintroduction of the experimental manipulation
- If the behaviour in the experimental period is different from that in the baseline period,
reverse when the experimentally manipulated conditions are reversed, and re-reverses
when the treatment is again introduced, there is little doubt that the manipulation, rather
than change or uncontrolled facts, has produced the change.
- Treatment aims to produce enduring change – the goal of all therapeutic interventions.
- Reinstating the client’s original condition would generally be considered unethical.
- The ABAB design is more appropriate when it is assumed that the effects manipulations
are temporary.

→ Mixed Designs
- Experimental and correlational research techniques can be combined.
- Participants from two or more discrete and typically non-overlapping populations are
assigned to each experimental condition.
- In interpreting the results of mixed designs, we must also be aware of the fact that one of
the variables is not manipulated but is instead a classificatory or correlational variable.

Meta-Analysis: The Effects of Psychotherapy and Beyond

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Chapter 5: Anxiety Disorders

Anxiety is regarded as having two distinguishable components.
- Physiological component
This is heightened level of arousal and physiological activation, as reflected by symptoms such as
higher heart rate, shortness of breath and dry mouth.
- Cognitive component
This is a subjective perception of the anxious arousal and the associated cognitive processes: worry
and rumination.
- Behavioural component
Anxiety involving avoidance and other safety behaviours, such as using alcohol to manage anxiety
at a party of bring a safe person.

Most students can relate to test anxiety and test-irrelevant thinking.

- Test anxiety
o The sense that anxiety pervades many aspects of life and the person feels totally
unable to do anything to control it.
o The root of must test anxiety, as well as several other types of anxiety is a sense of
a self as deficient and powerless.
o Students with test anxiety tend to be very self-critical and have negative thoughts
about themselves often during the test itself.
o The primary fear is that of being negatively evaluated by others, a diagnosis of
social anxiety disorder may be applied.
Anxiety disorders are diagnosed when subjectively experienced feelings of anxiety are clearly
present.
- Specific phobia – fear and avoidance of objects of situations that do not present any real
danger
- Social anxiety disorder – fear and avoidance of social situations due to possible negative
evaluation form others.
- Panic disorder – recurrent unexpected panic attacks involving a sudden onset of
physiological symptoms, such as dizziness, rapid heart rate, and trembling, accompanied
by terror and feelings of impending doom.
- Agoraphobia – fear of being in public places
- Generalized anxiety disorder – persistent, uncontrollable worry, often about minor
things.
- Separation anxiety disorder – the anxious arousal and worry about contact with and
proximity to other people, typically significant others
- Selective mutism – failure to speak in one situation (usually school) when able to speak in
other situations (usually home).
These disorders have an early age of onset, typically during childhood.
The survey found that estimates of LMR were highest for a major depressive episode (29.9%),
followed by six disorders: specific phobia (18.4%), social anxiety disorder (13%), post-traumatic
stress disorder (10.1%), generalized anxiety disorder (9.0%), separation anxiety disorder (8.7%)
and panic disorder (6.8%)
12 month prevalence data indicated that the three most prevalent disorder were specific phobia
(12.1%), major depressive episode (8.6%) and social anxiety disorder (7.4%)

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Two disorders with the earliest median age of onset (15 – 17 years old) were the phobias
(including specific phobia, agoraphobia, and social phobia) and separation anxiety.
The disorders with the latest median age of onset (23-30 years old) included two anxiety
disorders (panic and generalized anxiety disorder), as well as major depression.
Separation anxiety is the anxiety that results from not having contact or the possibility of losing
contact with attachment guides.

Specific Phobic Definition

- They are unwarranted fears caused by the presence of anticipation of a specific object or
situation.
- The fear and avoidance are out of proportion to the danger actually posed and are
recognized by the sufferer as groundless.
- Many specific fears do not cause enough hardship to compete an individual to seek
treatment.
- One of the newest phobias is nomophobia meaning no mobile phone – is a reflection of
our increasing reliance on technology.
o It is a pathological fear of remaining out of touch with technology that is experience
by people who have become overly dependent on using their mobile phones or
personal computers.
- Psychologist tend to focus on different aspects of phobias according to the paradigm they
have adopted.
- Psychoanalysts believed that the content of phobias has important symbolic value
- Behaviorist, tend to ignore the content of the phobia and focus instead on its function.

Specific Phobia Subtypes

Research is lacking on many specific phobias, in large part due to the avoidance associated with
them.

Social Anxiety Disorder (Social Phobia)

- Characterized by persistent, irrational fears of being judged by other people. Individuals
with social anxiety disorder try to avoid particular situations in which they might be
evaluated, fearing that they will reveal signs of anxiousness or behave in an embarrassing
way.
- There are three main types of situations feared and avoided by those with social anxiety
disorder: public speaking (other performance), social interactions, and being observed
in public.
- SAD could be classified as either generalized or specific, depending on the range of
situations that were feared and avoided.

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- SAD has a high comorbidity rate with other disorders and often occur in conjunction with
generalized anxiety disorder, specific phobias, panic disorder, avoidant personality
disorder, and mood disorder
- In children, this is often co diagnosed with selective mutism is often characterized by the
failure to speak at school when a child is able to speak at home, and recent research supports
the classification of selective mutism as an anxiety disorder in DSM-5.

Etiology of Specific Phobias and SAD

Behavioural Theories
→ Avoidance conditioning
The avoidance- conditioning formulation, is based on the two-factor theory originally proposed by
Mowrer (1947), holds that phobias develop from two related sets of learning
- Classical conditioning, a person can learn to fear a neutral similar (the CS) if it is paired
with an intrinsically painful or frightening event (the UCS)
- The person can learn to reduce this conditioned fear by escaping from or avoiding the CS.
This second kind of learning is assumed to be operant conditioning; the response is
maintained by its reinforcing consequence of reducing fear
→ Modelling
vicarious – the learning of fear by observing others.
Phobic reactions can be learned through another’s description of what could happen.
→ Prepared Learning
- People tend to fear only certain objects and events, such as spiders, snakes and heights, but
not others, such as lambs.
- This is relevant to learning fear may have used CSs that the organism was not prepared to
associate with UCSs.
- There is considerable evidence in support of the preparedness theory of phobias
→ The role of Diathesis
- A cognitive diathesis (predisposition) – a tendency to believe that similar traumatic
experiences will occur in the future – may be important in developing a phobia.
- An other possible psychological diathesis is a history of not being able to control the
environment.
- Data suggest that while some phobias are learned through avoidance conditioning,
avoidance conditioning should not be regarded as a totally validated theory; many people
with phobias do not report either direct exposure to a traumatic event or exposure to fearful
models.
→ Social Skills Deficits in Social Anxiety Disorder
- a behavioural model of social anxiety disorder considers inappropriate behaviour or a lack
of social skills as the cause of social anxiety.
- Social skills deficits may have arisen over time because the person was fearful of
interaction with others for other reasons, such as classical conditioning, and therefore had
little experience doing so.
- The lack of interpersonal skills in an adult who has SAD may therefore reveal little of
etiological significance

Cognitive Theories

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Focus on how thought processes can serve as a diathesis on how thoughts can maintain a phobia
or anxiety.
- Anxiety is related to being more likely to attend to negative stimuli, to interpret ambiguous
information as threatening, and to believe that negative events are more likely than positive
ones to occur in the future.
- Cognitive processes are strongly implicated in the etiology and maintenance of SAD.
Socially anxious people are more concerned about evaluation than are people who are not
socially anxious and they are highly aware of the image they present to others.
o Socially anxious people’s hypersensitivity to social cues is reflected by a tendency
to be cognitively preoccupied with situation in which they were treated negatively
by others.
o SAD is also linked with excessive self-criticism.
o Socially anxious people tend to view themselves negatively even when they have
actually preformed well in social interaction and they are less certain about their
positive self-views and relative to people without SAD, they see their positive
attributes as being less important
o Experimental data suggest that people with SAD have a cognitive bias toward being
more attentive visually to negative faces than to positive faces, but no such bias is
evident among people with OCD or in control participants
- Socially anxious people also seem to fear having a negative impact on other people; that
is, they are worried about causing discomfort in other people.
- Cognitive models of SAD link social anxiety with the following key characteristics
o Attentional bias on focus on negative social information and interpret ambiguous
situations as negative
o Perfectionistic standards for accepted social performances
o A high degree of public self-consciousness

- David Clark’s model of SAD has a clear treatment implications

o Clark advocates for the use of behavioural experiments and roles plays
o The key problems according to Clark is that people with SAD have an excessive
self-focus that amplifies their mistaken and rigid beliefs that they will be rejected
by other if they do not engage in appropriate behaviours
o Clark emphasized the importance of facilitation an external focus on other people
along with developing the realization that other people are not typically
judgemental and will not automatically be punitive and reject the person with SAD.
o One technique that follows from this approach is called “widening the
bandwidth.”
▪ Clients are instructed to act in ways that they feel are totally unacceptable
and then objectively watch for the lack of negative reaction from other
people.
- Rachamn, Gruter-Andrew and Sharfran reported that socially anxious students not only
anticipate negative social experiences, they also engage in extensive post-event
processing (PEP) of negative social experiences.
o Post-event processing is a form of rumination (dwelling) about previous
experiences and response to these situations, especially experiences involving other
people that do not turn out well.

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o Those high in social anxiety are more likely to ruminate and less likely to distance
themselves as a way of coping with a threatening social event.
o Children with SAD show a pattern of fewer positive thoughts and a greater number
of negative thoughts following a social evaluation experience.
o Negative PEP contributes to data with university student indicates the socially
anxious students who are induced into a state of high self-focus, compared with
those instructed to focus on the other people during a conversation, report the next
day a higher level of negative PEP thoughts but not a lower level of positive
thoughts.
o Overall, there are cognitive elements that are seen to play a role in the development
and maintenance of social anxiety disorder.

Biological Theories
Current work is focused extensively on the role of the amygdala, which is a cerebral structure of
the brain’s temporal lobe.
- Functional MRi and PET studies of specific phobia and SAD have examined response
across three conditions: negative emotion, positive emotion and neutral condition
o Results of meta-analyses show conclusively that people with these disorder,
relative to comparison participants, have greater activity in two areas associated
with negative emotional responses: the amygdala and the insula.
o Exposure-based therapy for clients with specific phobias leads to decreased
activation in some of the same areas of the brain.
o The various anxiety disorder may reflect a complex array of biological factors and
process
o Research in two areas seems promising, the automatic nervous system and genetic
factors

→ Autonomic Nervous System

The extent to which the autonomic nervous system is involved in fear and hence in phobic
behaviour, a dimension such as autonomic lability assumes considerable important.
Autonomic lability is a condition in which the autonomic nervous system is too sensitive and
too easily aroused.

→ Genetic Factors
Linkage analyses seek to identify the specific genes implicated in these disorders

Psychoanalytic Theories
According to Freud, phobias are a defence against the anxiety produced by repressed id
impulses.
- This anxiety is displaced from the feared if impulse and moved to an object or situations
that has some symbolic connection to it.
- These objects of situations- then become the phobic stimuli.
- The phobia is the ego’s way of warding off a confrontation with the real problem, a
repressed childhood conflict.

Panic Disorder and Agoraphobic

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Panic Disorder
A person suffers a sudden and often inexplicable attack of a host of jarring symptoms: laboured
breathing, heart palpitations, nausea, and chest pain; feelings of choking and smothering;
dizziness, sweating and trembling; and intense apprehension, terror, and feelings of impending
doom.
Depersonalization feeling of being outside one’s body, derealisation, a feeling of the world’s not
being real, as well as fears of losing control, of going crazy, or going crazy, or even of dying, may
beset and overwhelm the person.
- Panic attacks may occur frequently, perhaps once a week or more often; they usually last
for minutes, rarely for hours; and they are sometimes linked to specific situations, such as
driving a car
o They are referred to as cued or expected panic attacks when they are associated
strongly with situational triggers.
o The exclusive presence of cued attacks most likely reflects the presence of a
specific phobia.
▪ Eg. A person with a specific phobia of dogs may always have a panic attack
when in the presence of dogs.
- Panic attacks can also occur in seemingly benign states, such as relaxation or sleep, and in
unexpected situations; in these cases, they are referred to as uncued attacks.
- Recurrent unexpected attacks and either worry about having attacks in the future or a
change in behaviour as a result of the attacks are required for the diagnosis of panic
disorder.
- A person with panic disorder can have both unexpected and expected panic attacks; the
important point is the unexpected attacks are required for a diagnosis of panic disorder.
o When people are worried about future attacks, it is usually because they are
concerned that the symptoms really mean they are having a heart attack or they
have some other physical health condition.
o They may also be concerned that others will notice the panic symptoms and judge
them.
o They have cognitive symptoms such as a fear of “going crazy” as part of their panic
attack experience, this particular fear may extend beyond the actual panic attack’
their worry about future attacks may be because they view the panic attacks as a
sign of “going crazy”
- Panic disorder has been linked with a wide range of conditions, including depression,
generalized anxiety disorder, alcohol and drug use, and personality disorders.
o Panic disorder is also linked with physical conditions such as asthma, and in
people suffering form both, it is believed that the panic exacerbates the asthma and
vice versa.
o More than 80% of people diagnosed as having one of the other anxiety disorders
also experience panic attacks.
o The 12-month prevalence of panic attacks was 6.4%. Panic attacks were related to
numerous psychological and physical function variables, including poor overall
functioning, suicidal ideation, psychological distress, activity restriction, chronic
physical conditions, and self-rated physical and mental health.
▪ The authors concluded that panic attacks may be a marker of severe
psychopathology independent of a diagnosis of panic disorder.

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▪ Research such as this study has led to a diagnosis would be “social anxiety
disorder with panic attacks.”
Agoraphobia
A cluster of fears centring on public places and being unable to escape or find help should one
become incapacitated.
- To be diagnosed, a person would have to be anxious about at least two types of situations
out of the following five: public transportation, open spaces, enclosed spaces, line/crowds,
and being out of the house alone.
- When panic disorder or other anxiety disorder are present, they most often precede the
development of agoraphobia.
- Depressive and substance use disorders often develop after the onset of agoraphobia

Etiology of Panic Disorder and Agoraphobia

Biological Theories
Physical sensations caused by an illness lead some people to develop panic disorder.
- Early onset of panic disorder is associated with increased risk for family members
- Genetic diathesis may be involved, and specific chromosomes are being investigeated

→ Noradrenergic Activity
Panic is caused by over activity in the noradrenergic system.
o One version of this theory focuses on a nucleus in the pons called the locus ceruleus.
o Stimulation on the locus ceruleus causes monkeys to have what appears to be a
panic attac, suggesting that naurally occurring
o Yohimbine, is a drug that stimulates the nucleus coeruleus and has been linked
with causing panic attacks.
o Panic disorder may result from a problem in GABA neurons that inhibit
noradrenaline activity
▪ A PET study found fewer GABA receptor binding sites in those with panic
disorder.
▪ Improvement involves changes in GABA receptors for both anxiety and
depression.
→ Cholecystokinin (CCK)
- This is a peptide that occurs in the amygdala, hippocampus, cerebral cortex and
brainstem induces anxiety like symptoms in rats.
o This effect can be blocked with benzodiapenzines.
o Changes in cholecystokinin produces changes in the development of panic.
o Panic disorder is associated with hypersensitivity in CCK.
o CCK-4 injections show how amygdala activation is associated with the subjective
perception of anxiety.
o CCK is a key modulator of the fear network. It induces panic attacks in people
and has a genetic link to panic disorder diagnosis.
Psychological Theories
- The fear of fear hypothesis: agoraphobia is not necessary a fear of public places, but a
fear of having panic attack in public places.

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o There is a cycle: fearing of a panic attack leads to autonomic arousal which is

interpreted in catastrophic was and this leads to a panic attack.
- Anxiety sensitivity is presumed to be a dispositional characteristic that precedes the
development of anxiety disorders.
o Anxiety sensitivity in a study predicted the development of anxiety disorders,
mood disorders and alcohol disorders.
o Anxiety sensitivity is most closely related to panic disorder, but is also related to
other anxiety disorders.
- Individuals with agoraphobia and panic disorder were presented with faces and shapes
while in an fMRI
o Those with higher anxiety sensitivity had higher activation in the anterior
cingulate cortex and insula.
o These areas are involved in the processing of threat-
o High anxiety sensitivity is amendable to CBT.
Generalized Anxiety Disorder (GAD)
GAD Definition
- All encompassing worry
- The individual is persistently anxious often about minor things.
- Chronic, uncontrollable about all the manner things is the hallmark of generalized
anxiety.
- Most frequent worries concern their health and the hassles of daily life.
- Symptoms include tiring easily, muscle tension, difficulty concentrating, restlessness and
irritability.
- The lifetime prevalence for GAD is 4.2% for men and 7.2% for women.
- Typically begins in the mid-teens. Stressful life events play some role in its onset.
- High level of comorbidity with other anxiety disorders and with mood disorders
- Difficulty to treat, only 18% of those in treatment had full recovery.
- A group proposed that GAD should be changed to generalized anxiety and worry
disorder to reflect the hallmark of the disorder.
Etiology of Generalized Anxiety Disorder
→ Cognitive – Behavioural Views
- Those with GAD perceive threatening events as out of their control.
- Predictable events produce less anxiety than unpredictable events.
- Intolerance of uncertainty is associated with GAD, OCD and depression.
- A two factor model links GAD with classical approach-avoidance conflict.
o The two factors are intolerance to uncertainty and fear of anxiety.
- Another thought is that worry is reinforcing.
o Worry distracts people from negative emotions.
o Cognitive avoidance is linked to generalized and pathological worrying
o Cognitive avoidance occurs due to negative beliefs about worry and fear of
somatic symptoms of worry.
- There are also metacognitive beliefs about worry

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o Positive beliefs about worry include worry helps to solve a problem

o Negative beliefs about worry include that worrying is dangerous and can
increase anxiety levels and linked with feelings of worry
→ Biological Perspectives
→ GAD has both a genetic and environmental component and the heritable
component is comparable for both men and women.
- There are white matter abnormalities in the amygdala and cingulate cortex in GAD
clients.
→ GABA is linked to anxiety disorders.
- Drugs that inhibit the GABA system lead to increases in anxiety.
- Benzodiapenzines may reduce anxiety by enhancing the release of GABA.
→ Psychoanalytic View
- Anxiety is the result of an unconscious conflict between the ego and the id impulses.
- The source of anxiety is unconscious, so the person experiences distress without knowing
why.
Behavioural Approaches to Treatment
- Systematic sensitization is the main treatment for treating phobias.
o The individual imagines increasing frightening scenes well in a state of deep
relaxation.
- In vivo exposure involving real exposure to the phobia is more effective than imagine
states.
- Virtual reality exposure: involves exposure to stimuli that come in the form of
computer-generated graphics.
- Augmented reality exposure
o Combines VR and the physical world.
o Has been used in the treatment of small animal phobias
- Specific treatment for those with blood-injection phobias.
o Muscle tension applied to the skin help with treating the fear and fainting
associated with the fear.
- Social effective therapy with exposure-based therapy and social skills training was more
effective than exposure therapy alone
- Modelling also uses exposure to feared situations.
o Individuals are exposed to lived demonstrations of other people displaying
reactions to the feared object.
- Flooding
o The client is exposed to the source of the phobia at full intensity
o The extreme discomfort it causes is often why therapist use this as a last resort.
- Intensive relaxation treatment for GAD
If clients learn to relax when beginning to feel tense their anxiety can be kept under
control.
Cognitive Approaches

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- Cognitive therapy is superior to exposure and relaxation

- Therapy focuses on changing beliefs.
o Panic control therapy has three principal components
o Relaxation training
o Ellis and beck CBT
o Exposure to cues that trigger panic, interoceptive exposure
- In interoceptive exposure the client practices behaviors in the consulting room that can
elicit feelings of panic
→ The client learns to reinterpret sensations experienced and no longer sees
them as a lose of control
o Mindfulness and acceptance-based approaches are also popular for treating
anxiety disorders
o Goal is to become more open of anxious thoughts and feelings.
o Focuses on decentering: the tendency to focus on thoughts objectively without
getting caught in them.
o One type is lovekindness: being kind to oneself and then extending this kindness
to others.
Biological Approaches
o Drugs that reduce anxiety are referred to as tranquilizers, sedatives or anxiolytics
o Barbiturates were the first commonly used drugs for anxiety
- These drugs were highly addictive and replaced with propanediols and benzos
- Benzodiapenzines still addictive and can produce a severe withdrawal syndrome
o Drugs originally developed to treat depression have become popular in treating
anxiety disorders
• MAO inhibitors were better for treatment than benzodiazepine
→ These drugs are often not used because of dietary restrictions and
secondary side effects.
• They are the prefer treatment option for those with SAD.
o Problems with drug treatment
• Many drugs have severe side effects.
o Self-medication is very common in those with anxiety disorder and this is linked
to suicide attempts
Psychoanalytic Approaches
o Attempt to uncover the repressed conflicts believed to play the role in the fear
associated with anxiety
o Focus on getting the client to comfort the phobia.

