abnormal psychology midterm # 2 review dissociative...

PSYC 241 Fall Semester 2013

Abnormal Psychology – Midterm # 2 Review

Dissociative, Somatic Symptom and Related Disorders Dissociative Disorders - Severe maladaptive disruptions or alterations of identity, memory, and consciousness that are experienced beyond one’s control.

Defining symptom of these disorders is: Dissociation: The lack of normal integration of thoughts,

feelings and experiences in consciousness and memory. Types of Dissociative Disorders - Depersonalization-Derealization Disorder

Individual is affected by persistent or reoccurring feelings of depersonalization and/or derealization.

Depersonalization: An experience in which individuals feel a sense of unreality and detachment from themselves.

Derealization: An experience of detachment and altered relationship to the surrounding world, the individual perceives other people and objects in the environment as unreal, distorted and dream-like.

- Dissociative Amnesia

The inability to recall significant personal information in the absence of organic impairment following a traumatic event.

Localized: (Most common type) Failure to recall information from a very specific time period.

Selective: Loss of memory for only some parts of the trauma and other parts are remembered.

Generalized: Loss of all personal information from individual’s past.

Continuous: (Rare) Forgetting information from a specific date until the present.

- Dissociative Fugue

An extremely rare and unusual condition Individual travels suddenly and unexpectedly away from home,

accompanied by a loss for one’s past and personal identity. It is brief (a matter of hours/days) and ends suddenly Can be very severe – people may travel far from home:

- Establish a new home - Establish new relationships - New line of work - Display new personality characteristics


- Dissociative Identity Disorder “Multiple Personality Disorder” (DID) Characterized by the presence of 2 or more unique personality states

that regularly take control of the individual’s behavior. One of the most controversial and fascinating disorders recognized by

in clinical psychology. One personality is identified as the “host”, whereas the others are

known as “alters” Each of the personalities has their own distinct features,

memories, personal histories and mannerisms. Three Kinds of Relationships between the Alters (Sub

personalities): - Mutually Amnesic Relationships: Sub personalities

have no awareness of one another. - Mutually Cognizant Patterns: Each sub personality is

well aware of the rest. - One-Way Amnesic Relationships: (Most Common

Pattern) Some personalities are aware of others but awareness is not mutual. Those who are aware are known as “co-conscious sub personalities” and are “quiet observers”

Switching: The process of changing from one personality to another. Often occurs in response to a stressful situation.

Etiology of Dissociative Identity Disorder (DID) - Trauma Model

A diathesis-stress formulation Results from severe trauma in childhood (sexual, physical and

emotional abuse) paired with personality traits that predispose the individual to use dissociation as a defence mechanism/coping strategy.

No longer adaptive when used regularly as a coping method throughout childhood.

- Socio-Cognitive Model

Represents a different etiological position from mental health professionals that do not accept DID as a legitimate disorder.

Views “multiple personalities” = role-playing, where individuals begin to act in a way that is consistent with their own and their therapists’ beliefs about the disorder.

Treatment of Dissociative Identity Disorder (DID) - Psychotherapy:

Three Stages of Psychotherapy


1. Building therapeutic alliance (establishing a “safe” and trusting environment for the individual to discuss emotionally charged memories of past traumas)

2. Developing coping skills to provide patient with tools to deal with traumatic history

3. Integration of personalities (merging all alters into one personality)

- Hypnosis:

Popular method used to confirm the diagnosis, to contact alters, and to uncover memories of traumatic childhood abuse.

Criticism: Hypnosis has the potential of retrieving confabulated memories and personalities.

- Medication:

Not really useful when directly treating dissociative disorders, however psychopharmacology can be helpful at treating comorbid disorders (depression and anxiety). “Truth Serum” (Sodium Amytal), a barbiturate that causes

drowsiness can sometimes be used to recall previously forgotten memories or identify additional alters.

How Do Theorists Explain Dissociative Disorders? - The Psychodynamic View:

Support from case histories (Childhood Experiences) Theorists believe that dissociative disorders are caused by repression,

the most basic ego defence mechanism. Repression: Fighting off anxiety by unconsciously preventing

painful memories, thoughts, or impulses from reaching awareness. (Dissociative amnesia and fugue are single episodes of massive repression).

DID = Lifetime of Excessive Repression + Traumatic Childhood Events

- The Behavioral View:

Relies of case histories to support view. Dissociation grows from normal memory processes and is a response

learned through operant conditioning Dissociation = “Escape Behavior” Momentary forgetting of trauma Leads to a drop in anxiety

(Negative Reinforcement) increasing the likelihood of future forgetting.


Somatoform Disorders (DSM-IV-TR) Somatic Symptom Disorders (DSM-V) - Individuals report physical symptoms that cannot be supported by medical exams, but have reason to believe they reflect psychological factors.

Malingering Disorder: Individual adopts the sick role and complains of symptoms to achieve some objective (insurance money, evading military service or avoiding an exam).

Factitious Disorder (Munchausen Syndrome): Individual deliberately fakes or generates the symptoms of an illness to gain medical attention (sympathy, care and attention).