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Chapter 7: Somatic Symptom Disorders and Dissociative Disorders

Somatic Symptom and Related Disorders

Psychogenic illness or mass hysteria: a mass outbreak of conversion disorder among many
individuals usually due to prolonged exposer to stress in a Le Roy residence in New York
o these individuals suffered from a conversion (functional neurological symptom disorder)
disorder, which is a form of somatoform disorder.
o This disorder could have been exacerbated by the attention they received on social
media
o There was a train derailment near Le Roy that dumped TCE chemical that has not been
cleaned up. This chemical has been shown to cause neurological symptoms.
o Test failed to show an environmental cause for this mass hysteria.
o The ability to accept the conversion disorder hypothesis that this was caused by stress is
more common when we focus on the group instead of the individual
o A somatoform disorder is considered in the absence of no physical or medical cause.

Another cause of mass hysteria: 5 Amish girls experienced an outbreak of conversion disorder
symptoms that were common among them all. These symptoms were deemed to be related to
stressors and psychosocial pressures
o These are physical problems that reflect psychological adjustment problems.
o Challenge for physicians: are the physical symptoms due to medical explanations or
psychological problems.
o Until the most recent DSM revision, a somatoform disorder was ruled out if it was not
conclusive that there was no medical explanation. This has been removed in DSM-5
o In DSM-5 somatoform disorder was changed to somatoform symptom disorder.
o All these disorders are related to anxiety, they were all subsumed under the heading of
neuroses because anxiety was considered the predominant factor
o In DSM-III classification was based on observable traits, not ethology. Anxiety is not
necessarily observable in the somatoform and dissociative disorders.

Somatoform Disorders: individual complains of bodily symptoms that suggest a physical defect
or dysfunction- sometimes rather dramatic in nature- but for which no physiological basis can be
found
o A physical disorder that is unexplained and reflects psychological factors.
o Reflect the mind-body connection that physiological and psychological factors are linked.
o 9.5% of students had a somatoform disorder and ¼ of them had an anxiety disorder.
Illustrating the connection between body and mind.
o Predictors of a somatoform disorder also include depression and impairment in daily
activities.

Dissociative Disorders: individual experiences disruptions of consciousness, memory, and

identity
o Onset of both disorders is assumed to be related to some stressful experience
o Sometimes they co-occur together

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Conversion Disorder
Somatization Disorder
o Assumed to be linked to psychological factors, such as anxiety
o Two types of somatoform disorders: conversion disorders and somatization
disorder.
o Pain disorder and hypochondriasis are no longer distinct disorders in DSM-5.
o Little is known about these somatoform disorders.

- Above is a summary of somatoform disorders listed in DSM-V-TR, these are

controversial and there have been arguments as to whether these should be removed from
the DSM-5
- Also concerns arise that the distinction between psychogenic and disease-based symptom
differences being more apparent than real.
- All these disorders involve physical symptoms and/or concerns about medical illness and
therefore have been renamed somatic syndrome disorders.
- The focus is on whether these symptoms result in subjective distress and impairment
Case illustration: the difficulty of detecting malingering
- A 50-year old men was accessed in Canada and had diminished cognitive functioning,
but his pattern of errors on the memory test was consistent with malingering.
- However, a physiological assessment showed the man was suffering from dementia and
was not malingering.
o Factitious disorder: when individuals intentionally produce physiological or
psychological symptoms.
o Make up symptoms and inflict injuries on themselves.
o Motivation to adopt these physical and psychological symptoms is less clear.
o Factitious disorder by proxy or Munchausen syndrome by proxy: A parent
creates physical symptoms in their child.
▪ A case involves a mother trying to smoother her two-year-old daughter to
get attention for herself without an external incentive.
▪ If someone is making themselves ill the disorder is referred to as
Munchausen syndrome.
o In hypochondriasis (somatic syndrome disorder) individuals are preoccupied with
persistent fears of having a disease, despite medical reassurance to the contrary.
▪ Frequent consumers of medical services
▪ Likely to have anxiety disorders.
▪ Overreact to ordinary physical sensations and minor abnormalities.
➢ Not well differentiated from somatization disorder, which is
characterized by a long history of medical complaints.

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➢ Therefore, hypochondriasis has been dropped from DSM-5 and

this symptom expression is in somatic syndrome disorder category.
Illness anxiety disorder in the DSM-5, the person diagnosed is obsessed with having or
acquired a serious illness that has not been diagnosed.
Health anxiety is health related fears and beliefs based on interpretations or misconceptions of
bodily signs and symptoms being indicative of serious illness. (Present in hypochondriasis and
illness phobia.)
o General neurotic syndrome is a contributing factor in health anxiety and other
factors such as cognitive mechanisms.
➢ Moderately heritable, but most variance between people is due to
environmental factors.
o The illness Attitudes scale used to access health anxiety suggest it consist of four
factors.
➢ Worrying about illness and pain
➢ Disease convictions
➢ Health habits
➢ Symptom interference with lifestyle.
o Individuals with health anxiety have a catastrophizing of bodily sensations mindset.
➢ There is a clinical self-perpetuating pattern, with health anxiety
and catastrophizing contributing dynamically to one another.
Conversion Disorder (Functional Neurological Symptom Disorder in DSM-5)
- Sufferers may experience lose or impairment of sensations, called anaesthesia
- They may also experience anosmia (lose or impairment of smell) and aphonia (loss of
voice)
o Conversion was derived from Freud who thought that energy of repressed instinct
was diverted into sensory-motor channels and blocked functioning.
→ Anxiety and psychological conflict were converted into physical symptoms.
o Individuals with conversion disorder may develop hysterical blindness.
→ This illustrates the role that stress plays in conversion disorders.
o Frequently co-morbid with other axis I disorders (anxiety, depression, substance
abuse and dissociative disorders)
Somatization Disorder
o This disorder has been dropped from DSM-5, those who would have met the criteria
for this in the past will now meet the criteria for somatic syndrome disorder.
o The disorder is characterized by recurrent, multiple somatic complaints, with no
apparent physical cause for which medical attention is sought.
o Many changes have been made to somatic syndrome disorder is DSM-5
▪ Criterion A involves having a distressing or disabling physical symptom
that may be explained or unexplained.

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- The DSM-5 requires the presence of only one symptom to be diagnosed with somatic
symptom disorder.
- The old DSM required 13 symptoms to be diagnosed. There is a change in prevalence of
this disorder due to change in criteria.
▪ Criterion B use to involve the presence of somatic symptoms, but now
involves determining the presence or absence of psychological features.

- There is a general stress factor with four components

o Gastrointestinal symptoms
o Fatigue
o Cardiopulmonary symptoms
o Pain symptoms
Etiology of Somatoform Disorder
- People with this form of disorder are oversensitive to physical sensations, over attend to
them or interpret them catastrophically.
- May have a memory bias for information connoting physical threat.
- A behavioral view holds that aches, discomfort and dysfunctions are the manifestation of
unrealistic anxiety bodily systems.
- Once normal function is disrupted the maladaptive pattern may continue because of the
attention it receives or the excuses it provides.
- The reporting of physical symptoms has been seen as a strategy to explain poor
performance.
o A study examined the hypothesis that illness behaviors are learned through the
exposure to parental illness
o Children of mothers with this disorder acted differently then others kids
o They expressed more safety and health needs than other kids.
Etiology of Somatoform Disorders
→ Psychoanalytic Theory of Conversion Disorder
- Offered Freud a clear way to examine the unconscious.
- Freud proposed that conversion disorder is caused when a person experiences an event
that causes emotional arousal, but the memory is cut off from conscious.
- The conversion symptoms are related to a traumatic event that proceeded them.
→ Behavioral Theory of Conversion Disorder and Cognitive Factors
- A person with a conversion disorder behaves according to his or her conception of how
people with a disease would act.
- There are specific situations in which conversion disorder behavior is more likely to be
adopted.
o If the person had experience with the role to be adopted.
o The enactment of the role must be rewarded.
- An individual will enact a disability only if it allows them to reduce stress or reap other
positive consequences.

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→ Cognitive factors seen in people with conversion disorder are consistent with
cognitive interpretations, including the tendency to discount the importance of
psychological factors contributing to the physical compliances.
→ Research is also looking at the role of cognitive mechanisms.
- When children and adolescences with a conversion disorder were evaluated with a test
battery of neurocognitive functioning, they were linked with deficits in attention, working
memory and executive functioning.
→ Biological Factors in Conversion Disorder
- The research that exist suggest that conversion disorder has no genetic basis.
- Some studies point to some brain structures involved in conversion disorder.
- Conversion disorder symptoms are more common on the left side of the body than on the
right side of the body, controlled by the left brain.
- Connectivity between the amygdala and motor areas is enhanced.
- Stimulation of a numbed hand or foot did not activate the somatosensory region of the
brain, however stimulating the non-numbed hand or foot did activate it.
o An individual with hysterical mutism (nonvocalization) showed impaired
connectivity between speech related brain regions and brain networks that
regulate anxiety.
o These pieces of evidence may only tell us about how the conversion disorder
occurs and not why it occurs.
o These differences in the brain could be consequences of conversion disorder
rather than a cause.
Biopsychosocial Account of Conversion Disorder

Therapies for Somatoform Disorders

- The results of randomized controlled studies vary depending on whether the focus was on
medically unexplained symptoms or a more severe clinical delineated somatoform
disorder.
o Benefits of treatment are less evident in those with medically unexplained
symptoms.

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- People with somatoform disorders define their problems in physical terms, so they
interpret a referral to a psychologist as an indication the doctor thinks the illness is all in
their head.
- Somatoform disorders are expensive and difficult to treat, and they are less durable and
lasting than treatments for other mental illnesses.
- Cognitive and behavioral therapist believe the high levels of anxiety linked to
somatization disorder are associated with specific situations.
Dissociative Disorders
- Characterized by a change in a persons sense of identity, memory or consciousness.
- Dissociative trance: a narrowing or lose of awareness showing unresponsiveness or
insensitivity to environmental cues.

Dissociative Amnesia
- Unable to recall important personal information, usually after some type of stressful
event.
- Information is not permanently lose, but it cannot be retrieved during episode of amnesia.
- The memory loss involves all events during a limited period of time following the
traumatic experience.
- The memory lose may cause some disorientation and wandering.
- With total amnesia the person loses knowledge of friends and family.
- The episode may last for several hours to years and it has complete recovery and only a
small chance of reoccurrence.
- People with dissociative amnesia show reduced glucose (hypometabolism) in the left
inferolateral prefrontal cortex, where this region is associated with autobiographical
memory.
Dissociative Fugue
- Memory loss is more extensive in dissociative fugue.
- The person becomes amnesic and leaves home and work and assumes a new identity.
- The person may even establish a complex social life
- Fugues typically occur after a person experiences a stressful event.
- Recovery is usually complete
Depersonalization/ Derealization Disorder
- Persons perception is experience of the self is disconcertingly and disruptively altered.
- Involves no disturbance of memory, instead it involves a sense of self triggered by self
- DSM-5 retains this disorder, but also included derealization: a fogginess or sense of
detachment from the situational context and things in the situation.

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- Comorbid personality disorders, anxiety disorders and depression are frequent.

- Higher severity of illness is associated with strong illness identity, psychological illness
causal attributions and depression.
Dissociative Identity Disorder
- Diagnosis requires a person to have at least two separate ego states or alters- different
modes of feeling and acting that exist independently of one another.
- Usually one primary personality and treatment is typical sought by primary alter.
- The existence of alters must cause long-lasting and considerable distress in ones life, it
can not be a temporary change from taking drugs.
- Begins in childhood, but rarely diagnosed into adulthood.
- Much more common in women than men
- Depression, borderline personality and somatization are co-occur typically.
- Can be associated with amnesia and depersonalization.
- Individuals suffering may have a disorganized or insecure attachment style.
- DID is often mislabelled as schizophrenia
→ Controversies in the Diagnosis of DID
- One study found that different identity states show different reactions to trauma related
behavior.
- DID clients have a traumatic identity state that can access repressed memories and a
neutral identity state that that is protective and inhibits traumatic memories.
- A bias for social threat cues was identity state dependent.
- No evidence of inter-identity amnesia
- There are numerous cortical and subcortical activations during switching between states.
- The nucleus accumbens was activated suggesting the idea that there is a reward in
switching to escape trauma.
- Activation of the pre-frontal cortex associated with attentional shifts.
Etiology of and Therapies for Dissociative Disorder
- Dissociative disorder refers to mechanism, dissociation, that is thought to cause the
disorder.
- Consciousness is usually a unified experience involving cognition, emotion and
motivation
- Under stress memories are stored in such a way that they are not accessible to
consciousness
- Behavioral therapist consider dissociation as an avoidance response that protects the
person from stressful events.
- Two major theories of DID and associative models:
o Trauma model of dissociation: DID begins in early childhood as a result of
severe physical or sexual abuse.
o It is proposed that a diathesis is present above those who develop DID.
o Trauma is believed to cause the distress and an inability to tolerate leads to
dissociation.

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o Fantasy model of dissociation: People who develop DID are very prone to
engage in fantasies.
Therapies for Dissociative Disorders
- People in these disorders behave in ways that are indicative of forgetting earlier parts of
life.
- These individuals may be unaware of their repressed thoughts.
- Psychoanalytic treatments try to lift repressions.
- There are links between treatment for DID and PTSD as they are often comorbid.
- Age regression: the individual is hypnotized and asked to think back to events in early
childhood
- The primary goal for individuals with DID is integration of several personalities.
Treatment can be enhanced by helping the client cope better with present day challenges.
- Treatment took almost 2 years and up to 500 hours per client in one case
- There is a 3-stage process to treatment:
o Safety, stability and symptom reduction
o Working directly and in depth with traumatic memories.
o Identity integration and rehabilitation.

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Chapter 8: Mood Disorders and Suicide

General Characteristics of Mood Disorders
- Mood disorders involve disturbances in emotion, from the sadness of depression to the
elation and irritability of mania.
- They are often present with other disorders which can increase their severity and result in
poorer prognosis.
Depression: Signs and Symptoms
- Depression is emotional state that is marked by great sadness along with feelings of guilt
and worthlessness.
- Symptoms include:
o Withdrawal from others
o Loss of pleasure in usual activities
o Sleep and appetite affected.
o Paying attention is exhausting for depressed people.
o Individuals may speak slowly and use a low monotonous voice
o When comforted with a problem no ideas for its solution occur to them
o May neglect hygiene and make numerous somatic complaints with no
physical basis.
- Symptoms and signs of depression vary across the lifespan.
o Depression in children results in somatic complaints. Ex. Headaches.
o In older adults depression is marked by complaints of distractibility and
memory loss.
- Symptoms of depression vary cross-culturally
o Depression is less prevalent in China than in North America due to the
tendency of Chinese individuals to not express emotions.
o People from various cultures emphasize more somatic complaints rather
than emotional symptoms.
o Only 15% of individuals in Canada are psychologizers (people who
emphasize the psychological aspects of depression)
o Most depression although recurrent, dissipates with time
Mania: Signs and Symptoms
- Mania is an emotional state or mood of intense but unfounded elation, accompanied with
irritability, hyperactivity, talkativeness, distractibility and impractical plans.
- Individuals in a manic episode that may last from several days to month, is recognized by
their loud and incessant remarks.
- The individual shifts rapidly from topic to topic and their speech is difficult to interrupt.
- Mania comes on suddenly over the period of a day or two.

Two major mood disorders are in DSM-5: major depressive disorder and bipolar disorder.
Diagnosis of Depression

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DSM-5 diagnosis requires of presence of at least 5 of these symptoms for 2 or more weeks and
one of the symptoms must be depressed mood or loss in pleasure or interest in doing things:
o Change in sleep
o Sad depressed mood most of the day nearly everyday
o Loss of pleasure or interest in all or almost all activities
o Shift in activity level becoming lethargic or agitated. Psychomotor agitation or
retardation.
o Change in appetite
o Negative self-concept, self-reproach and blame, feelings of worthlessness and
guilt
o Complaints or evidence of loss of concentration
o Recurrent thought of death or suicidal
o Loss of energy, fatigue nearly every day
- Persistent depressive disorder (a depressive disorder that combines major depressive
disorder and dysthymia).
o Predictors of chronic depressive disorder include a co-morbid diagnoses, a
younger age of onset and a history of more frequent bouts of depression.
o The predictors for persistent depressive disorder include: being female, never
married, two or more medical conditions, limits on activity and reduced
contact with family.
o MDD is currently the second leading cause of disability.
Focus on Discovery 8.1
- The gender differences between males and females can be traced back to adolescence as
girls are more likely than boys to have certain risk factors for depression.
o Females are more likely than males to engage in ruminative coping, while males
are more likely to engage in distractive activities.
o Males focus more on a more adaptive form of reflective pondering whereas
females focus more on maladaptive rumination or brooding (moody pondering)
- An interpersonal form of rumination known as co-rumination in which friends discuss
their problems with each other has been linked with depression in females, but this also
fosters strong friendships.
- Females are more likely to engage in silencing the self-a passive style of keeping upsets
and concerns to oneself to maintain important relationships.
- Another theory is the objectification theory based on the tendency to be viewed as objects
and this has a greater influence of women than men.
- Theories propose that women and girls are more likely than boys and men to take a more
active role in generating stress for themselves. However, studies failed to show this.
Diagnosis of Bipolar Disorder
- Bipolar I involves episodes of mania or mixed episodes that involve symptoms of both
mania and depression.

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- A diagnosis of a manic state requires an elevated or irritable state and abnormally and
persistent increase goal directed activity or energy plus 3 additional symptoms, four if
irritable.
- The symptoms must be sufficiently severe to impair social and occupational functioning.
o Increased in goal directed activity
o more talking than usual
o flight of ideas or subjective impression that thoughts are racing
o less than usual amount of sleep needed
o elevated self-esteem and feeling like you have special powers and talents
o distractibility
o excessive involvement in pleasurable activities that have reckless
consequences
- Violent behaviors can occur during severe manic episodes.
Heterogeneity with the Categories
- Melancholia refers to a specific pattern of depressive symptoms.
o No pleasure in any activity (anhedonia)
o Depressed mood is worse in the morning
o They awaken two hours t0o early
o Loss appetite and weight
o Are lethargic or extremely agitated
- Peripartum/postpartum depression: both manic and depressive episodes may occur
during pregnancy or within four weeks of childbirth.
- Both bipolar and unipolar depression can be sub diagnosed as seasonal if there is a
regular relationship between the depressive episode and a particular season of the year.
- The most common is winter depression or seasonal affective disorder
o Linked to the decrease in daylight hours.
- Seasonal subtype is found in 11% of individuals diagnosed with depression
- Some individuals are subsyndromal (have fewer symptoms than those that meet DSM
criteria)
- Decreased sunlight caused decreases in activity in the serotonin neurons of the
hypothalamus and these neurons regulate sleep.
- Cyclothymic disorder: the person has frequent periods of depressed mood and
hypomania, which may be mixed with or alternated with normal mood for a period of two
months.
o Have paired sets of symptoms in their periods of depression and hypomania.
o Do not experience full-blown episodes of mania, hypomania or depression.
o To be diagnosed they need to experience periods of hypomania and
depression at least half the time for at least 2 years.
Psychological Theories of Mood Disorders
Psychoanalytic theories of depression
- The potential for depression is created during early childhood.

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- During the oral stage, the child’s needs are oversatisified or undersatisified and they
become fixated in this stage and dependent of instinctual gratifications association with
it.
- The person in adulthood may now become dependent on others for maintenance of self-
esteem
- When a love one dies early in childhood, the mourner incorporates or introjects the loss
person. We then unconsciously harbour hate for those we love, and this person becomes
the object of hate and angry.
- The period of introjection is followed by a period of mourning work, the mourner recalls
memories of the lost one and separates themselves from the person who died. This can go
wrong and develop into self-blame, self-abuse and depression.
o The mourners resentment towards the lost love one is directed inward.
Canadian Perspective 8.2
Cognitive perspective: Depression is associated with two personality styles: sociotropy and
autonomy
- Sociotropic individuals are dependent on others. They are concerned with pleasing
others, avoiding disapproval and avoiding separation.
- Autonomy is an achievement related construct that focuses on self-critical goal striving,
distress for solitude and freedom from control.
o This predicts recurrence of depression even after controlling for the history of
depression.
- Psychoanalytic approach: depression is associated with introjected and anaclitic
personality traits
- Anaclitic orientation involves excessive dependency on others.
- The introjected orientation involves excessive levels of self-criticism.
o There is a strong link between dependency and depression.
o This is linked to the dimension of perfectionism. Depressed individuals have
higher levels of self-oriented high personal standards and socially prescribed
perfectionism.
- Congruency hypothesis: reflects stress approach
o If a non-depressed person with a certain personality trait(diathesis) experiences a
stressful event congruent with their diathesis they will become depressed
Cognitive Theories of Depression
→ Beck’s Theory of Depression
- Depressed individuals feel as they do because their thinking is bias towards negative
interpretations.
- In childhood depressed individuals acquire a negative schema-a tendency to see the world
negatively
- Negative schemata fuel and are fueled by negative biases.
- Negative cognitions include dysfunctional attitudes that bias the interpretation of
events.

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- There are two main themes of dysfunctional attitudes:

o Dysfunction beliefs reflecting the need for approval
o Dysfunctional beliefs reflecting the need for achievement and perfection.
- Depressed individuals have the following cognitive biases:
o Arbitrary inference: a conclusion drawn in the absence of sufficient evidence or
any evidence at all.
o Selective abstraction: a conclusion drawn on the bias of one of many elements in
a situation.
o Overgeneralization: A sweeping conclusion drawn on the basis of a single trivial
event
o Magnification and minimization: exaggerations in evaluating performance.
- Beck’s cognitive model states that due to repeated activation, negative schemas become
organized into a depressive modes and these account for depression.
- There are two key issues when evaluating beck’s theory:
o Whether depressed people actually think in the negative ways Beck discussed
o Instead of the negative beliefs following the depression, the negative thoughts
may cause the depressed mood.
▪ There is bidirectionality to this: negative thoughts can cause depression
and depression can cause negative thoughts.
- However Beck’s theory has the advantage of being testable.
o Beck’s theory has encouraged focusing on the thinking of the client in order to
change their feelings.
o There is a problem with his theory being tested: when therapy is being tested, the
therapist follows protocol. The same features are not accessed in therapy as
delivered in the community.
- Self reference coding task study involve presenting participants with positive or negative
single world adjectives.
o Asked to indicate whether the adjectives applied to them by stating yes or no.
o Depressed individuals’ relative to non-depressed individuals endorsed more
negative words and less positive words as self-descriptive
o Depressed individuals have a cognitive bias recalling more negative words with
depressed content.
- A study wanted to test if the differences involve cognitive accessibility rather than
cognitive availability.
o Depressed and non-depressed may not differ in whether their schemas involve
positive or negative content, they may differ in cognitive processing.
o In the stroop task involves were presented with emotional words and asked to
state the color of the word and ignore the word itself.
o Non-depressed students did not differ in their response time to manic words,
depressed words and neutral words.
o Depressed students took longer to respond to depressed oriented words. These
were the words cognitively accessible to them.

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- Another study ran a develop of attention task

o Dysphoric and depressed individuals do not selectively attend to negative and
positive material, but non-depressed individuals distract themselves from negative
material and focus on positive material.
o Individuals with a history of depression in a neutral mood tend to divert their
attention when presented with a negative stimulus. This is a protective bias
- Another study involved multiple tasks to determine if depressed and non-depressed
individuals differ in cognitive accessibility and organization.
o Depressed individuals had a negative self-representational system and a lack of a
well-organized positive template of the self.
→ Helplessness/Hopelessness Theories
- Learned helplessness theory: an individual’s passivity and sense of being unable to act
and control his or her life is acquired through unpleasant experiences and trauma the
individual tried unsuccessful to control.
- Attribution and learned helplessness
o Attribution-the explanation a person has for his or her behavior.
o They can attribute it to internal or external causes, global or specific causes or
stable or unstable causes.
- The way in which a person explains failure will determine its subsequent effects.
o Global attributions cause a person to generalize their failures.
o Stable attributions make attributions long term.
o Internal attributions are more likely to diminish self-esteem.
- An individual prone to depression is likely to show a depressional attributional style: a
tendency to attribute bad outcomes to personal, global and stable measures in faults.
→ When people with this style (diathesis) experience an aversive outcome(stressor)
they become depressed.
→ This style is related to childhood sexual abuse, parental overprotectiveness
and harsh discipline.
→ Hopelessness theory
- Some forms of depression (hopelessness depressions) are caused by states of
hopelessness, an expectation that the desired outcome will not occur or that the
undesirable outcome will occur, and a person cannot change the situation (helplessness)
- Advantage of hopelessness theory:
o Can deal directly with the comorbidity of depression and anxiety disorders.
→ Interpersonal Theory of Depression
- One reason depressed people may elicit negative reactions in others is that they tend to
reject their partners and display few positive social behaviors.
- Depression individuals with an autonomous orientation are oriented towards themselves
rather than others.

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- Depression and martial discord frequently co-occur. Critical comments by spouses are a
significant predictor of recurrence of depression.
→ Psychological Theories of Bipolar Disorder
- People with bipolar disorder have higher levels of dysfunctional attitudes.
o Also have problems with autobiographical memory and the ability to generate
solutions to task.
- Manic phase is seen as a defense against a psychological state. Manic states serve a
protective function.
Biological Theories of Mood Disorder
The evidence that certain neurotransmitters in drug therapies help to treat mood disorders
provides evidence that mood disorders have biological factors associated with them
→ Genetic Vulnerability
Genetic factors do not determine when manic symptoms will occur
- There is evidence for certain genes playing a role in bipolar disorder
o Bipolar disorder results from a dominant gene on the 11th chromosome
o Attempts to replicate the results above have however had mixed success.
→ Neurochemistry, Neuroimaging and Mood Disorders
- Low levels of norepinephrine and dopamine led to MDD and high levels led to
mania.
- In the 1950s, two other drugs, tricyclic and monoamine oxidase inhibitors were found
effective in relieving depression.
- Tricyclic drugs (imipramine and Tofranil) are a group of antidepressant medications
named because their molecular structure is characterized by three fused rings.
o They prevent norepinephrine, serotonin and dopamine reuptake so that more
neurotransmitter is left in the synapse and can be transmitted to the next neuron.
- Monoamine oxidase inhibitors (tranylcypromine and parnate) are named because they
keep monoamine oxidase from deactivating the neurotransmitters.
- Newer antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs)
(fluoxetine and Prozac)
o Specifically inhibit the reuptake of serotonin.
- Researchers have also looked at the metabolites of these neurotransmitters found in the
urine.
o The problem is that these levels of neurotransmitter are not direct measurements
of the levels of neurotransmitters in the brain.
- Another line of research focuses on how antidepressants alter the chemical messengers
that a postsynaptic receptor sends to a postsynaptic neuron.
o If receptors are overly sensitive, they should respond to low amounts of
neurotransmitter
o Drugs that increase dopamine levels have been shown to cause manic episodes in
individuals with bipolar depression, suggesting dopamine receptors are overly
sensitive.

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- In a study a diet was used to reduce the levels of serotonin in those in remission from
depression by lowering levels of tryptophan.
o 67% of individuals experienced a return in their depressive symptoms.
- In another study with non-depressed individuals with a positive or negative family history
of depression had their tryptophan levels lowered.
o Those with a positive family history of depression experienced a depressed mood
when their tryptophan levels were lowered.
- Many functional activation studies have been conducted on mood disorders to determine
how depression relates to brain activity.
o Amygdala, hippocampus, anterior cingulate and prefrontal cortex are main brain
structures involved in MDD and bipolar disorder.
o Hyperactivity in the amygdala and hypoactivity in the prefrontal cortex is
related to diminished cognitive appraisal and depression.
o Both recurrent depression and long-duration untreated depression are related to
decreased hippocampal volume.
- A study examined whether monoamine oxidase levels are elevated during untreated
depression.
o There are elevated MAO-A levels in postpartum mothers during the period
associated with post partum blues.
- Neurobiological mechanisms for bipolar disorder have also been examined.
o Neurobiological mechanisms for bipolar disorder are still unclear and debated.
There are many reasons for these inconsistent results across studies:
▪ Small sample sizes (creates difficulty replicating)
▪ Different equipment used across studies
▪ Different patient characteristics.
→ The Neuroendocrine System
The hypothalamic pituitary adrenocortical (HPA) axis may play a role in depression
- The limbic system is linked to emotions and effects the hypothalamus.
- The HPA axis is thought to be overactive in depression because it produces disturbances
in sleep and eating.
Cortisol levels are high in depressed individuals because of the excess release of
tryptophan by the hypothalamus.
o This excess release of cortisol from the adrenal gland causes an enlargement of
the adrenal gland.
o These high levels of cortisol have led to biological test for depression-
>dexamethasone suppression test.
▪ Dexamethasone suppresses cortisol secretion. But when given at night,
those with depression do not experience lower or suppressed cortisol
secretion.
▪ The failure of dexamethasone to suppress cortisol levels suggest
overactivity in the HPA axis in depressed individuals.

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▪ The failure of dexamethasone to suppress cortisol levels stops when the

depressive episode ends.
- The role of the right and the left hemisphere in depression:
o There is evidence both hemispheres are involved in depression, but the depression
varies.
o Right hemisphere dysfunction involves symptoms of flat effect
o Left hemisphere dysfunction involves symptoms of agitation and sadness.
→ Deconstructing Depression
- Heightened amygdala or limbic activity leads to oversensitivity to emotional events.
o This manifest as negative emotional bias and recall (cognitive reactivity)
o Selective attention to the negative results in cognitive distortions and the
formation of dysfunctional attitudes.
- Frequent occurrences of these negative distortions shape the content of the schema.
o These negative distortions and interpretations also shape the content of the HPA
axis, which leads to overactive serotonin levels and depression.
Therapies for Mood Disorders
- Depression is widespread and incapacitating and needs treatment.
- Bouts of depression tend to recur, and suicide is a risk
- Many depressed individuals do not have their disorder identified and are not given
proactive care.
- Clinical course of depression is highly variable.
o Some people with MDD may not require the intensive care
o For individuals with mild MDD., watchful waiting, self-guided management and
stepped care may help.
Psychological Therapies (psychodynamic therapy)
o The treatment involves trying to bring insight to the patient about their repressed
conflict.
o Short-term psychoanalysis and CBT are both equally effective in treating
depression.
o Short-term psychodynamic therapy is as effective as antidepressants in treating
mild or moderate depression.
- Interpersonal therapy, which is the present form of psychodynamic therapy combines
interactions between the depressed individual and the social environment.
o It is effective for reducing unipolar depression and maintaining treatment gains.
o The individual learns ways in which their current interpersonal behavior might
interfere with obtaining pleasurable relationships.
o It emphasizes better understanding of the interpersonal problems giving rise to
depression.
o The focus is on the clients current life, not the past
o A metanalysis found that IPT is effective, but not superior overall to other
treatments.

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▪ IPT is more effective than control conditions and adds to pharmacology,

but pharmacology is superior over IPT.
▪ IPT was the better predictor in protecting people who had recovered from
depression from relapsing.
Cognitive and Behavioral Therapies
- The therapist encourages the client to identify examples contrary to their negative
thoughts and to monitor private monologues and identify patterns of thought that
contribute to depression.
- Beck stated that depressed individuals are likely to think of themselves as inept and
incompetent if they make a mistake.
o The overall emphasis is on persuading the person to think differently
o These schema are an extension of Ellis rational emotive method and one of Ellis
irrational beliefs.
▪ “the individual must be competent in all things in order to be worthwhile”
o Beck adds a behavioral component to his treatment.
▪ If individuals are depressed, he encourages them to force themselves to do
things like get out of bed or go for a walk.
▪ If a change in behavior helps a person to achieve the goal of cognitive
reconstructing, then that’s better. But behavioral change by itself does not
alleviate depression.
- Studies have examined the effectiveness of Beck’s CT.
o One study showed that CT is more effective than tricyclic imipramine (Tofranil)
in alleviating unipolar depression.
o CT has an effect of preventing subsequent bouts of depression
o A diary reporting symptoms of CT showed that after 6 sessions clients reported a
reduction in daily sad affect, negative thoughts and reactivity to negative stressors
and increased positive affect.
- Some outcomes contribute to less favourable outcomes of CT
o They are less effective when used to treat people with high levels of dysfunctional
attitudes and high pre-treatment scores of depression
o It is less effective for those with more chronic depression, more episodes and
earlier onset.
- In another test of cognitive therapy it was found that:
o Those that score higher on neuroticism were more responsive to pharmacotherapy
▪ These individuals may benefit from treatment sequencing: treatment with
pharmacotherapy and then CBT when they are better able to use CBT
strategies.
- Another study focused on problem-solving therapy, which is a CBT intervention that
focuses on problem solving skills and attitudes
o This was deemed as effective as other psychosocial interventions and
pharmacology and more effective than attention support groups and no treatment.
Mindfulness-Based Cognitive Therapy

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- Combines mindfulness meditation to increase awareness in the body and mind with
cognitive intervention
- MBCT has also been shown to be effective in reducing symptoms of depression in those
with chronic recurrent depression with a history of suicide ideation
- MBCT is effective in treating anxiety and depression, however one limitation is that there
is limited studies with credible controls.
- CBT and MBCT work because they increase metacognitive awareness and by reducing
the tendency to ruminate.
- MCBT reduces the over generality of autobiographical memory effect.
o When asked to recall past events, depressed individuals usually tend to recall
broad, categorically events lacking in specificity, instead of specific detailed
events.
o This over generality effect reflects the negative schema described by Beck
- Another approach relative to the prevention of relapse is preventive cognitive therapy
delivered to clients after CT.
o This helps individuals who have experienced more than 3 depressive episodes
stay well longer.
Student Perspective 8.1
- The prevalence of depression among students is elevated. There is a 12% prevalence rate
in college and university students age 19 to 25.
- The three most common disorders among university women were generalized anxiety
disorder, depression and nicotine dependence.
- Both CBT and relaxation training have been found to be useful
o Perfectionism is associated with depression. An online intervention that combined
CBT with stress management to manage dysfunctional perfectionism was
beneficial in reducing depression and anxiety associated with perfectionism.
o Males students are highly underrepresented when it comes to prevention
measures. There needs to be more prevention measures developed for males.
Psychological Treatment of Bipolar Disorder
- A CBT intervention targeted at thoughts that go away when individuals go through a
manic episode has been shown to be effective in treatment bipolar disorder.
- It is difficult to get bipolar clients to take their medication regularly because they often
lack insight it the destructive nature of their behavior.
o Education about bipolar disorder and its treatment can improve adherence to its
treatments.
o Education about bipolar disorder may also improve social support from family
and friends.
▪ Individuals with bipolar disorder are more likely to relapse if they return
after treatment to an environment with hostility and over involvement
(expressed emotion)
- Common features of psychological treatment for relapse prevention in bipolar disorder
include the following:

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o Psychoeducation
o Promotion of medication adherence
o Promotion of daily routines and sleep
o Monitoring of mood
o Detection of early warnings of relapse
o Coping strategies and problem-solving techniques.
- Evidence continues to be mixed on whether structural psychological interventions are
beneficial in relapse prevention.
o One meta-analysis concluded that only psychoeducation is useful and only in
specific conditions
o Another meta-analysis suggested that CBT, group psychoeducation and family
treatment are beneficial on top of pharmacotherapy.
- About 1/3 of those with bipolar disorder seek psychotherapy and those that seek it score
higher on illness severity.

Biological Therapies
→ Electroconvulsive Therapy (ECT)
- Introduced in the early 20th century.
- Cerletti, was interested in epilepsy and sought a means to induce seizures. He saw
seizures induced in animals by electrical shocks administered to the head in animals.
- He used shock administered to the side of a human head to treat depression and
schizophrenia.
- ECT treatment is restricted today to profoundly depressed individuals.
- ECT is being used frequently in Canada and elsewhere because when it works it is faster
than psychotherapy and antidepressants.
- ECT entails the induction of a momentary seizure and unconsciousness by passing a
current of 70 to 130 volts through a clients head.
- Previously electrodes were placed on both sides of the head, so the current flew through
each hemisphere, which is known as bilateral ECT.
o In bilateral ECT the person was usually awake and this triggered contortions of
the body
- In unilateral ECT the current passes through the non-dominant (right) cerebral cortex
o Client is now given a short acting anaesthetic and then a strong muscle relaxant
o It reduces metabolic activity and blood circulation to the brain and may inhibit
aberrant brain activity.
o ECT leads to improvements in problem-solving and this lead to changes in brain
activity.
- Unilateral ECT was compared to ultra brief pulse ECT
o Ultra brief pulse was evaluated because it may result in less cognitive deficits.
o Some research has suggested that brief pulse ECT is more effective with no
difference in side effects.
▪ Given the study limitations it is premature to conclude this.
- One issue with ECT is the high relapse rate.

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o ECT was effective in treating both unipolar and bipolar depression, but the
remission rate was 51.5%.
- Many groups protest against ECT
o They suggests that ECT is inhumane, pose considerable risk and is not effective.
o Prior clients believe that ECT has led to permanent damage.
o There is variability in outcomes experienced, as other people believe ECT saved
their lives.
o Reports conclude ECT is effective but that safeguards such as informed consent
are needed to protect the rights of the clients.
o Concerns have been raised about certain people receiving a large number of
treatments.
Deep brain stimulation and repetitive transcranial magnetic stimulation
- Deep brain stimulation is used for treating treatment resistant depression once ECT,
psychotherapy and medication have failed.
o Treatment is based on the observation that the subgenual cingulate cortex is
overactive in tre atment resistant depression.
o This treatment disrupts focal limbic-cortical circuits by stimulating the subgenual
cingulate cortex believed to be involved in treatment resistant depression.
▪ Has been shown to be effectively safe in treating unipolar and bipolar
depression.
▪ Has also been shown to be effective in treating OCD, substance abuse
traumatic brain injury, anorexia nervosa and dementia
- The limitations of deep brain stimulation is that it can cost up to 250000 per person
- Repetitive transcranial magnetic stimulation is a non-invasive method of brain
stimulation using brief magnetic pulses to stimulate the brain
o This elicits a treatment response in those with depression and pain and may be as
effective as ECT.
o Elevations in glutamate levels were shown in adolescents treated with transcranial
magnetic stimulation.
Drug Therapy for Depression
- Drugs are the most commonly used treatment for mood disorders
- The use of antidepressants has increased exponentially.
- Antidepressants do not work for everyone and side effects are sometimes serious. It is
difficult to find personal characteristics that might predict treatment response.
- There are three major categories of antidepressants:
o Monoamine oxidase inhibitors: Parnate
o Tricyclic antidepressants: Tofranil and Elavil
o Selective serotonin reuptake inhibitors (SSRIs): Prozac and Zoloft
- SSRIs were the most commonly used antidepressant for those who had a major
depressive episode in the past year
- Antidepressant medication is often used with some form of psychotherapy.

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o The combination of CT and medication works better together than either in

isolation.
- STAR*D project (sequence treatment alternatives to relieve depression) focuses on
modified treatment processes for adults with major depression in outpatient settings.
o Clients first receive medication for 8 to 12 weeks and then if symptoms remain
after 8 to 12 weeks other types of treatment are used.
o Clients usually receive 2 or more treatments in total for maximum benefit.
o Studies show that following medication with psychotherapy is effective in
reducing relapse rates.
o The results of the project are encouraging and disappointing
- There are many negatives involved in treatment with STAR*D
o The cumulative remission rate after four treatment steps is 70%
o No pre-treatment factors provided clues about which specific medications are best
for a certain client
o 1/3 of those who had been receiving medication did not show improvement by 6
weeks.
o Depressed clients with signs of anxiety had poorer response and remission rates.
o Minority participants had poorer quality of life, more comorbidity and greater
attrition.
→ Drug Therapy for Bipolar Disorder
- People with mood swings in bipolar disorder are helped by lithium, taken in salt form as
lithium carbonate (mood stabilizer)
→ 80% of individuals with bipolar experience some benefit from lithium
→ This drug is effective for patients when they are depressed and manic. It is much
more helpful for bipolar clients than unipolar clients.
→ Lithium is typically taken with an antipsychotic Haldol (calming effect)
→ Lithium was never approved for use by the Food and Drug Administration
- There are serious and lethal side effects, so lithium needs to be prescribed and used
carefully.
- Discontinuation of lithium increases the risk of recurrence.
- Rates of lithium use have decrease in previous years due to concerns about the side
effects.
- About ¼ of individuals using lithium experience abnormalities in thyroid and parathyroid
glands. Therefore, calcium levels need to be monitored in those taking lithium
→ Treatment for Seasonal Affective Disorder
- Therapy for those with winter depression involves exposing clients to bright white light.
- Phototherapy (bright white light exposure) is a highly effective treatment for seasonal
effective disorder
- Phototherapy is useful in reducing seasonal affective disorder and suicidal tendencies.
- Phototherapy is more effective when used with CBT.
o CBT focuses on identifying the negative thoughts involved during the winter
months and encouraging the person to engage in everyday pleasurable activity

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Preventing the Onset of Depressive Symptoms

- Research has focused on whether prevention-based programs can reduce the incidence of
depression
o In studies of CTs there was a reduction in the incidence of depression by 22%
o Prevention based on IPT is more effective than prevention based on CBT
o Prevention is worthwhile because it leads to small or medium effect sizes in
reducing the incidence of depression.
Suicide
- Suicide was the 9th leading cause of death in Canada in 2012 and the 2nd leading cause of
death in males and females aged 15 to 24.
- Suicides rates are increasing and are at the highest level in 30 years
- About ¼ of all suicides are female, suicides are therefore more common among men.
- Females have lower rates of suicide mortality, but higher rates of suicide attempts. This it
the gender paradox of suicide behavior.
- Suicide ideation: refers to thoughts and intentions of killing oneself.
o Associated with a sense of helplessness, hopelessness and despair.
- Suicide attempts: self-injury behaviors intended to cause death, but do not lead to death
- Suicide gestures: involve self-injury in which there is no intent to die.
- Suicide: behaviors intended to cause death, where death actually occurs.
- What are some factors that suggest that attempts will occur:
o ideators with a plan are more likely to make an attempt than those without a plan.
o A history of prior attempts make it more likely another attempt will occur
- Suicide attempters: male gender, fewer years of education, psychiatric diagnoses,
comorbidity and a history of sexual and physical assault.
o Hopelessness and self-criticism were robust predictors of suicide attempts.
- What factors predict death due to suicide?
o Severity of suicide ideation
o Hopelessness/depression
o History of bipolar depression
o Unemployed.
- Loved ones of those who commit suicide have a high mortality rate in the year after the
love one dies.
o If a person who committed suicide also had a psychiatric disorder, love ones have
to deal with the stigma of suicide and mental illness.
Focus on Discovery 8.3
- There are many myths regarding suicide which include:
o People who discuss suicide will never commit suicide
▪ Fact: About ¾ of those who take there own life having communicated
their intention before hand.
o Suicide is usually done without warning
▪ Fact: Suicide is actually usually done after warnings signs have been seen.
o Suicidal people clearly want to die

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▪Fact: Most people who contemplate suicide are ambivalent about their
own deaths
o The motives for suicide are easily established
▪ Fact: we actually do not understand why people commit suicide
o All who commit suicide are depressed
▪ Fact: many people who take their own lives are actually not depressed and
may even be at peace with themselves
o Improvement in emotional state means a lessened risk of suicide
▪ Those who commit suicide especially those who are depressed usually do
so after their energy begins to rise.
→ Suicide and Psychological Disorders
- 15% of those who have been diagnosed with MDD actually commit suicide.
- Depressive symptoms of suicide include weight or appetite loss, insomnia, feelings of
worthlessness and recurrent thoughts of death or suicide intention.
- Individuals with MDD that report more suicide attempts have more current general
medical conditions, more current alcohol and substance abuse, more report of suicide
ideation and 9 year earlier onset of depression compared to individuals with MDD that
have not had suicide attempts.
- Comorbid anxiety disorders also increase risk of death by suicide in depressed
individuals.
- In individuals with bipolar disorder, hopelessness predicted depression during depressive
phases, whereas a subjective rating of severity of depression and younger age predicted
suicide attempts in mixed episodes.
- Females, but not males who perceive themselves as rejected were more likely to make a
suicide attempt.
- Individuals with borderline personality disorder usually make attempts at suicide and
succeed
- The suicide rate for male alcoholics is greater than for the general population of males.
Disinhibition during intoxication may make individuals less able to resist their thoughts
of suicide.
- The number of completed suicides among those with schizophrenia is comparable to the
number of completed suicides in those with depression
- Of males who complete suicide, 78% screened positive for psychopathology at the age of
8. Self-reports of depression did not predict suicide outcome.
- Outcome of suicide was predicted by conduct and internalizing problems
- Female suicide was not predicted by any of the factors at age 8.
→ Perspectives of Suicide
→ Durkheim’s sociological Theory
- Egoistic Suicide: is committed by people who have few ties to the family, society or the
community. These individuals feel isolated from others.
- Altruistic suicide: viewed as a response to societal demands. People feel apart of a group
and sacrifice themselves for what they take to be the good of suicide

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- Anomic suicide: triggered by a sudden change in a persons relationship with suicide.

o This theory has difficulty in examining differences among individuals in a given
society in their reactions to the same societal demands
Psychological Theories
- Most people who contemplate or commit suicide are ambivalent. There is a narrowing in
the perceived ranged on options.
- People with a plan for suicide usually communicate their intention as a cry for help or
withdraw from others.
o Behaviors include giving away possessions and putting financial affairs in order.
→ A Risk Factor Model
- Predisposing factors are enduring factors that make a person more vulnerable to suicidal
behavior (psychological disorder, abuse, early loss)
- Precipitating factors are acute factors that create a crisis (end of relationship, job loss,
rejection)
- Contributing factors increase exposure to predisposing or precipitating factors (physical
illness, sexual identity issues)
- Protective factors decrease the risk of suicide behavior (personal resilience, adaptive
coping skills)
- Childhood sexual abuse is one potent predisposing risk factor.
→ Baumeister’s Escape Theory
- Suicides arise from a strong desire to escape from aversive self-awareness, painful
awareness of shortcomings
- Unrealistic high expectations and the probability of failing to meet those exceptions play
a role in this perspective
- Perfectionist have very high standards and are more likely to experience such
discrepancies
→ The perfectionism social disconnection model
- Trait perfectionism and self-criticism have been implemented in suicidal acts.
- Perfectionism is a risk factor for suicide. Socially prescribe perfectionism was a
significant predictor of suicide ideation, interpersonal hopelessness and achievement
hopelessness
- Interpersonal perfectionism creates a sense of alienation and isolation, that amplifies
hopelessness and self-loafing that come with perfectionism
- The association between suicide and the need to avoid being imperfect was mediated by a
history of being bullied.
→ Joiner’s Interpersonal Theory of Suicide
- The idea to commit suicide is a product of two interpersonal constructs
o A thwarted need to belong
▪ Individuals are at risk when they feel alienated
o Perceived burdensomeness
▪ Individuals are also at risk when they regard themselves as burdens.

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- Perceived burdensomeness could actual mediate the relationship between perfectionism

and suicide.
- Suicide occurs when the individual has both the will and ways to commit suicide.
o The capability to commit suicide accounts for the differences between those who
attempt to commit suicide and those who actual go through with it.
o Greater capability is associated with greater tolerance to physical pain and those
higher is sensation seeking and distress tolerance.
→ Shneidman’s approach
- The majority of people with psychiatric disorder do not commit suicide
- The perturbation of the mind in order to commit suicide is not a mental illness
- Suicide is a conscious solution to a problem that is causing intense psychological pain
(psychache)
o The solution ends suffering and pain
- Other factors such as depression are relevant if they are related to psychache
- Psychache mediates the relationship between perfectionism and suicide.
→ Additional psychological factors
- Suicide is regarded as an individuals attempt at problem solving. Problem solving deficits
predict suicide attempts. Their problem-solving skills are more rigid than others.
- The expectation that things in the future will be no different than they are right now
seems to be more related to suicide than depression.
- Hopelessness mediates the rumination-suicide ideation link.
- Negative cognitive distortions are also associated with suicidality.
- Fortune telling was not a significant factor once hopelessness was taken into account.
Canadian Perspectives 8.3
- The Innu people are 13 times more likely to kill themselves than other people in Canada
- The suicide range among the children is 3 to 7 times the national average of other
children.
- Some factors that could contribute to these high rates of suicide are loss of cultural
identity and physical and sexual abuse.
- Aboriginal societies have experienced cluster suicides: multiple suicides by groups in the
community.
- Risk factors associated with suicide included being male, having a friend who attempted
suicide, a history of abuse.
o Two protective factors were church attendance and doing well in school
o The highest factors among females for suicide risk are crack use, psychiatric
problem and alcohol abuse.
- Among the aboriginal individuals the differences in suicide rates are associated with the
degree with which cultural identity is maintained and preserved overtime.
Physical Factors in Suicide
- Chronic traumatic encephalopathy (CTE): a progressive neurogenerative neurological
disease involving atrophy of key areas of the brain.

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o This has been implemented in the role of suicides of NFL players and marines
- There may be genetic factors as well for suicide risk
o Monozygotic twins have a higher risk for suicide than dizygotic twins.
o Cluster B personality and aggressive-impulsive behavior mediate the relationship
between familial predisposition and suicide.
o Low level of 5-HIAA have been found in individuals in several diagnostic
categories who committed suicide.
Preventing Suicide
- SUPRE-MISS is used to prevent suicide. SUPRE refers to suicide prevention and MISS
refers to multi-site intervention study on suicide behaviors.
- The four themes for suicide prevention include
o Health and empowered individuals
o Clinical and community preventive services
o Treatment and support services
o Surveillance, research and evaluation.
Treating the underlying mental disorder
- Most people that attempt to kill themselves are suffering from a treatable mental disorder
- When Beck’s cognitive approach reduces depression, it also reduces suicide risk.
- Efforts to prevent suicide should focus on the underlying psychological disorder
Treating suicidality directly
- Reduce the intense psychological pain and suffering
- Lift the blinders-help the individual see other options other than the option to take their
own life
- Encourage the person to pull back from the self-destructive act.
Suicide prevention centres
- Staffed by non-professionals controlled by psychologists and psychiatrists.
- Initial contact is made by phone and that phone number is widely known in the
community.
- The person tries to access the probability that the caller will make a suicide attempt and
tries to dissuade the caller from doing so.
- Staffers are taught to adopt a phenomenological stance: to view the suicidal persons
situation as the way they see it. This empathy for suicidal people is referred to as turning
in.
Cultural and Ethical Issues in dealing with suicide
→ Therapist responsibility
- The suicide of a therapist client is grounds for a malpractice lawsuit
→ Physician Assisted Suicide
- This is a highly charged issues
- This topic is of current interest in Canada due to the case in 2012 of Gloria Taylor who
petitioned for an assisted suicide to end her case of Lou Gehrig disease

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- On February 6th, 2015 the Supreme Court of Canada ruled that the laws against assisted
suicide are unconstitutional.
→ C-14 bill passed by the house of commons allows for assisted suicide in
medical competent adults in the advance stages of a serious illness where
death is foreseeable.
- 60% of physicians were in favour of the legalization of assisted suicide.
→ Physicians had more positive views if they provided care to HIV patients.
→ Another factor was location. More favourable views came from Canada, British
Columbia and Quebec.
→ Caring for the suicidal client
- Must be prepared more energy and time than usual.
- The therapist should be prepared that they will become an essential figure in this persons
life and that they will be a source of dependency, but also hostility and resentment when
they try to offer help.
- CBT and IPT combined with depression had efficacy in reducing suicide intention.
- There is evidence that new antidepressants play a role in falling suicide rates.
- Lithium plays a role in reducing suicide in those with bipolar disorder and unipolar
depression
- Clozapine plays a role in reducing suicide in those with schizophrenia.

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Chapter 10: Eating Disorders

- Many people are overweight and dieting to lose weight especially in women is common.
- Eating disorder symptoms can reflect transitions involving psychological processes and
life transitions.
- Started in the DSM in 1980, as one subcategory of disorders beginning in adolescence.
- Improved criteria for anorexia nervosa and bulimia nervosa were included in the DSM-5
along with Binge eating disorder.
- There are gender differences where women are more likely to have eating disorder.
However, 1 in 3 or 1 in 4 cases still involve men
- The disorders had mostly the same age of onset, but it was slightly earlier for bulimia
nervosa. Bulimia also has a higher persistence.
- There is an increase in the likelihood of children between the ages of 5 and 9 to be
admitted to hospital for an eating disorder.
- Hospitalization for eating disorders is highest among women in the 15 to 19-year old age
range. Rates are also high among those age 10 to 14 and 20 to 24.
Clinical Descriptive of Eating Disorders
- There is great heterogeneity in eating disorder symptom expression, therefore the most
common diagnosis is eating disorder not others specified (EDNOS)
→ This category has been used has a catch all category that suggests problems in the
diagnostic system.
→ EDNOs is a clinical condition and not a category because more evidence is
needed to elevate it as a diagnostic category.
→ EDNOs is an eating disorder comparable in degree and severity to anorexia
nervosa and bulimia nervosa.
→ DSM-5 dropped the EDNOs description in favour of new descriptions
▪ One category is unspecified feeding or eating disorder: this is used for any
eating disorder that causes significant impairment but does not meet
diagnostic threshold.
▪ Another category is other specified feeding or eating disorder: atypical,
mixed or subthreshold conditions.
❖ Includes subthreshold binge eating disorder and bulimia nervosa
❖ Night eating syndrome: repetitive tendency to wake up and eat
during the night and get upset about it.
❖ Purging disorder: a form of bulimia that involves self-induced
vomiting or laxative atleast once a month for a minimum of six
months.
❖ One key feature that separates those with purging disorder from
others is their impulsivity.
- The diagnosis of anorexia nervosa and bulimia nervosa share several key features
including the fear of being overweight.
o There are some implications these may be two variants of a single disorder where
co-twins who have anorexia nervosa are more likely to have bulimia nervosa.

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Anorexia Nervosa
- Anorexia means loss of appetite and nervosa indicates that it is for an emotional reason.
- The term is a misnomer because most with anorexia do not loss their appetite for food,
they are preoccupied with food.
- There are four criteria for be diagnosed with anorexia nervosa and they include:
o The person must refuse to maintain a normal weight and weights less than 85% of
what is considered normal for their age and height
▪ DSM-5 has modified this criteria and no longer refers to the 85%
guideline- their revised version involves restriction of energy intact
resulting in a low body weight.
o The person has an intense fear of gaining weight and this fear cannot be reduced
by weight loss
o The person has a distorted sense of their body shape.
o In females it can cause amenorrhea, the loss of their menstrual period.
▪ This criteria has been eliminated from DSM-5 because many adolescence
and women who have anorexia nervosa and do not meet this criteria are
still similar to those who meet all four criteria for a diagnosis.
- The self-esteem of those with anorexia nervosa is closely linked to maintaining thinness.
- Anorexia nervosa typically begins in the mid-to-late teenage years after dieting and
exposure to stress.
- Co-morbidity is high. Those with anorexia are also prone to depression, social phobia and
panic disorder.
Physical Changes in Anorexia Nervosa
- Self-starvation and the use of laxatives produce undesirable consequences.
- Blood pressure falls, nails become brittle, mild anemia may occur and the skin dries out.
- Some individuals loss hair from their scalp and may develop Laguna, a fine soft hair on
their bodies
- Levels of electrodes are lowered, and this can cause tiredness, weakness and cardiac
arrhythmias.
- Brain size declines and neural abnormalities are common.
o White matter deficits are restored in the brain upon recovery from anorexia
nervosa.
o Deficits in grey matter are irreversible
Prognosis
- About 70% of those with anorexia nervosa eventually recover.
- Recovery often takes 6 or 7 years and relapse is common before a stable pattern of weight
is maintained
- Changing the distorted views of themselves is extremely difficult
- Anorexia nervosa is a life-threatening illness.
o Death rates are 10 times higher than the general population and two times higher
than for those with other psychological disorders.
o No other disorder that has equal mortality rates

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o A shorter time to death was associated with chronicity, later age of onset and not
being in a relationship.
o Suicidality was not linked to a shorter death in those with anorexia nervosa,
BUT it was in those with bulimia nervosa.
Focus on Discovery 10.1
- The tendency to engage in intentional self-harm and self-injury is very common and it
increases the risk for subsequent suicide attempts.
- Intentional self-injury is associated with expericing eating disorders and the vulnerability
to eating disorders.
o This is high among those high in impulsivity
- In one study about 17% of youth between 14 and 21 engaged in non-suicidal self-injury
o Mean age of onset was 15 years old
o The main forms were cutting, scratching and self-hitting
o More self-injury was linked to depression and difficulties regulating attention and
impulsivity.
o Self-harm among young women was related to body shame and a history of
parental criticism.
- There are four reasons why self-harm may occur, they include:
o Interpersonal reasons
o To suppress an unwanted social stimulus (social negative reinforcement)
o To suppress negative emotions (automatic negative reinforcement)
o To generate feelings (automatic positive reinforcement)
- One factor that could account for self-injury is the internet self-injury message boards.
o This was referred to as the virtual cutting edge.
o Online social interaction provides support for those with a history of self-harm,
but they also normalize and encourage further acts of self-injury.
- The strongest predictors of self-injury were prior history of self-harm, higher
hopelessness and personality disorders with dramatic and erratic symptoms.
Bulimia Nervosa
- Bulimia means ox hunger and nervosa means for an emotional reason.
- This disorder involves rapid consumption of a large amount of food followed by
compensatory mechanisms, such as vomiting, fasting or excessive exercise to prevent
weight gain.
- DSM-5 defines a binge as eating an excessive amount of food with a defined period of
time (2 hours)
→ This binge must also include a sense of lack of control over the behavior.
→ Binge-eating and compensatory behavior must occur atleast once a week for a
period of three months.
- Bulimia nervosa is not diagnosed if the bingeing and purging only occur in the context of
anorexia nervosa. The diagnosis in this case would be anorexia nervosa, binge-eating-
purging type.
- Represents a discrete category that differs qualitatively from normality.

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- Binges occur in secret and may be triggered by stress and the negative emotions it brings.
- Stressors that involve negative social interactions are potent elicits for bingeing
o Bulimics have high levels of interpersonal sensitivity, as reflected by self-
criticism following social interactions.
- DSM-5 criteria requires that the self-evaluation by influenced by body shape or body
weight.
- Binge episodes followed by lower self-concept, mood state and social perception.
- The person engaged in bingeing often feels a lack of control over the amount of food
being consumed.
- Binges are not always as large as the DSM implies and there is a lot of variation in the
calorie intact consumed by individuals with bulimia nervosa during binges.
- They report losing control during binges to the point of a dissociative state and they feel
ashamed of their binges.
- After the binge is over, disgust, feelings of discomfort and fear of weight gain led to
purging- induced vomiting and excessive exercise to undo the calorie intact.
- In the DSM-5 there needs to be bingeing once a week for a period of 2 months.
- A morbid fear of fat is an essential criteria for a diagnosis of bulimia nervosa because:
o It is the core psychopathology of bulimia nervosa
o It makes the diagnosis more restrictive
o Makes the syndrome closely related to anorexia nervosa.
- Fat talk is the tendency of female friends to take turns disparaging their bodies to each
other.
- Typically begin in late adolescence and early adulthood. There are different
developmental trajectories:
o One group has high steady symptoms, and another has increasing behaviors.
- Many females do not meet diagnostic criteria but show risk of subsequent vulnerability to
problems.
o The vulnerability for an eating disorder can be detected at a high age
o For females as their body mass increased, their body dissatisfaction decreased.
- For many people with BN they are overweight before the diagnosis and the binge eating
often starts after dieting.
- There is diagnostic crossover: more than 18% with AN develop BN, while 7% with BN
develop AN.
o Mortality is much less common in BN than AN however.
Student Perspective 10.1
- Fat talk reflects a conversional norms that it is somewhat excepted for people to express
negative opinions about their bodies as a way of fitting in.
- Fat talk reflects a highly defensive and negative sense of self
o Engaging in fat talk is associated with body shame, greater body self-
consciousness, a lower sense of empowerment and maladaptive eating attitudes.
o It is linked to increases in body dissatisfaction, negative affect, disordered eating
and more frequent checking of one’s body.

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Binge Eating Disorder

- The disorder includes recurrent binges, atleast once per week for atleast 3 months, lack of
control during the bingeing episode and distress about bingeing
- Binge eating episodes must involve 3 of the following:
o Eating more rapidly than normal
o Eating until feeling uncontrollable
o Eating alone due to feelings of embarrassment
o Eating large amounts of food when not hungry
o Feelings disgusted with oneself or depressed or guilt.
- It is different from AN because there is absence of weight loss and it is different from
BN because the absence of compensatory measures.
- It is linked with impaired work and social functioning, depression, low self-esteem,
substance abuse and dissatisfaction with body image
- Greatest risk factors are childhood obesity, abuse, depression and low self-concept.
- The average lifetime duration is 14.4 years, which is larger than that for AN and BN

Biological Factors
Genetic Factors
- A role of genetics is suggested because both AN and BN run in families.
- Females with a relative with AN are 4 times more likely to develop the disorder
themselves.
- There is higher identical twin than fraternal twin concordance rates for AN and BN.
- Some genetic variants have been identified but have not achieved genome wide
significant
- The genetic basis for the internalization of the ideal thin suggest a genetic basis between
psychology and biology for why some people are more susceptible to body image issues.
Eating Disorders and the Brain
- The hypothalamus regulates eating and hunger
- Individuals with lesions to the lateral hypothalamus loss weight and have no appetite.
- The hypothalamus and the paraventricular nucleus have both been implicated in AN.
o Some hormones such as cortisol, which are regulated by the hypothalamus are
low in those with AN
o These low levels of hormones do not cause the disorder, the occur as the result of
self-starvation.
- The weight loss of animals with hypothalamus lesions does not parallel anorexia.
o Those with anorexia starve themselves despite being hungry
o The hypothalamus does not account for body-image disturbance or fear of
becoming fat.
o Therefore, the hypothalamus is not a highly likely factor in AN.
- Endogenous opioids are substances produced by the body that reduce pain sensations,
enhance mood and suppress appetite

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o Starvation among those with anorexia nervosa may result in increases in

endogenous opioids resulting in a positive euphoric state.
o Increased exercise among those with eating disorders increases opioids and is
reinforcing.
o Bulimia may be mediated by low levels of endogenous opioids, which promotes
the ingestion of food.
- Research on endogenous opioids found that they may play a role in bulimia.
o The more severe cases of bulimia had the lowest levels of the endogenous opioid
beta-endorphin.
o Clients with bulimia have decreased mu-opioid receptors in the insular and this is
associated with fastest.
- Lower levels of serotonin metabolites have also been found in those with BN.
o These are linked to negative mood and self-concept changes
o Genetic polymorphisms at birth in serotonin may also be limited by exposure to
harsh environments.
o Environmental estrogens predisposition females to gain weight and engage in
dieting that may become excessive.
▪ However, recent studies have found a link between genetic variance in
serotonin for AN but not for BN.
Socio-Cultural Variables
- Females feel more pressured by unrealistic images than males. Toys reflect this
unrealistic ideal (ex. Barbie Doll).
o 5-and 6-year olds exposed to Barbie Dolls have an increased tendency to suffer
lower self-esteem and achieve greater desire to achieve the ideal body shape.
- Video games have also shown an increasing tendency to portray female bodies as too
thin, whereas males are portrayed as large compared to then standard average weight.
- There is growing evidence for the role of body dissatisfaction in males and how the
idealization of a hyper-mesomorphic lean and muscular body image is providing pressure
and body dissatisfaction.
- A study looked at a 28-year old Dutch women with a 10-year history of Bulimia nervosa
who was sensitive to the cultural pressures of being thin despite being blind.
o This women first became aware of societies unrealistic beauty standards when she
played with a Barbie doll at 13 years old.
o She picked up on societal pressures to be thin on the internet and in conversions.
o She started to feel pressure to feel thin because she learned from the media that to
be accepted she must be thin and perfect.
- Body image pressures contribute to restrictive eating in various ways:
o Women eat less to be portrayed as more feminine.
o A study found that women who are portrayed as eating heavily are seen as less
feminine than women who are portrayed as eating less heavily.
o The above is the Scarlett O’Hara effect: eating lightly to reflect femininity.
- The cultural pressures to be thin are increasing, but more and more women are becoming
overweight.

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o The obesity prevalence has doubled since 1990.

o This increase in obesity is related to a tendency for humans to eat to excess to
store for a time when food may be less plentiful.
- Internalization of societal standards increases the risk among males and females for the
development of eating disorders
- In school aged children more than ¼ females feel they are too fat and by the age of 15,
43% of females feel they are too fat.
- Society has become more health and fat conscious and dieting has become more
common.
- The socio-cultural ideal of being thin is the ideal vehicle through which people learn to
fear being or feel fat.
o Obese people are viewed by society as less smart and lazy
o This anti-fat bias is pervasive, such that even obese people endorse these views of
themselves. Thinner people are more likely to endorse these anti-fat biases.
- The media continues to promote thinness. There is even an increase in the amount of pro-
anorexia websites.
o These websites glorify starvation and reinforce irrational beliefs about the ideal of
thinness.
o Individuals use these sites to get weight loss advice and relate thinness with
happiness.
o These sites have been linked with body dissatisfaction, dieting and negative
affect, but not bulimia.
o These online forums can be good and bad for ones health.
▪ It can provide them with the social support they are lacking offline, but it
can also increase maladaptive behavior.
Gender influences
- The gender differences among women and men for eating disorders is influenced by the
fact women are more influenced by the cultural ideal of thinness.
- Women are usually valued more for their appearance, whereas men are valued more for
their accomplishments.
- Women are more concerned than men about being thin and more likely to diet
- There is growing concern that appearance pressures are increasing for men as well with a
heightened drive for muscularity, which can take the form of muscle dysphoria (an
obsessions with not being as muscular as the ideal).
Cross-Cultural Studies
- Eating disorders are far more common in industrialized societies than non-industrialized
societies.
- There are more eating disorders in Western societies than non-Western, but this gap is
closing in recent years.
o The prevalence of EDs has increased in non-western societies, but it is still low
compared to Western cultures.

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- The differences in eating disorders across cultures suggests the importance of culture
presenting realistic or unrealistic views of ones body.
- In china, the fear of fat criteria for those with AN, may not been seen in anorexic females
in China.
- A subtype of bulimia known as the herbal purgative class was seen in Fiji, characterized
by the use of herbal purgatives.
Cognitive-Behavioral Effects
- Cognitive behavioral roles emphasize fear of fatness and body-image distortions as the
motivating factors in starvation and weight-loss.
- Behaviors that achieve thinness are negatively reinforcers for the anxiety about being fat.
- Dieting and weight-loss may be positively reinforced by the sense of control they create.
- Perfectionism and a sense of personal inadequacy may make a person more likely to
develop an eating disorder.
- Even brief exposure to images of young models can install negative mood in young
women.
- Chronic dieters feel thinner after looking at images of the thin body and this motivates
them to diet (thinspiration effect). This can cause distress when the individual is not able
to meet this unrealistic thin.
- Another strong drive for thinness is criticism from peers and parents about being
overweight.
o Girls aged 10 to 15 were evaluated twice within a 3-year period.
o Obesity at the first assessment was related to being teased by peers.
o At the second obesity was linked to body dissatisfaction, which was into
symptoms of an eating disorder.
- Bingeing results frequently when diets are broken. A lapse that occurs in diet for
someone with AN is likely to cause a binge.
Psychodynamic View
- The core cause in eating disorders lies in disturbed parent-child relationships
- The core personality traits of low self-esteem and perfectionism are found in those with
an eating disorder.
- The eating disorder fulfills some need, such as the need to increase one’s personal
effectiveness or to avoid growing up sexually.
- Early psychodynamic theories interpreted AN as arising from a conflict drive, but create
views view it as associated with a deficit drive, which is a way to compensate for deficit
in the self.
- Some psychodynamic theorist view AN as an attempt by children raised by ineffective
parents to ward off feelings of helplessness and powerlessness.
Family Systems Theory
- The symptoms of an eating disorder are best understood by considering both the afflicted
person and how their symptom are embedded in a dysfunctional family structure.

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- The child is seen as physiological vulnerable and the child’s family has key features that
promote the development of an eating disorder.
- The child’s disorder plays a role in helping the family members avoid other conflicts.
- The families of individuals with eating disorders have the following characteristics:
o Enmeshment: overinvolvement and intimacy in which parents speak for the
children
o Overprotectiveness: family members have an extreme level of concern for others
welfare
o Rigidity: families try to maintain the status quo and do not deal effectively with
events that require change.
o Lack of conflict resolution: avoid conflict or are at a state of chronic conflict.
Characteristics of Families
- Results on characteristics in families that result in eating disorders have been variable
because of the different methods used.
- Self-reports usually reveal high levels of conflict within the family
- Parents of clients with eating disorders report higher levels of isolation and lower levels
of mutual involvement and support.
o These characteristics could however be the result of an eating disorder and not the
cause of it
Child Abuse and Eating Disorders
- Self-reports of sexual abuse are higher for those with eating disorders
- 25% of women with an eating disorder reported a history of sexual abuse.
- The presence and severity of abuse predicts more extreme psychopathologies.
- Both sexual and physical abuse are linked to an eating disorder. Having endured all 3
types of abuse amplifies the risk of an eating disorder.
Personality and Eating Disorders
- Trait negative emotionality and perfectionism have achieved risk status for the
development of an eating disorder
- Six personality factors have been linked consistently with an eating disorder: avoidance
motivation, lower extroversion and self-directedness, neuroticism, perfectionism and
sensitivity to social rewards.
- When looking at the role of personality it is important to remember that the eating
disorder could have caused the personality and not the other way around.
- In a study for six weeks, men volunteered to only eat 1500 calories a day and all lost
about 25% of their body weight.
- Narcissism has also been focused on in AN and BN studies.
o Perfectionism consists of two factors: self standards and external pressures
imposed on the self.
o Self-oriented perfectionism (setting high standards for the self) and socially
prescribed perfectionism are both high in those with eating disorders.

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o Bulimic symptoms are found among females who are characterized by

perfectionism as well as body dissatisfaction and low self-esteem
o Some individuals respond social pressures to be perfect by engaging in
perfectionism self-presentation.
▪ These individuals try to maintain an image of perfection and are
determined not to make mistakes.
▪ Individuals with eating disorders are overly concerned with how they are
viewed by others.
▪ There is an increase in the need to seem effortless perfect in front of
others, known as the Stanford Duck Syndrome-the tendency for students
at Stanford university to respond to strong social pressures by seeming
calm on the surface, while hiding their anxiety and tendency to work hard.
Treatment of Eating Disorders
- It is difficult to get those with an eating disorder treatment because usually they deny
they have a problem
- Up to 90% of those with eating disorders are not in treatment
- Some people with bulimia end up in treatment because their dentist have spotted a key
indicator-the erosion of the teeth enamel
- Hospital is usually required for those with anorexia, so their ingestion of food can be
gradually increased
- Weight restoration is the immediate primary goal in a person with anorexia.
- One problem of those with eating disorders and treatment is the high rate of relapse
- Relapse is more common in those with the binge-purge anorexia subtype and those who
have OCD and lower motivation to recovery.
Biological Treatments
- Usually BN is comorbid with depression, so it is treated with antidepressants.
- Fluoxetine (Prozac) was found to be superior to placebo in reducing binge eating and
vomiting.
o It reduced depression and decreased distorted attitudes.
o However, another study found that there were no benefits from the use of Prozac
following weight restoration.
o Fluoxetine is the only approved medication for the treatment of eating disorders.
Psychological Treatment of Anorexia Nervosa
- Therapy for anorexia is generally a two-tied process.
o The immediate goal is to help each person gain weight to avoid medical
complications and death
o The second goal is long-term maintenance of weight gain
- The central feature of AN is an extreme need to control eating
o The issues of self-control should be the primary focus of treatment. Other targets
for treatment such as low self-esteem, difficulty expressing emotions,
interpersonal difficulties are not addressed unless they interfere with the treatment
process.

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o Treatment should also focus on a persons need for self-control in general.

- In a study at Toronto general Hospital cognitive behavioral maintenance therapy was
significantly better at preventing relapse than a control condition.
- CBT is the treatment of choice for bulimia nervosa and binge eating disorder, while
family therapy is the treatment of choice for anorexia nervosa.
- In Minuchun’s family therapy there is a specific view
o The view is that the family member with an eating disorder takes away from other
family conflicts
o Family therapy attempts to treat the eating disorder as an interpersonal rather than
individuals problem and attempts to bring family conflict to the forefront in
treatment.
o This view has been unsupported in recent years because it places too much
emphasize on a specific family type.
o It is also unsupported because it places blame on the family of the individual with
the illness.
- Current approaches to treatment focus on the Maudsley Approach
o Recruits parents and encourages them to find creative ways to feed their children.
o Parents are taught they are not to blame, but they are the key agents of change
o Family-based and individual based treatment are equally effective at the end of
treatment, but family-based treatment is superior 6 to 12 months post treatment.
- CBT has had the greatest impact in the treatment of eating disorder, but research also
examines how psychodynamic therapy can be used to treat eating disorders
o Psychodynamic therapy has yielded promising findings both post-intervention and
at follow-up
- There have been no longitudinal studies showing that family dysfunction precedes
anorexia. A child developing anorexia could be the cause of family dysfunction.
Psychological Treatment of Bulimia Nervosa
- Individuals with BN are usually overconcerned with weight gain and body appearance.
They judge their self-worth by their weight and shape.
- They adhere to rigid patterns of eating with strict rules regarding how to eat. These rules
are broken, and this lapse escalates into a binge.
- After the binge feelings of disgust and fear of becoming fat lead to purging.
o Purging temporarily reduces anxiety from having eaten to much, but it reduces the
sufferers self-esteem.
- Fairburn’s CBT focuses on certain things that include:
o The client is encouraged to question societies views for physical standards.
o They need to notice and change their beliefs that encourage them to starve
themselves to avoid becoming overweight.
o They are taught that all is not lost if they eat high calorie food.
o They are taught assertion skills to help them cope with unreasonable demands
placed on them by others.
o The overall goal is to develop normal eating patterns.

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o The CBT challenges irrational beliefs to help them develop normal eating
patterns.
o The client and therapist learn that situations that trigger a binge and than learn
more adaptive ways to cope with this situation.
- CBT is the most commonly used and empirically supported treatment for body
disturbance issues.
o However, although CBT is effective about half the clients relapse after 4 months
and this is predicted by less motivation to change and higher initial levels of food
intake.
o IPT has fared well with CBT in treatment effectiveness.
▪ 2/3 of those who were treated with CBT achieved remission, whereas 1/3
of those treated with IPT achieved remission.
- If CBT took the form of schema-focused CBT it would be more effective. This would
focus on:
o Identify and modify the core beliefs that create negative schema.

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Chapter 11: Schizophrenia

Schizophrenia – psychotic disorder characterized by major disturbances in thought, emotion,
and behaviour: disordered thinking in which ideas are not logically related, faculty perception
and attention, flat or inappropriate effect and bizarre disturbances in motor activity.
- The name does not reflect perhaps the most salient symptom – aberrant perception – and
the current name promotes stereotypes of people with schizophrenia.
- This is the most severe psychopathologies
o Its severity is reflected by mortality rates.
- Schizophrenia sometimes begins in childhood, it usually appears in late adolescences or
early adulthood, somewhat earlier for men than for women.
- People with schizophrenia typically have a number of acute episodes of their symptoms.
- Hospitalization is sometimes necessary.
o In Canada, hospitalization rates are typically much higher among young men than
young women.
- Comorbid condition appear to play a role in the development, severity, and course of
schizophrenia.
- Comorbid substance abuse is a major problem for people with schizophrenia.
o Conley and colleguaes measured the link between depressive symptoms and
functional outcomes in longterm treatment of people with schizophrenia.
o About 40% of the particiaptns were depressed at the outset.
o Over the next 3 years, thoe diagnosed with schizophrenia who were also
depressed, relative to a non-depressed group; were most likely to use relapse-
related metnal health services; to a safety concertn; to have substance-related
problems; and to report poorer life satisfaction, quality of life, mental
functionaing, family relationship, and medication adherenece.
o Cormorbid anziety disordres can impose an additional buden on people with
schizophrenia and result in futerth decline in their perceived quality of life.
Clinical Symptoms of Schizophrenia
Positive Symptoms
- Compreise excesses or distortions, such as disorganized speech, hallucinations, ad
delusions.
- They are the presence of too musch of a behaviour htaht is no apparent in most people,
which the negatice symptoms (described later) are the absence of a behaviour that should
be evident in most people.
→ Disorganized Speech (formal thought disorder, disorganized speech)
A disorder in which the client has problmes in organizing ideas and in speaking so that a listerner
can understand
Incoherenece- found in the converstaino of individauls with schizophrenia. It is difficult ot
undersynad exactly what the prson is tyring to tell the interviewer.
Loose associations/ derailment – speech may be disordered. In these cases, the person may be
more successful in communication with a listener but has difficulting stiektcin to one topic.
→ Delusions
- Beliefs held contraty to reality, are commone positive symptoms of schizophrenia.
Persectory delustion like thse were found in 65% of a large, cross-national sample of
people with schizophrenia.
- The following descritiosn of these delusions are drawn from Mellor

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o The person may be the unwilling recipient of bodily snestiaon of thorught

imposed by an external agenecy
o People may believe that htier thoughts are broadcast or transmitted, so that other
know what they are thinking
o People may thin their thoughts are beig stolen from the,. Suddently and
unexpectedly, by an external force
o Some people believe that thir feeligns are congrolled by an external force
o Some people believe that their beavhiour is controlled by an external force
o Some people bleive that impulses to behave in certain ways are imposed on them
by some external force

→ Hallucinations and Other Disorders of Perception

- A person may mention changed in hwo his or her body feels, or the perosn’s body may
become so depersonalized that it feels lie a machine.
- Hallucinations- sensory experiences in the absence of any stimulations from the
environment.
o They are more often auditory than visual; 74% of one smapel reported having
adutiou hallucinations.
- Some hallucinations are thought to be particularly important diagnostically because they
occur more often in people with schizophrenia than in other psychotic people.
o Some people with schizophrenia report having their own thoughts spoen by
another voice
o Some people claim that they hear voice arguing
o Some people hear voice commenting on their behvaiour.

Negative Symptoms
- Consists of behavioural deflicts, such as avolition, algoia, anhedonia, flat. Affect, and
asociality, all of which are described below.
- Attentional deficits contribute to clear reductions and impairments in woring memory.
- These sympotoms tend to endure beyond an acute episode and have profound effects on
people’s lives.
- It is important to distinguish among negtavie symptoms that ar truly symptoms of
schizophrenia and those that are due to some other factor.

→ Avolition
Lack of energy and seeming absence of interst in or an inability to persist in wha ar eusaly
touritne activies.
- Clients may become inattentive to grooming nad personal hygeien, with uncombed hari,
dirty naisl and disheveled clothes.
→ Alogia
In poverty of speech, the sheer amount og speech is greatly reduced. In poverty o content of
speech, illustrated in the following excerpt, the amount of discourse is adequate, but it converys
little information and tends to be vague and repetitive.
→ Anhedonia
- In inability to experiences pleasure. It is manifested as a lac of interest in recreational activites,
failture ot develop close relationship with other people, and lac of interest in sex.

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- They are aware of their symptom.

→ Flat Affect
- Virtually no stimulus can ecliit an emotional response.
- Flact affect is found in a majority of people with schizophrenia.
- The concept refers only to the outward expression of emtion and not to theprson’s inner
epeirnce, which may not be impoverished at all.

→ Asociality
Severly impaired social reltionahips.
- They have few friends, poor social sills, and little interst in being with toher people.
- Many reported childhood “social troubles”.

Other Symptoms
→ Catatonia
Defined by several motole abnormalities.
- Catatonic Immobility- clients adopt unusal postures and maintain them ofr very long
periods of time.
- Waxy flexiblitiy- an other peopon can move the persons’ limbs into strange postions that
they maintain for extended periods.
→ Anappropriate Affect
The emotinals response of these indivdials are out of contect; for exmaples the clien may laugh
on hearing that his or her mother just died or become enraged when asked a simple question
about how a new garment fits.
- The sumptoms of schizophrenia have profound effect on people’s leives, as well as the
lives of theif families and friends.
- Delusions and hallucinations may cause considerable distress, compounded by the fact
that hopes and dreams have been shattered.
- Cogntivie impariemtns and avolition make stable eplousemd difficult, with
improverishement and ofter homelessness the restuls
- Strange behaivour and social-skills deficits leads to loss of friendsand a solitary existene.

History of the Concept of Schizophrenia

Early Descriptions
The concept of schizophrenia was formulated by two European psychiatrist; Emile Kraepelin and
Eugen Bleuler, first presented his notions of dementia praecox, the early term of scizphrenia.
- EH differentiaed two major groups of endogenours, or internally cused psychoses: mani-
depressive illness and dementia praecos.
- This invluded several diagnostic conerps – dementia paranoids, cataonia, and
habephrenia
- The formulaitons of the next major figure, represented both a specific attempt to define
the core of the disorder and a move away from Kraepelin’s emphasis on age of onset and
course.
o Bleuler broke with Kraepelin on two major points: he believed that the disorder
did not necessarily have an early onset, and he believed that it did no inevitable
progress toward dementia.

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o With age of onset and deteriorating course no longer considered definfinf features
of the disorder, Bleuler faced a conceptual problem.
- The metaphorical concept that he adopted for this purpose was the “breaking of
associative threads”/
o Goal-directed, efficient thinking nad communication were possible only when
these hypothetical strucutres were intact.
o The notion that associative threads were disrupted in people with schizophrenia
could then account for other problmes.
o Bleuler viewed attentional difficulites, for example as might result from a loss of
purposeful direction in thought – as the cuase of passive repsones to objects and
people in the immediate surroundings.

The Historical Prevalence of Schizophrenia

- Bleuler had a great influence on the concept of schizophrenia as it developed in the
United States.
- Over the first part of the twentieth century, the breadth of the diagnosis was extended
considerabily.
- The reason for the increase in frequency of diagnossoes of schizphrniae in the United
Staes are easily discerned.
- The concept of schizophrenia was futerh broaden by three additional diagnostic practices
o US clinicans tended to a diagnosed schizophrenia whenever delusion of
hallucinatiosn were present.
o People whom we would now diagnose das having a personality disorder wer
diagnosed as haibign schizohphrenia accoridngo t he DSM-II criteria.
o People with acute onset of schizophrenic symptoms and a rapid recovery were
diagnosed as having schizophrenia

The DSM-IV-TR Diagnosis

- The diagnostic criteria wer epresented in explicit and considerable detail
- People with symtoms of a mood disorder were specifically excluded.
- DSM-IV-TR required at least six months of disturbance of the diagnosis
- Some of what DSM-II regarded as midl fomrs of schizophrenia insead became diagnosed
as personalit ydisroder
- DSM_IV-TR differentiated between paranoid scizohphrenia.
o Delusional disorder is troubled by persistne persecutory delsuison of by
delusional jealousy, which is the unfonded conviction that spouse of lover is
unfaithful
o There are also delusion of being followed, somatic delusions (believing that
usualy a complete strager with a high social stuate)
Categories of Schizophrenia in DSM-IV-TR and Their Elimination in DSM-5
→ Disorganized Schizophrenia
Kraepelin’s hebephrenic form of schizohphernia
- Speech is disorganized and difficult lfor a listenr to follow
- Clisent may speak incoherently, stringing together similar0 sounding words and even
inveting new words, often accompaiend by siliness of laughter

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- They amay have flat effect or experience osntat shifts of emtion, breaking into
inexplicable fits of laughter and crying
- Their behaviour is generally disorganized and not god directin
- Clinet sotmies deteriorate to the point of incontinence, voiding anywhere and at any time,
and complete neglect their appearance, never bathing or combing hair.
→ Catatonic Schizophrenia
- Clinets typsically alternate between catatonic immobility and wild excitement, but one of
thes symptoms may predominante.
- These clients resist instrucutions nd suggestions and often echo (repeat back) the speech
of tohers
- The onset of catatoni reation may be more sudden than the onset of other forms os
chizphgrnai, although the person is linkely to have previously shown some apthay and
withdrawal form reality.

→ Paranoid Schizophrenia
This is assigned to a substantial numbero f recently admitted clinets to spychitartic hosptials .
- The key to this diagnosis is the presence of prominent delusions
Grandoise delusions
- They have exaggerated sense of their own important, power, knowledge, or identiy
Delusional Jealousy
- The unsubstantiated belif that their partner is unfaithful.
- The other delusison described earilyer, such as the sense of beign persecuted of psied on,
may also be evident
Ideas of reference
- They incorporate unimportant events within a delusions framework and read personal
signifnace into the trivival acitivies of others

- Individuals with parniod schizophrenia are agitated, argumentative, angry and sometimes
vilent.
- They remain emotionally responsive, although they may be somewhat stilted, formal and
intense with tohers.
- They are also more alert and verbal than are people with other types of schizophrenia

→ Additional Ways of Conceptualizing Heterogeneity

Undifferentiated schizophrenia appies to people who meet the diagnostic criteria for
chizophrenia
Residual Schizophrenia is used when the client no longer meets the fullcriteria for
schizohphrenia but still shows some sings of the disorder
- There is a continuing interst in differentiating the forms of schizophrenia.
- Radically different and promising approach focuses on schizophrenia subtypes that differ
qualitatively in terms of neurocognitive features that involved brain abnormailites.
- The cluster analysis identified five subtypes, including one group with normative, intact
cognition.
o The other four groups incuded an “executive subtype” which was dsitinuguisted
by impairment onf the Wisconsion Card Sortign test; an “executive subtype’
which was distinguished by impairment on the Wisconsin Card Sorting Test; an

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“executive-motoe subtype” which had deflicits in card sorting and motor

functioning; a “motor subtype” whichhad deflicts only in moto functioning, and a
“dementia subtype” which had pervasice and generalized cognitive impairment.
o These subtypes differed on other variables, such as duration of symptoms and
extent of hospitalization.
- A distinction between positive nad negative symptoms seems to be a fundamental
distinction that continues to be used in reasehc on the etiology of schizophrenia
Etiology of Schizophrenia
The Genetic Data
The role of genetic factors in various forms of psychopathology is widely acknowledged and a
large proportion of research fidning is detected to the study of genetic factors.
- This work introduced several key themes that have stood the test of subsequent research,
including the assertion that multiple genes are implicated in schizophrenia and other
forms pf psychopathology, and that schizophrenia is not due to a specific single gene.
→ Family Studies
- The relatives of people with schizophrenia are also at increased risk for other disorders
that are thought ot be less severe forms of schizophrenia.
- The data gathered by the family method thus support the notion that a predisposition to
schizophrenia can be transmitted genetically.
- The behaviour of a parent with schizophrenia for example, could be very distrurving to a
developing child.
o There for the influce of the environment cannot be discounted as a rival
explanation for the higher morbidity riskes.

→ Twin Studies
The analyses suggested that negative sympomts havea s tonger genetic component than do
positive ones

→ Adoption Studies
- the sutudy of children whose mothers had schizophrenia but who wre reared form early
infancy by non-schizophrenic adoptive parents has provided more-conclusion
information on the roel of genes in schizophrenia by eliminating the possible effects of a
deviant environment.
- Children reared without contact with their so-called pathogenic mothers were still more
likely to become schizophrenia than were the control participants.
→ Molecular Genetics
Thanker noted that the hung for schizophrenia-related genes turned out to be more difficult than
expected for several reasons
- The hung of schizophrenia-related genes turned out to be more difficult thatn expected
for several reasons
o Lack of preciseness in defining the boundaries of the clinical phenotype
o Absence of biological test that confirm diagnostic categorization
o Clinical heterogeneity and the complex nature of schizophrenia
- They have focused on five disorders that appear to share a common genetic vulnerabitliy:
schizophrenia, major depressive disorder, bipolar disorder, autism specturn disorder, and
attention-deficit/hyperactive disorder.

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- Initial wordk indicates that htes disorders invoeld single-nucleotide polymorphisms in

regiosn on chromosomes 3p21 and 10a24, and in tow calcium subunits: CACDA1C and
CANB2.
- Cannot conclude that schizophrenia is a disorder complete determeine by gentic
transmission nand by bioigicl factors, for we must keep in mind the distinction between
phenotype and genotype and Gottesman’s early emphasis and environmental factors.
o The role of both factors is suggested by outcomes experienced by the Genain
quadruplets.
Genain ina pseudonym used to protect the identity of the four sisters who line in a US
Midwestern statel All the sisters developed schizophrenia vby the tiem thye reached the age of
24.
The differences amond the sisters demonstrate that the course of the disorder can be variable and
clearly that all peope diagnosed with schizophrenia are not alike.
The sisters’ different outcomes illustrate the need to consider genetic factsr and environemental
factors jointly.
It is impossible to pinpoint exactly the factors that contrivbuted to the outcomes experienced by
the Genain quadruplets.
o Genetic factors can only predispose individauls to schizophrenia.

Biochemical Factors
→ Dopamine Activity
- The dopamine hypothesis is the longest standing biologically based theory of
schizophrenia and it has predominated for over four decaded.
- The hypothesis that schixophrenia is related to excess activity of dopamine is based
principally on the knowledge that drgus effective in treatgin schizophrenia reduce
dopamine activity.
- Antipsychotic drugs- being useful in treating some symptoms of schizophrenia, produce
side effects resembling the symptoms of Parkinson’s deisease.
- Parkinsonism is known to be casued in part of low levels of dopamine in particular
nerve tract of the brain.
o it has been confirmed that becauseo f the structural similarities to dopamine
molecule, molecules of anitpyschotic drugs fit into and thereby block postsynaptic
dopamine receptors.
o The dopamine receptes tha are blocked by first-generation or converntional
anitpsychotics are called D2 receptors.
- There are several subclasses of dopamine recepts that differ I the specific of how they
signal the postsynaptic neuron.
- The action of the drgus that help people with schizophrenia, it is but a short inductive
leap to view schizophrenia as reuslitng from excess actibity in dopamine nerve tracts.
- Dopamine theory
o Came from the literature on amphetamine psychosis.
o Amphetamines can produce a state that closely resembles paranoid schizophrenia,
and they can exacerbrate the symptoms of schizophrenia.
o Amphetamines casue the release of catecholamins, including norepinephrine and
dopamine, into the synaptic cleft and prevent their inactivation.

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o Additional evidence fro the dopamine hypothesis came for post-mortem studies of
people with schizophrenia.
o A key piece of evdicne is the link btween more potent antipsychotic drugs and
dopamine D2 receptors.
o Based on data just reviewed, researched at first assumed that schizohphrenia was
caused by a dopamine excess. But as other studies progressed this assumption did
not gain support.
▪ Major metabolic of dopamine, homovanilic acid (HVA) was not found in
greater amount in people with schizophrenia.
▪ Some post-mortem studies of brains of schizophrenic people, as well as
PET scans of schizophrenic people, have reveals that dopamine receptos
are greater in number of are hyper-senstivie in some people with
schizohphrnia.
o The key change involved the recognition of differences among the neural
pathways that use dopamine as a transmitter
▪ The excess dopamine activity that is thought to be most relevant to
schizophrenia is localized in the mesolimbic pathway and the therapeutic
effects of antopsychotics on postivie symptoms occur by blocking
dopamine receptors there, thereby lowering activity in this neural system.
o The mesocortical dopamine pathway begin in the same brain region as the
mesolimbic, but it projects to the prefrontal cortex.
▪ The prefrontal cortex also projects to limbic areas that are innervated by
dopamine.
▪ These dopamine neurosn in the prefrontal cortex may be underactive and
ths fial to exert inhibitory control over the dopamine neurons in the limbic
area, with the result that there is overactivity I nthe mesolimbic dopamine
system.
▪ This proposal has the advantage of allowing the simultaneous preence of
postivie and negative symptomsi n the same person with schizophrenia.
o Because anitpsychotics do not have major effects on the dopamine neurson in the
prefrontal cortex, we would expect them to be relatively ineffective as treatments
for negative symptoms, and they are.
- Schizophrenia has widespread symptoms covering percepton, cogntivition, motor active
and social behaivour.

→ Other Neurotransmitters
Dopamine neurons generally modulate the activity of other nueral systems; for example, in the
prefrontal cortex, they regulate BAG neurons.
- Serotonin neurson regulate dopamine neurosn in the mesolimbic pathway
- Glutamate, a transmitter that is widespread in the human brain, may also pkay a role.
o Low levels of glutmate have been found in cerebrospinal fluid of people with
schizohphrenia.
Schizophrenia and the Brain: Structure and Function
→ Enlarged Ventricles
- Structural problmes in subcortical temporal-limbic areas, such as the hippocampus and
the basal ganglisa, and the prefrontal and temporal cortex

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- A reduction in crotical grey matter in both the temporal and frontal regions and reduced
volume in basal ganglia and limbic strucutres suggesting deterioration and atrophy of
brain trissue.
- Large ventric la in people with schizphrnia are correlated with impaired performance on
neuropsychological tests. Poor adjustment prior to the onset of the disorder, and poor
response to drug treatment.
o Large ventircel are no specific to schizphrniea as they are also evidcnet I nthe CT
scans of people with toher psychoses usch as psychosis such as bipolar disorder.
→ The Prefrontal Cortex
- The prefrontal cortex is known to play a role in behaivours such as speech, decision-
making and willed action, all of which are disrupted in schizophrenia. A
- Auditory halluciotn result when the prefrontal corte is accompanied by activity I nthe
termporal gyrus
- Lack of illness awareness is related to poorer neuropsychological performance more
often in clients with schizophrenia than in biopolar participants, supporting the
hypothesis that lack of awareness is related to defective frontal-lobe function.
- Glucose metabolism in the prefrontal cortex has also been studied while clients are
preforming neurospychoglical testsof prefrontal function.
- Failure to shoe frontal activation has also been detected bythe fMRI conducted a meta-
analysis of functional imgagin studies that contrasted peple with schizphrnia and
“healthy” volunteers specifc araes relative to comparison participatns, suggesting that
“cogntii e controls deficits strongly contribute to epxisode memory impairment in
schizophrenia
- The frontal hypoactivation is less pronoused in the non-schizphrnie twin of discorand MZ
pairs, again suggesting that this brain dysfunction may not have a genetic origin.
- fMRI to test the hypothesis the violet people with schizophrenia and comorbid anti-social
personality and substance use disroders show a different pattern of prefrontal fucnitoning
than seriously vilent peope with schizophrenia only.

→ Congenital And Developmental Considerations

- They are the consequence of damage during gestation or broth.
- Waddingon and colleagues used the Congenital Anomalies data set in the Prenatal
Determinants of Schizphrenia study to conduct a systematic, prospective examination of
the relation between congential anomalies, earily associated functional impariments, and
risk of schizophrenia in adulthood.
- It was reported that the presence at birth of in infancy of “craniofacial/midline anomalies
and/or early functional impariments that commonly occur as a symptom of CAN anomly”
were associated with a doubling of the risk for schizophrenia spectrum disorder.
- Hgih rates of delivery complications when babies were born to women with
schizophrenia; such complications could have led to a reduced supply of oxygen to the
brain, resulting in damge.
- Although the data are not entirely consistent, another possibility is that a virus invaded
the brian nad damages I during fetal developemtn.
- People who had been exposed to the virus during the seconf trimester of pregnancy had
much high rates than those who had been exposed in either of the other trimeterst or
among non-exposed control adults.

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- Cortical development is in critical stage of growth during the second trimerst- nerons are
being produced in the rudimentary brain called the neural tube.
- Post-mortem analyses of neurons in the brains of individuals with schizophrenia have
shown reduced number of cells in the outer layed of the cortex in both the prefrontal and
the temporal areas
- A widespread thinning of the cortx of people with schizophrenia has been reported,
apparently resulting fro mloos of dendrites and axons nad neurons in the frontal cortex
have been shown to be smaller than normal in people with schizophrenia
- The brains of people with schizophrenia are damaged early in development.
o An injury to this area may remain silent until the period of development when the
prefrontal cortex begins to play a larger role in behaviour.
→ Related Research
- Recognizing that the symptoms implicate many areas of the brain, research has moved
away fro mtrying to find some highly specific “lesion” and is examining neural systems
and the way different areas of the brain interact with one another.
- This work calls attention to the possible role of a wider ranger of brain stuctures in
schizophrenia.
- The extent of a more broad-bsed cognitive impairment needs to be examined with respect
to the heterogenetiy of schizophrenia
- A growing body of work suggests the schizophrenia is related to dysfunction of
functionally and anatomically connected netwroks of brain regions.
o The authors conclude that white matter pathology plays a critical role in the
cognitive impariemtns seen in schizophrenia.
o In future we can expect to learn more about toher important developemtns in our
understaidn of brain strcutre and function in people with schizophrenia

Psychological Stress and Schizophrenia

- The coreelations between social class and schizophrenia are consistent, but they are
difficult to interpret in causal terms
- Some people believe that stressors associated wit hbeing in ow social class may cause or
contribute to the development of schizophrenia (sociogenic hypothesis)
- The degrading treatment a person receives from others, the low level of education, and
the lack of rewards and opportunity taken together may make membership in the lowest
social class uch as stressful experience that an individual – as least on who is predisport
develops schizophrenia.
- The stressors encountered by those in the lowest social clas could be bioloigcla

→ Social Class and Schizophrenia

- The relation between social class and schizophrenia does not show a continuous
progression of higher raters of schizophrenia as the social class becomes lower.
- There is a decidedly sharp deifference between the number of people with schizophrenia
as he social class becomes lower.
- The correlations between social class and schizophrenia are consistent, but they are
difficult to interpret in causal terms.
- Sociogenic hypothesis – the stressors associated with being a lower social class may
cause of contribute othte developemt of schizophrenia.

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- The degrading treatment a person receives from tohers, the low level of education, and
the lack of rewards and opportunity taken together may make membership I nthe lowest
social class cu has stressful expericne that an individual – at least one who is predisposed
– develop schizophrenia.
- Social-selction theory – the reverses the direction of causality between social class and
schizophrenia.
- During the course of their developing psychosis, people with schizophrenia may drift into
the poverty-ridden areas of the city.
- One way of resvolign the conflict between these opposing theories is to study the social
mobility of poepe with schizophrenia.
o Consistent with the social-selection theory, some studies found that people with
schizophrenia are downardly mobilr in occupational status.
o This approach has not resovled the isse.
o This could be considered evidence in favour of the sociogenic yptoehsis that
lower-class status is conducie to schizophrenia.
- A subsequent study in Isreal employed a new metholody, simultaneously investigating
both social class and ethnic backgorun.
- The rates of schizophrenia were examine in Isreali Jews of European ethnic background
and in more recent immigrants to Isreal from North Africs and the Middle East.
- The datt are more supportive of the social-selection theory that of the sociogenic
ypothesis. n
→ the Family and Schizophrenia
- Etiology and the role of the family
Early theorists regarded family relationships, especially those between a mother and her son, as
crucial in the development of schizophrenia.
o Schizophrenogenic mother was coined to describe the supposedly cold and
dominiant, conflict0inducing parent who was said to produce shcizphrenia in her
offspring.
o These mothers were characterized as rejecting, overprotective, selc-sacrificng,
impervious to the feelings of other, rigid and moralisti about sex and fearful of
intimacy- a very destructive view sine it basically blamed the moterh for a sever
psychiatric disorder in a child.
o Some findsin suggest that the faulty communicatiosn of paretns play a riel in the
etiology of schizophrenia.
o Further evdicen favouring some role for the family comes from an adoption study
by Tienari and his colleages.
- Relapse and the role of the family
A study of clients with schizophrenia who returned to live with their famileid after discharge.
o Interviews were conducted with parents of spoursed before discharge and rated
for the number of critical comments made about he client and for expression of
hostility toward or emotional overinvomented with him or her.
Expressed emtion (EE), families ewre divided int o two groups: those revealing a gret deal of
expressed emtion, called high-EE families, and those revealing little called low-EE familes.
o At the end of the follow up, 10% of the client returning to low-EE homes had
relapse.

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Research indicaed that both interpretations of the operation of EE – the casucal and the reactice-
may be correct
o The finding were that
▪ The expression of unusual thorughts by the clients elicited higher levels of
crtical comments by family members who had previously been
chractertized as high in EE
▪ The high-EE familes, critical commetns by family members led to
increased expression of unuscla thoughts.
o In this study, ti found that bidirectional relationship: critical comments by mbmers
of high-EE familed elicted the increased expression of unsucal thoguths by
clients, and uncuale thoguhts expressed by clients lef to increased ciritcal coming
in high EE famied.

Developmental/ High-Risk Studies of Schizophrenia

The major limitation of such developmental research is that the data were not oringcally
collected with the intention of describing preschizophrenic people of of prediction the
developemtn of schizophrenia form childhood behaviour.

Therapies for Schizophrenia

The American Psychiatric Association treatment guidelines for schizophrenia recommend a
multi-point treatment course that consists of several strategies known to improve funcitoncal
outcome:
- Selection and application of anipsychotic medication to control actue psychotic
symptoms, inclduign strategies for maintiang adherence
- Identification and treatment and comorbid disorders, including substance use and
depressive disorder
- Use of psychosocial treatment approached with demonstrated effectiveness in improving
symtoms and ability to function soically and vocationally.
- The principal reaon for abandonment of lobotomies was the introduction of drugs that
seems to reduce the beahivoural and emotional excesses of many clients.

Biological Treatments
→ Shook and Psychosurgery
- Prefrontal lobotomy – surgical procedure tha destroys the tracts connecting the formal
lobes to lower centres of the bring.
o the initial reports clained high rates of success variations of psychosurgery.
o The lobotomy proceduere was used especially for those who behavior was
violent.
→ Drug Therapies
antipsychotic drugs - theses drugs are also called “neuroleptics” because they produce side
effects similar to the symptoms of a neurotlogical disease
→ First-generation (conventional) antipsychotic drugs
Chlorpromazine (Thorazine) was first used therapurtically in the US and rapidly becasne the
preferred treatment ofr schizophrenia.
- This was not a cure

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- Had many side effects, some advacnes have been made in controlly side effects of second
–genration antipsychotics, but now there are emergin concerns of side effects that
enhance the risk of cardiometiabolti dysfunction.
- Clients who responed positively to antipsychotic are kept on socalled maintenance doses
of the drug, just enough to continue the therapeutic effect.
→ Second-generation (atypical) antipsychotics
atypical anitpsychotics relative to antipsychotics in gn=enral, it that at effective dose levels, the
atypical anitpsychotics are less likely to cause side effect.
- Antipsychotic drugs are an indispensable part of treatment for schizophrenia and will
undoubtedly continue to be an improtat compent
-
Psychological Treatments
→ Social Skills Training
- Designed to teach peioke wit schizophrenia behaviorus tha can help the succedd in a wide
variety of interpersonal siutations – disucing their meiaction with their psychiatrist,
ordering meals in a restuarnt, filling out job applicatiosn, saying no to offers to by drus o
n th stress -.
→ Family Therapy and Reducing Expressed Emotion
these therapies have several features in common beyond the overall purpose of calming things
down for the clients by calming things down for the family.
- They educate cient and familes about he biological vulnerablilty that predisposed peope
to schizophrenia, cognitive problmes inherent to schizophrenia, the symptoms of the disorder,
and signs of impending relapse.
- they provide info about and advice on monitorying the effects of antipsycotic medciaotn
- they encourage family members to blame neither themselves not the client for the
disorder and for the difficuatlies all are having it copign with it
- they help improve communcaiotn and probmel-solving skills within the family
- they encourage clients and their fmailed to expand their social contract,s escpially their
support networks
- they instill a degress of hopd that things can improve, including the hope that the client
may not have to return to the hosical

→ Cognitive-Behavioral therapy
Their conceptual model of cognitviton and schizophrenia, suggested that cognitive-behaviorual
therapy can facilitate motivation and engagement in social and vocational activites.

Teatment Focus on Basic Cognitive Functions

- It is well established that people diagnosed ith schizophrenia, as a group, have deficits in
virtucally all facets of cognitive fucntions and whow performance deficits on a range of
simple and complex task.
- One apperach called cognitive enhancement therapy (CET), was evaluated ina. Teo-
year RCT of clients who were also taking medicaiotns.
o The approach was compared with a nenriched supportive therapy that include
educational and supportive aspects of personal therapy.

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o Other studies have shown that a schizphreani clinet’s ability to recnogised fcaily
affect in other, working memory, and attention can all be improved thorught
congitve training.
Other

Contemporary Trends and Issues

General Trends in Treatment
The joint emphasis on pharmacological and psychosocial intervetnions in reflected cureenty inf a
variety of ways:
- Famileid cand clients are givne realistic nad scietntically sound informtiaon about
schizophrenia.
- Medicaion si only parto the whole treatment picture
- It is increasingly recognized that early intervention is important in influcnign the course
of schizophrenia over time
- It is alos important to teach clinets skills and more reality-based thinking so that htye can
control their emotions and fucniton more noramly outside the hosptia nad probably
reduce the EE encourted both inside nad outside the home.

Further Issues in the Care of People with Schizophrenia

→ Homeless Mentally ill
The benefits that have accrued to those who received hosugin. Key fnding include
- Housign First can be implemented effectively in cities of varying sized and ethnoracial
compostions
- Housing First rapidlgy puts and end to homelessness
- House First makes better use of public dollars – especially for those who are high-service
users- and is a sound finciaical investment
- There are many ways in which Housing First can change lives and it yields positive
benefits that go well beyond the anticipate postivie outcomes
→ Employment and Housing
Obtaining employment pses a major challente gor poepel with schizphrnei becauseo f bias
agasint those who have been in psychiatric hosptials

→ De stigmatization
there needs to be more worok for destigmatizing the condition of schizophrenia

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Chapter 13: Personality Disorders

Classifying Personalaity Disorders: Clusters, Categories, and Problems
Beginning with DSM-III. Personality sidoers wer eplaced ona separate axis, Axis II, to ensure
that diagnositicans would pay attention to their possible presences.
- Axis II descrbied many personality disorder catergoires that either di or did not apply to
people with clinical dysfuction.
- The axis element was removed in DSM-5 ut iti now gernally accepted that more episodic
disorder may be accopained by long-lasting personaliy disorder, while for some people,
the perosnlity disorder is the main adjustment problem.
The traits I nwhich a personality disorder excists
- Disrodered peraonlity is indicated by ridgied and infleciable behaviours. Thus, the
afflicted person ahs difficualty altering his or her behaiovur according to changesi nt he
situations.
- The person engaged in self- defating behiaovur that foster vicious cycles.
o Bheaviours and cognitions simply perpetuated and exacerbate exsisting conditons.
o Self-deafing beahviours gets us farther away form our goals rather than closer tot
them
- There is “sturucutral instability”. This term is used to to refer to fragility to the self that
“cracks” under conditions of stress. This would pertain to a student whos funcitons at a
resonaly high level during the early part of a term byt loses the abilty to cope due to he
moutnign pressure of multiple deadlines.
- Liveslye, Schroeder, Jackson and Hand regard personality diorser as a failtye or inability
to come up with adaptive solutions to life tasks. It is identified three types of life tasks
and preposed tha filature with any one taks is enough to warrant a personality disorder
diagnosis.
o There three tasks are
▪ To fomr stable, integratdedm ad coherent represtion of self and others
▪ To develop the capcarity fo intimacny and positive affliccaiton with other
people
▪ Function adaptively in society be negaign in prociak and co=operative
behaiours
- DSM-5 contians a descripting of genral perosnlity disorder to outline when a genral
personality disorder exists and then assessment can establish whether someone is
characterized by a pericaulr PD.
- AMPD crierion assesses “levels pf personity function” accourding to two themsee
o Self (indentiy and selfdirection_
o Interpersonaly (emphath and intimanc)
- AMPD criterion B involed rating a person across fie borad trait dimensions: negative
affectivyt, deteachment, antagonism, didhibition, and psychoticsm

Assessing Personality Disorders

A significant challenege in assessing personality disorder is that many disorder are egosyntomic:
the person with a personality disorder is typically unaware that problem exists and may not be
experiencing significant personal disteres.

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- This suggests that the assessment and diagnosis of perosnity disorders are enhavned when
the significant others in an indivdial’s life become infomrants.
- Another significant diagnosis challenge is that the substnatioal properiton go licnets are
deemed to have a genral preonlaity disorder as PD nor otherwised specific.
- Although clinical inteviews are preferable when weeking to make a diagnosis,
researchers often realy on the used of self-report measures when assessing personality
disorder symtoms
- Two key issues involeding self-report measures of persnlity disorder need to be
considered
o The various self-report measures differ in their content and are not equivalent
o A general concertn involing self-reprot measures, inciluding PD emaures, is tha
the cut-ff points used with sekf-report response to determin the presence of a
personality disorder often overestimate the number of people who meet diagnostic
criteria for particular disorder
Personality Disorder Clusters: Odd/Eccentric Cluster
Personaly disorder have been groups in to three clusters
- Individauls in cluster A (paranoid, schizoid, schiaotypical) seem odd or eccentric. These
disorder reflect oddness and avoidance of sical contact
- Those in cluster B (borderline, histrionic, narcissistic, and anti-sical) seem dramatic,
emotional, or erractic. Behaviours are extrapunitive hostile.
- Those in cluster C(avoidant, dependent, and obsessive- comppuslive_ appear fs

- The empirical evidence n the validiy of thse clusters is mized, and some evidcne suggest
ath tperhaps a fourth clutster reflection obsession and inhibition should also be considerd.
- The odd/eccentric sluter compises three diagnosis: paranoid, schizoiod, and schizotypai
PDs. The symptoms of these disorders bear some similarity to the symptoms of
schizophrenia, especially to the less sever symptoms of its prodromal and residual phases.
Paranoid Personality Disorder
The indivial with paranoid personliaty disorder is suspicison of other. Peope with this
diagnosis expect to be mistreated or exploited by others and thsu are secretive and always on the
lookout for possible isgns of trickery and abuse.
- Indivdiauls with PPF are preoccupied with unjustified doubts about the trustworthiness or
loyalty of others.
- This diagnosis is idffernt form schizophrenia, parnaiod type, because symptoms usch as
hallucinations are not presnt and these is less impairment in social and occupational
function.
- It differes from delusional disorder because full-blown delusion are not presnt
- PPD occurs most frequently in en and co-occurs most frequently with schizoprypcal
borderline, and avoidant perwonaltiy disoreer.

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- Data suggest that iti is one of the more commonly diagnosied personality disorders in
community sampled and that parnodi personltiy disorder is best repestned as a continuous
dimensions rather than a discrete category
Schizoid Personality Disorder
- They do no appear to desire or enoy social reltioanhips and usually have no close friends
- They appear dull, blanc and aloof and haven o warm, tender feelings for others.
- They rarely report strong emotions, haveno interest in sex, epxereinces few pleasureable
acitivyt.
- Comorbidity is highest for schizotypcal, avoidant, and paranoid personality disorder,
most likely because of the similar diagnostic criteria in the four categroeis.
Schizotypal Personality Disorder
- People with schizotypal personality disorder usually have the interpersonal ddiculites of
the schizoid personality and excessive social anxiety that does not dimish as they get to
know others.
- Cogntiive limitations and resctrictions found in schizophrenia are also evidnce in
schizotypal personality disorder.
o Those with schizotypcal persnlity disorder may also have ood beliefs or magical
thinking and recurrent illusions.
o Their speech, may use words in an unusaly and unclear fashion
- A significant problem in the diagnosis of schizotypial perosliaty disorder is its
comorbidity with other personiaty disorder.
- Epidemiolgical data suggest that comorbitiy is higher for schizotypal personality disorder
than for any other persolnity disorder.
- Epidmiolgical dta suggest that comorbidity is higher for schizotypal personality disorder
than for any other personality disorder and the degree other personality disorder nd the
degree of comorbidity with borderline preosnliaty disorder and narcissitic personality
disorder continue to be very high.
Etiology of the Odd/Eccentric Cluster
- Family studies of paranoid personality disorder for the most part find higher than average
rates in the relative of peile with schizophrenia of delusional disorder
- Family studies have shown that the relative of people with schizophrenia are at increased
risk for this disorder.

- Genetic factors paly some role in etiology, but a study of twins in tNormawy found that
the heritabiltis of personalitydisroder were modest and ranged rom 20 to 41%.
- Family studies probide at least some evidnce that persolity disorder of odd/eccentric
cluster are related to schizophrenia.
- People with schizotypai lperosnltiy disorder have dficit in cognitive and neuropsycholgial
fucntions.

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- Givne the comorbityd associated with schizotypal personality disorder, it is importantto

establish whether predictors are linked uniquely with the disorder.

Personality Disorder Clusters: Dramatic/Erractic Cluster

Borderline Personality Disorder
The diagnoses in the dramatic/ erratic cluster – borderline, histrionic, narcissitic, and anti-social
persontiy disorder – include clinetsi with a wide range of symptoms, ranging form variable
behaivour to inflated self-esteem, exaggerated emotional displays, and anti-social behaivour.
- The core features of this disorder are impulsivity and instability in relationships, mood
and self-image.
o Attitude nad feelings toward other people may vary considerably and inexplicably
over short periodso f time
o Emotions are erractice and can chift abrutlym particularly from passionate
idealization to comtemptuous anger
- The instability in relationships is reflected in the social networkds of peioek tieh BPD. A
revealing glimpse of their social worlds emerged form an investigation by Lazarua and
Chevean that examine the social networokds of women with BPD vs. healthy control
participants.
o They cannot beat to be lone, have fears of abandonment, and demand attion
o Subject to chronic feelings of depression and emptiness, they often attempt
suicide and engage in various forms of self-hard and self-mutilating behaivour
o Self ahrm was also evidnce in the famous case of Susan KAysen, who
documented her experience with bordelrin persinty disorder in the book
- Clinicans nad research have used the term :borderline persoity” for some tiem but have
given it many meantins
- The term implied that the person was on the borderline between neurosis nad
schizophrenia.
- The DSM concept of borderline perosnity no longer has this connotations.
- The current conceptualtization derived form two main sources
o Gunderson, Kolb and Austin propsed a set of specifc diagnostic criteria similar to
those that ultimately appeared in DSM-III.
o Diagnostic criteria was a study of the relatives of those people with schizophrenia
done by Sptizer et al.
- BPD typically beings in early adulthood.
- It has been assumed that the prognosi of BPD is not favourable, but Paris reviewd
existing evidence and conclude that most clients with BPD recover over time.
- When when treatment gains are rezliaed, the overall level of functioning often remiants
relatively poor.
- There also seemsto be al sting vulneraity to epxience negative life evets; a study of
middle-aged people who previously had a BPD diagnosis sowed that they expeirneced a

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greater frequenty of negative life events, both in termso f self- reported and interviewer-
assessed life events.
→ Etiology of Borderline Personality
Object-relations theory
Object-relations theorists hypothesize that peopke react to their wolrd thought the perspective of
people form their past, primarity their parents of other priary cargivers.
- Althoguth people woth BPD have weak egos and needs constant reassuring, they
retainthe capacitrye to test realtiy
- They are intouch with reality be frequently engange in a defene mechanism called
splitting.
o Rthis tendency caused extreme difficulty in regulating emotions because the
person wth BPD sees the wordl, including himself or herself, in black-and-white
terms.
o BPD report a low level of care by their mothers.
o Resrach conducted in Toronto by Links and van Reekum indicates that people
with BPD also frequently report childhood sexual and physical abuse.
Biological factors
Na analysis reported that heritability estimates range across four studies fomr 37% to 69%.
- These same researchers found in their studies tha someone with first-degree relative with
BPD bs someone whitout a first-degree relaive with BPD, had a three to four times
greater likelihood of beign diagnosed with BPD. There are also indications that gentic
factors palya substantioal role while environemtnal factors play a realtively small role.
- Data suggest poor functioning of the frontal lobes, which may plya arole in impulsive
behaviours.
- BPD clients preform poorly on neurolotical tests of frontal-lobe functioning and show
low glusoce metablosim I nthe forntal lobes
- People with BPD have an overactivtion in the insula and posterior cingulate cortex, and
undersactivation across a region that stretch form he amygdala to the dorsolateral
prefrontal cortex.
Linehan’s diathesis – stress theory
Purposes that BPD develops when people with biological diathesis for having difficultiy
controlling thiter meotionals are rasied in a famiy environemtn that is invalidty.
- An invalidtating environemtn is one in whichte prsons wants and feeligns are discounted
and disresptect and effort ot communication one’ feeligns are disregrated or even
puncihsed.
- An extreme form of invalidation is child abuse, sexual nad nonsexual
- A key piece of evidnce supporting Linehan’s theory concerns childhood physical and
sexual abuse.
- The tendency for people to blame themselves for thinks that they ar clearing no responbitl
for and that are well byond their control is due in part to our tendency to need to maintain

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“an illusion of control” that is fueled by the fera inherent in realieding that some things
are beyond our control
Histrionic Personality Disorder
The diagnosis of histrionic personality formerly called hysterical personity is applied to
peoplw who are overly dramitc and attention-seeking.
- They often use feautes of their physical appearance, such as unuscal cloth, makeup or
hair colour to draw attention to themselves
- These indivdiauls, alhtought displaying emiton extravangtly are thought to be meotinall
shllow.
- They are self-centred, over concerned with tier attractiveness, and uncomfortable when
not the centre of attention.
- They can be inappropriately sexually provocative and seductive and are eaily influenced
by others
- Htie rspeech is often impressionistncand liackign in deaitl.
→ Etiology of Histronic Personality Disorder
Narcissistic Personality Disorder
- Preoccupied with fantasies of great success.
- They require almost constant attention and excessive admiration and believe that only
high-staute people can understand them
- Their interperosnaly relatioships are disturbed by their alck of empthay, feelingsof envy,
arrogance and their tendency to take advantage of toher.
- Relationship are alos problematic because of their feeligns of entitlement – they expect
others to do special not-to-be-reciprocated favours for them
- Dark riad- consists of the combination of narcissim, psychopathy, and
Machiavellianism.
o People who are narcissictic also tend to have the other elemtns of the triad
o The concept of psychopathy and itsl ink with anti-social tendiecne are describe
belof
o Machiavellianimsis a peronslity style characterized by an extreme willngess to
take advantage of toher when the opportunity presnt itself brcause peope wkth
orientation essentially belive that everyone is out for himself or herself
o Also supplemented with addition of the dimension and sadism and as a reslt now
tcalled the dark tetraed
o Sadism is a tendancy to enhoy cruelty in everyday life
- An important point hta emergy from this reent work ist hat when we foecus on personliy
dimendison in reseahc concentrated on persolniy varibel, there is a tendency to lsoe isgh
of a person-centred apracoha dn the fact that several coreelated dimentions tha relfct
persoliy dysfunction may esixt within the ame person

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→ Etiology of Narcisstic Personality Disorder

- Very sensitive to criticism and deeply fearlful of failure
- Sometiems they seek out other whem they can idealize because they are disappointed in
themselves, but others are not allowed to become genuinely close
- Their relationship are few and shoolwo
- Their inner livesa re impoversiehd because despire their self-aggrandizement, they
actually think very little of themselves
- Kohut suggest aht whena parents respone to a child with respect, warmth, and empthya
the child is endowed with healthy self-esteem. When parent further their own needs
rather than directly approve of htier children, the result may be a narcissistic personality
o Children neglected in this way do not develop an internalized, healthy self-esttem
and have trouble accepting heir own shortcoming.
Anti-Social Personality Disorder and Psychopathy
→ Characteristics of Anti-Social Personality Disorder
DSM-5 concept of anti-socal personltiy disorder invoeld two majory compnents
- A conduct disorder is presnt before the age of 15. Truancy, running away form home,
frequent lying, theft, arson and deliberate destruction of properly are majory symptoms of
conduc disorder
- This pattern of anit-socal behaiovur continues in adutls

- The diagnoses invoeld not only certain patterns of anii-socail behiouar byt patterns that
began in childhood
- Other symtoms inclue failure to conform to iscla norem, deceitfulness, impusivity,
irritabliey nad reckless disregard for the safety of self and others
- APD became prominent topic in Cadna as a result of April 2013 inquest exmaing the dath
of ashly smith, the girl who coke herself to death.
o There are many troubling aspects of this case.
→ Charateristics of Psychopathy
Linked closely to the writing of Hervey Cleckly and his classic book. This criteria for
psychopthe refer less to anti-social behaivour per se than to the psychopathic indival’ thoughs nd
feeligns.
- ONe of the key characteristic of psychotpahtys ipovert of emtoions, both psotive nad
ngetaiv.
o Psychopathic peopelw have no senseo f hacne and even their seemingly psotive
feelignso for thers are merely an act.
o The psychopath is superficially charming and manipulates other for personily gian
o They exploit other even if it invoeld the use of violenve and aggereion

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o Their lack fo anziety may make it impossible for psychopaths to learn from
theirmistakes, and their lack of positive metion leads tem t bheaviour
irresponsible and oftern cruely otwards others.
→ Controversies with Daignoses of APD and Psychopathy
The two diagnosis – APD and psychoahty- are realted by they are by no means identical
- One study found that only about 20% of people with PD scoared high on he Hare PCL-R.
o Harpur and Hare observed that alsmot allpsychopaths are diagnosed with APd byt
many peaopld diagnosed with APD do not meethe critier for sychopahty of PCL-
R
- Extensice reseach ahs now identified factors nad processed the distinguist APD and
psychopathy.
o Dlear differeince have merged in defencie reactivyt suggesting thst psychopathy
is distingused bya low fear dispotion.
o This deflicit in psychopathis described in more datil below
o Other resaech ahs found that factors bleived to distingus APD and psychopathy
actually do not.
o A study of male prison inatme found tha PD and featues ps psychopathy wer both
associated with a hisotyr of suicide attemps
o It was belied previously tha cognitive control delficts were linked with APd but
psychopathic indivdiuasl had elevated cognitive control, but hera gins, recetn data
indicate tha APD and psychopathy are both assoicaited with delifst in cognitive
control
→ Research and Theory on the Etiology of Anti-Social Personality Disorder and
PScyhoapthy
- Childhood roots of psychopathy
Evidence is accumulaitngo n the nature of psychopathy in children and youth. Research ahs
shown that following
o Genetically influenced psychopathic personality in adolescents is a stonrg
predicotry of adult anit-soicl bheiaovur
o Female youth offenders, realitve to high psychopathy are more likely to have a
histpry psychatir hospticalliatin fi they are high is psychopathy
o Chidlren with psychopathi tratis have abnormal prefonrtla cortex responsiveness
o Tests of regional grey matter volume aong incarcerated male adolescents link
psychopathy with decread grey matter volumes if diuffes paralimbic brain
regions, leading the researched to conldue that psychopath in younger people is
best viewed as a neruodevelopemtnal disorder
o Canadian youth with pre-exisitng elevated levls of psychopathy are more likely to
joing youth gangif they acome fomra neigbourhood of residential instability in
terms of high neighourhood turnover artes

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Personality Disorder Clusters: Anxious/Fearful Cluster

Avoidant Personaltiy Disorder
Applies to people such as Jared in Bried Case Example who are keenly sensitive to the
possibility of criticism, rejection of dispproval and are reluctant to enter into relationship unless
they are sure they will be liked .
- Highly comorbdw ith depend personality disorder.
- Both avoidant persontliy disorder nad social phobia are related toa syndrome tha occurs
infJapan called taijinkyoufu.
Dependent Personality Disorder
Lack of both self-confidnecenad sense of autonomy
- People with DPD view themselves as eakd nad other people are powerful.
- They also have an intense need to be taken care of, which mekas thme feel uncomfortable
when alone
- They may be preoccupied with fers of being left alone to take care of thsemvles.
- They subordinate their own needs to ensure that they do not break up protective
relstiohsip
- An important cavera about DPD was expressed by Chen, NAttles, and chen
- Too great a need to connect with other can constitude maladjustment in North America,
but connective with others is healthy and valued in collectivistic culture in places wuch as
East Asia
Obsessive-Complusive Personlaity Disorder
These people are known as perfectionist, preoccupied with deials, rules, scheudles and the like
- These people often apy so much attention to deail that they never finish project
- Theyre are work-oreinted rahtehr than pleasure =-oreitned and have inorderin diffuicult
making decision and aloocating time
- Their interperosnlay relstihon are often poo because the yare stubborn and emand that
eveyrting to be done their way.

Therapies for Personality Disorders

Schema therpaye for personality disorder.
- Disconnection and rejection
- Impaired autonomy and prefomance
- Impaired limits
Each themes is tapped by several subscale factors
This can be adapted to main themes inherent in a particular persontliy disorder

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Schemea therpaye for borderline perosilty disorder involed three pahses of treatmen
- Bonding between the clientand therapist and emtoinal regulation
- Schema mode change
- Development of authomuy
Therapy for the Borderlien Personality
→ Dialectical Behaviour therapy
This has three overall goals for borderline indivdials
- Modulate and contrll their extreme emotional and bheiaorus
- Tolerate feleings distressed
- Trust their own throughts and emotionas
Therpay of Psychopathy
The primary reasons for their unsuitability for psychothrepyar is thaty they are unable and
unmotived to form any sort of trusting, honest relatioshp with a therapist
- People who lite almost without knowi, who care little for the feeligns of toher and
understand their own even less, who appear not to realize that hwat they are doing is
morally wrong, who lack any motivation to obey society’s law and moreses, and who
living only fohte prestn, have no concern for the cuture are, all in all, extremel poor
candiated for therapy.

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Chapter 16: Aging and Psychological Disorders 39

Issues, Concepts, and Methods in the Stiudy of Older Adults
Diversity in Older Adults
Ther word “diversity” is well suited to the olrder population. People tend to become less alike as
they grow older. That all old people are alike is a prejudice held by many people. The may
differences among people who are 65 ando lrder will beocoem increasing ly evident.
Age, Cohort, and Time-of-Measurement Effects
Chronological age is not as simple a variable in psychological research as it maight seem. There
other factos assoicted with age may be at work, we must be cautious when we attribute
differnecei in age groups solely to agin. In the field of aging, as in studies of earlier developemtn,
a distinction is made among three effects.
- Age effects areht consequences of being a given chronological ge
- Cohort eefcts are the consequences of having been borin in a given year and having
grown up during a particular time period with tis own unique pressures, problmes,
challenges and opportunities. A cohort effect exisists if these poel have osme factor that
distinguished them form people who turned 65 of older at an aeariler age or later date.
- Time of measurement effects are confound that aris because evenst at an exct point in
time can have a specific effect on a variable being studied over time,
Teo major research dsignes used to asses developmental change, the cross-sectional and
longitudinal.
- Cross- sectional studies, the investigarot compares different age groups at he same
memoment in time ofn the variable of interest. Cross-sectional studies do not examine the
same people over tiem; consequwntly, they allow us to make statements only about age
effects in a particular study or experiment, not about age changeds over tiem
- Longitudinal studies, the researcher slecetls on cohort – say, the graduating class of
2002 – and peridociatlly retests it using the msae measure over a number yours. This
desging allows researched to trace indivdal patterns of consistency or change over time –
cohort effects- and to analyze how beahivour in early life related to behaivour in old age
Cohort effect refer to the fact hat peopleof the same chronoligcal age may differ considerably
depeding on when they wre born
An additional problem with longitudinal studies is that participatns often drop out as the studies
proceed, creating a bias comlnly called secletive mortality. The lead-able people are the most
likely to drop out, leaving a non-represntative group of people who are usualy healthier than the
general population. Thus, fidnign based on longitudinal studies may be overly optimistic about
the rate of decline of a variable such as sexual activity over the lifespan.
Diagnosing and Assessing Psychopathology in Later Life

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The diagnostic criteria for older adults are basically the same as for younger adutls. The nautrea
nd manifestatiosn of mental disorder are usally assumed to be the same in adulthood and old age,
even though little research supports this assumption.
- Accurate assessment of eldery people for the purposes of establishing diagnosis and
conducting research requires assessment measure tairlored to elderly poel.
- A meaure of cognitive functioning is often included as standard practice inreaserch to
determein whether the elderly respondent has experienced decline in cognitive abilty.
- Researchers often assess cognitive functioning wtihte Mini-Mental State Examination.
- The MMSe is a brief mearue fo an idnvidiual’s cognitive state, assessing “orientation,
memory, and attention .. abitliy to name, follow verbal and written commands, write a
sentene spontaneously and copy a coplex polygon.
- Some elderly people will have diminished attention spans, one goal is to develop short
but reliable mearues suitable for screening purposes.
- A releatiely simple meaure usedto detect demeitan and Alzhimer’s disease is the clock-
drwaing subtest of the Clock Test.
o The clock test was devleopemt by Holly Tuokko of the Univeristy of Vicotiria
and her associated.
o They wer asked to imaging htat htei ciricla is the face of a clock and to put the
numbers on the clock and then draw the hahnd plancement for the time of 11:10.
Up to 25 different types of errots can occur, including omissions, perserverations,
rotaitons, misplacement, distori bing, substitution and addtions.
o This simple test has been found to reliable and valide, thought results vary
depending on the scoring system used.
- Another assesemtn ogald is to create measure whose itme content is toailered directly to
the concernt and symptosm reported by elderly ple , not to those of younger respondents.
- One well-known measure crafted for the elderly is the Geriatir Depression.
- The GDS has acceptable psychometric characteris and is regarded as the sandrad measure
for assessing depression in the elderly.
- The Geriatirc Suicide Ideation Scale is a 31 item meaure that is the first mearue of suidice
ideation created specifically for the elderly.
- Subsequent research with a community sample attested to the psychometric feature of the
GSIS and its subscaled, and it established that high GSIS scaore are associated with
ihigher levels of loneliness and osical hopelessness and lower levels of social support nad
well-being
Rage of Problems
One concertn expressed by the Wolrd Healht Orgnaization (WHO, 2002) is htat elderly people
with a mental disorder may suffer from “double jeopardy”; this is, they suffer the stigmas
associated with being olrder and being mentally ill.
It is important to remember that in addition to a lifetime of exposure to losses and to toher
stressors, olderadults have many positive life experiences, coping mechanism, and wisdom on
which ot draw.

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Older adutls who beling to groups that provide meningul, strong roles for them seem to have a
easier time adjusting to gorwing old.
Old Age and Brain Disorders
Althought majoriy of older peoep do no have braind disorder, these pek account ofr more
admission and hospital inpatinet days than any other geriatice condition.
Dementia
Accoridngto the DSM-5, the preferred term instead of “dementia” is “neurocognitive disorder”
to be used in settings where docots and pateitns are famility with the term.
- Sometimes call “senility” is gernal descriptive erm for gradual deterioration of
intellectural abilities to the point that social and occupational funcitons are impaired.
- Difficutly remebefing thigns, escpially recent evens, is the most prominent symtoms and
reported memory probme in people who objectly have normal cogition predict
subsequent dementia.
- People with dementia may leave tasks unfinished because they forget to return to them
after an interruption.
- The people who had started to fill a teakettle a the isnk leaves the water running; a parent
is unable to remember th name of a daughter or son.
- Hygiene may be poor and appearance slovenly because the person forgets to beathe or
how to dress.
- People with dementia also get lost, even in familiar settings.
- Judgement may become faulty, and the person have difficulty comprehending sitautiosn
and making plans or decisions.
- Porple with dementia relinquishe their standards and los control of their impules; they
may be use coarses language, tell inappropriate joeks, pr shoplife.
- The bility to deal with abstract ideas deteriorates, and disturbances in emotions are
common, including symtoms of depression, flatness of affect, and sporadic emotional
outbursts.
- People with demential are likely to show language disturbances as well, such as vague
patterns of speech.
- Although the motor system is intanct, they may have difficulty carrying out motor
activities, such as those involed in curshing teeth or dressing themselves.
- They may also have trouble recognizing familtiy surroudnings or naming common
object.s
- Episode of delirium, a state of great mental confusion may also occur.
o These should be distinguesd from paraphrenia, the term used to describe
schizophrenia htath as its onset during old age .
- Thse course of dementiamat may be progressive, statisc or remitting, depednign on the
cuase,
- Many people with progressive dementia eventually become withdrawn and aptehtic. In
the terminal pahse of the illness, the persontiy loses its sparkle nad integrity.

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- Relatives and friends say that the peson is just not himself or herself anymore
- Social involvemtn with tohers keep narrowing.
- The person is obilicious to his or her surroudningd .
- The prevalen ce of dementia increase with advancing age .
- One US study found a prevalence of 13.9% for peope k71 and older and 9.7% prevalcne
of Alzheimer’s disease.
- The prevalence of dementia was 5% for those aged 71-79 years old, but 37.4% for htose
aged 90 years and older.
- This same team eteam of investigators estimated later that another 22.2% of those aged
71 years or older have some form of cognitiveimpairment without dementia
→ Types and Causes of Dementia
Dementias are typically classified into three tyeps. Alzheimer’s diesae is the most common.
Therea re frontal- temporal and frontal-subcortincal dementias, which are define by the area of
the brian that are mot affecte.d
- Alzheimer’s Disease
o The person aften blames other for personaly failigs and may have delusions of
being persecutre
o Meneory continue to deteriorate, and the person comes increasingly disorinetaed
agitated
o Imaging of braing changes show clear signs of decline hta are often beyond a
person’s awareness
o Main physiolgicla change in the brian, evidcent at autopsy, is an atrophy of the
cerebral cortex, firsthe entorhinal cortex and the hippocampus and late the frtonal,
tmeproal and parietal loves
▪ A neurons and synapses are lost, the fissures widen and the ridges became
narrower and flatter.
▪ The ventircles also become enlarged
▪ Plaques- small, round areas making up the remnants of the lost nerurons
and b-amyloid, a waxy protein depostis – are scattered thorught he cortex.
▪ Tangled, abnormal protein filamens - neurofibrillary tangles –
accumulate with the cell bodies of neurosn
• These plaues and tangels are presnt throughouthe cerebral cortex
and the hippocampes
o The cerebellum spinal cord, and motoe and sensory areas of he cortex are less
affected, which is hwy LAzheimer’s suffered fo not appear to have anything
phsycaill wrong with them until late in the disease process.
o People are able to walk around normally, and their over-learned habits, such as
making small talk, remain intact, so that in short encourtners, strangers may not
notice anyting amiss
o There is a very strong evidcen for a gentic basis fro ALzheirm’s.

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o The enviroemnt is likely to paly a role in the most cases of LAzhimer’s as

demonstrated by reports of long-lived MZ twins who are discorandat for the
disorder.
o Genral research on cognitive decline in the elderly supports the phrase “use it or
lost it”.
▪ Remaining active a the cognitive level may buffer or protect an indivdal in
terms of he degree of cognirive decline experienced
▪ A review conducted by Cadnaian investiagors continue to support the use
it or lsot it.
▪ The review by Milgram at al. support three conditions
• Cognitive actiiyt helsp preserve cognitive function
• Cognitive activy helps crystialized intelligence more than fluid
intellingece
• Ther is uspprot for the cognitive reserve hypotheseis
▪ cognitive reserve hypothesisi the notion that high education levels delay
the clinical expression of dementia because the brain develops backup or
reserve neural strucurre as a form of neuroplasticity.

- Frontal-Temporal Dementias
o It typically beigns in a person’s late fifities.
o The usual cognitive impariemtns of a dementia,frontal-temproal dementias are
marked by extrem behaiovural and personality changes
o Sometiems people are very apthetic and unresponcei to heir environment; at toehr
times, they show an oppite pattern of euphora, overactivye and impulsivity.
o Alzheimer’s dises, frontal-temproal dementias are not closely linked to loss of
cholingerigc neurson.
o Serotonin neruson are most affected , and tehres I swidespreaad loss of neruson in
the forntal and temporal lobers
o Pick’s disease is one cause of frontal-temporal demntia

- Frontal-subcortical Dementias
Both cognition and motor activyt are affecte.d Thypes of rontal-subcortical dementias include
o Huntington’s chorea, now referred to more commonly as Huntington’s disease,
is caused by a single doinnate gene location on chromonse 4 and it diagnosed
prinicaply by neurologists on the basis of genetic testing. Ita major behaivoural
feaure is the present of wrting movements. The best-known person with this
diseas ithe late folk songwriter and signer Woody Hutehr.
o Parknson’ disease ia marked by meucal treoens, muscular rigidity and akinesia
and can elad to dementia

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o Vascualr dementias second more commont type, next to Alzheimer’s disease.

This is known by the DSM_5 as “major or mild neurocognitive disorder”. It is
diagnosed when a ptenting wit hdementias have neurological signsu ehc as
weakenss in arm or abnoarml reflecesd or when brain scans who evidcne of
cerebrovascular disease.
- Other causes of dementia
Encephalitis gever failure, nertic term for any inflammation of brain tissues ,is cuased yb viruses
that enter the brain either from toher partso the body or from the biest of mosquieoties or tiscks.
Meingitis inflammation of the membranes covering the otubrian, isusally cuaed by a bacterial
infection. The organism that produces the veneral disease pyohilis can invdade the brain and
cause dementia
Head traumeans,brain tumors, nutritional deficinese, kidney or liver faliltuyerm ad endocrine-
gland problmes such as hyperthyroidism can result in dementias. Exposure to toxins, sucahs
alead or merucury, as well as croncie use of drugs, inclduign alchold, are additional causes
→ Treatment of Dementia
Biological treatmetnsof Alzhelmer’s disesase
Firce drugs have been approced fro sue thsu far: tacrin, donepezil, rivastigmine, galantamien,
and memantine.They also reported that questions have been raied for critis about the ocest of
effectivesness of thes treatment fro a societal persepctice.
Psychosoical treatments of Alzheimer’s disease for the individual and the family
- The overall goal is to minimize the disreuption caued byteh eprson’s behaivoural
changed.
- Health workers achieved this by allowing the person and the family the opportunity to
discusee the illness and its conseuqences, providing accurate information about ti,
halping famiy members care fohte person in the hoem, and encouraign a realize attiude in
dealing wtith disease’s epecific challenges
- Counselling the person with Alzheimer’s is difficualt
o Cogntive losses, psychotherapye provide little long-erm benefit for those with
severa deteriortation
o Some patients seem to enjoy and be reassuremd by occasional converstaiong with
professionals and with toher not directly involed in their lives – in booh indivdal
nad group seetings.
- Interventions emploued with normally funciotning older audlts, like Bulter’ s life review.
- IN contrast to approaches taken with toher psycolgical problmes, denial may be the best
coping mehcanims avialbe rather htan being forced to acknoloedge proms
- Eveyr instituionalied indvidal with severly diabislty demntia, there are at least two
indivdals with dementia living in the community, usally suppritng by a souse, daughter or
ther maily member.

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- Given the extene t o which family membrs are relied on the stressors and challenges
facing famileis, issued a call for much greater recognition of the roles paleyd by fmaileis
and greater integration of familes into social system and the removeal of practice and
poicy barriers that lmit the support that famlied recived form psychotolis
- Caring for a personw with Alzhierm’s have been shown to be extremely stressful and
distressing
- Analyses reported by Candain Study of Healht and Agin Workign Group indicate tha
depression is twice as evidcen among caregivers as among on-cargivers.
- Tis CSHA study is improtnat because it is one for the few caregiver studies that began
with a nationally represtative smapel of dinvidal suffering form dementia and their
cargivers
- The link between role-seocif deands of caregivering and burden are migitage by resilitncl
resilsine promotes well-being among cargeivers experinceing signifcnat burer.
- Optimsin the caregive is also protective
Delirium
The term implied being off track of deviating for mthe usual stte.
- Typically described as a “clouded state of consciousnesss”
- The patients has great trouble concentrating and focusing attteniong and conneot atina a
coherent and directed stream of thorught
- The person with delirim is frequently restless, partically at ngiht.
- This sleep-waking cycle beomce disturbed, so that the person is drowys duing the day
and wake restless and agitated during the night
- Vivid dreamsn a nightmare are commonet
→ Causes of Dellrium
- The causes of delirium in order audlrs can be grouped into several genral classes: urg
intocisaiotn and drug-withdrawl, reaction, metabolic, and utritioanl imblances, infectiosn
or fevers, neurological disorder, and the stress of a change I the person’s surrdoung
- This may happen afer srugry most commonly hip replacements.
- Althoguth delirium usualy delvoeps swift, the exact mode of sonnet sepdns on the
underlying cuase
- Resutlingform a rtoxic reaction or consion has a naburtpy onset, whe ninfecitoor metoabi
disorunar underline delirimm the onset of ysmtoms is more gradual
→ Treatment of Deliriu
Comple recovery from delirium is poosibel f ithe synform is idneifit correctly and the udnelrying
cuase promptly treat.
It gnernaly takes on rot four weeks for the condiotn to clear; tit takes longer in older vs. yoiuger
people.

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- Primary prevention strategies appear to reduce high rates of delirium, as well as the
duration of delirium episode in hospitalized older audls.
- Oftern- negleict aspect of management of delirium is education the fmaiy of ap erosn
with dementia to distinguish the manifestatison fo dementia and delirium
Social involvemtn
Old Age of Psychological Disroders
Overall Prevalence of Mental Disorders in Late Life
Depression
→ Causes of Depression in Older Adults
- Mnay elderly peoplein poor physical helaht are dpressed and it is often difficult to
ascertain whether the heath problmes arcmae fist and were a results of being depressed
- Thw oversight can lead to worsening of the depression and emidcal condition
- Numerosu findinding point to the improtnace of sica support as a stress buffer for elderly
people faced with life challenges
- Retirement has vee nasusmed to have negative conaueq, the resreach does not suppro this
→ Treatment of Depression
Reminiscence therapy for depression requires inidvidal to reflect o ntheir past and presnt
situation to help achieve a sence of selc- aceetapce ad nreduce self blame.
Anitdepressant can be somewhat useful.
Substance-Realted Disorders
→ Alchol Abuse and Dependence
→ Medication Misuse
Sleep Disorders
→ Causes of Sleep Disorders
Sleep apena
→ Treatment of Sleep Disorders
Pharamacotheprya is most comone fomr of treamten for sleep disorder for people of all ages, but
this epsically ture for the eldery.
→ Suicide
Only a few seek out help. Elderly are neglect whe nit comes ot suidice prevention. One approach
veign evaluated is an intiate.
Treatment and Care of Olde Adults

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Treatmetn of Older Adults

Nursing and Home Care
Older people needing mental health treamtnet typically live in nursing hoes or recive
community-based,
Many oler poepl wihs to saty at home as long as possible
Alternative Living Settings
Issues Specific to Therapy with Older Adults
Guidelines wer agreed upon in six distinct areas
- Attitudes
- General knowleddge about adult devleopemtn,aging, older adults
- Clinical issues
- Assessment
- Intervention, consultation, and other service provision
- Education
The guidelines were put tother by the Candaian Coalitiaotn for Senior’s Mental HEalht.
The initial seris of guideliens for seniors’ metnal health address
- Assessment nad treatment of delirium
- The assessment and treatment of depression
- The assessment of suicide risk and the prevention fo suicde
- The assessment and treatmen of mental health issues in long-term care hoems
Content of Therapy
The widespread concern that old people are soically isolated and need to be encouraged to
interact more with others
Process of Therapy
The very process of being in therapy can fost dependcy.
All therapist must be able to interpret the facil expression fo their clients and therby udnersant
the meing fo thie words or reaction and appreciate their pehnoenmolfical phenomenological
experience of the world.

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