Types of Somatic Symptom Disorders - Conversion Disorder

Loss of functioning in a part of the body that appears to be due to a neurological or other medical cause, but without any underlying medical abnormality to explain it.

Most dramatic somatic symptom disorder Motor Deficits:

- Paralysis - Localized Weakness - Impaired Coordination/Balance - Inability to Speak - Difficulty Swallowing/Lump in Throat - Urinary Retention

Sensory Deficits:

- Loss of Touch/Pain Sensation - Double Vision - Blindness - Deafness

Glove Anesthesia: The loss of all sensation (touch, temperature and

pain) throughout the hand, with the loss sharply limited at the wrist, rather than following a pattern consistent with the sensory innervation (nerves) of the hand and forearm.

La Belle Différence: Lack of concern about the nature and implications of one’s symptoms.

- Somatization Disorder (DSM-IV-TR) Somatic Symptom Disorder (DSM-V) Somatization Disorder (DSM-IV-TR)

Individuals report multiple recurring complaints of physical ailments that not appear to have an organic basis. - Must Report (Somatic Symptoms):

Pain Gastrointestinal Symptoms


Sexual/Reproductive Symptoms Symptoms that suggest a Neurological Condition

Somatic Symptom Disorder (DSM-V)

1 or more somatic symptoms that are maladaptive and distressing

Excessive thoughts, feelings and behaviors related to somatic symptoms or health concerns. - Individual is anxious about the bodily symptoms that

they are experiencing - Causes of Conversion and Somatic Symptom Disorders

In the past, Conversion + Somatic Symptom Disorders Were know as “Hysterical Disorders”

Hysterical Disorders: Excessive and uncontrolled emotions underlie the bodily symptoms

Today’s leading explanations: The Psychodynamic View

1. Sigmund Freud Hysterical disorders represent a conversion of underlying emotional conflicts into physical symptoms (E.g. Electra Complex)

2. Today’s Psychodynamic View Sufferers of the disorders have unconscious conflicts carried from childhood.

a. Primary Gain: Bodily symptoms keep internal conflicts out of conscious awareness.

b. Secondary Gain: Bodily symptoms further enable people to avoid unpleasant activities or receive sympathy from others.

The Cognitive View - Hysterical disorders are a form of conversion and

somatic symptom disorder that provides means for people to express difficult emotions.

- Emotions Converted into Physical Symptoms

The Multicultural View - Western Clinicians Hold bias that sees somatic

symptom disorder as an inferior way to dealing with emotions

- Personal Distress Transforms into Somatic Complaints (Bodily and Psychological reactions to life events are influenced by one’s culture)


- Illness Anxiety Disorder (Hypochondriasis)

Long-standing fears, suspicions, or convictions about having a serious disease, despite medical reassurance that the disease is not present.

Misinterprets bodily symptoms or bodily functions.

Theorist’s Explanation: Behaviorists: Classical Conditioning or Modeling Cognitive Theorists: Oversensitivity to bodily cues.

Treatments:

Antidepressants Exposure and Response Prevention (ERP) Cognitive-Behavioral Therapies (CBT)

- Somatic Symptom Disorder “Predominant Pain” (Pain Disorder)

Must have complaints of pain in one or more body sites sufficiently serious to warrant clinical attention.

Pain must be severe enough to cause significant distress or to disrupt the individual’s daily life, possibly leading to an inability to work, attend school, or socialize with others.

Symptoms must be chronic with a duration lasting more than six months.

“Somatization” Pattern vs. Predominant Pain Pattern Somatization Pattern: Long-lasting physical ailments that

have little or no organic basis. - Pain Symptoms - Gastrointestinal Symptoms - Sexual/Reproductive Symptoms - Neurological Symptoms

Predominant Pain Pattern: Primary feature of somatic

symptom disorder is pain. - Pattern develops after an accident or illness that has

caused genuine pain - Pattern may begin at any age. - Pain Assessment:

Patient History Diagnosed when psychological factors are in the

onset, exacerbation, severity or maintenance of pain symptoms. (High risk of addiction to pain medications)


- Body Dysmorphic Disorder (BDD) Excessive preoccupation with an imagined or exaggerated body

disfigurement, sometimes to the point of delusion Significant distress or impairs functioning Believes everyone notices this “defect”

- People often seek plastic surgery or dermatological treatment, but often feel worse rather than better afterwards.

Theorist’s Explanation: Physical and psychological explanations that have been

applied to anxiety and OCD disorders are also used to explain BDD.

Clinicians: Treat clients by applying same methods of treatment for OCD

- Antidepressants - Exposure and Response Prevention (ERP) - Cognitive-Behavior Therapy (CBT)


Substance-Related Disorders - Overlaps with Eating Disorders, in terms of treatment and how patients are not really open to seeking help. DSM-IV-TR DSM-V - DSM-IV-TR: Intoxication vs. Abuse vs. Dependence - DSM-V: Eliminated boundary between Abuse and Dependence Intoxication vs. Substance Use Disorder Substance Intoxication - A reversible and temporary condition due to the recent ingestion of (or exposure to) a substance. - Must demonstrate clinically significant maladaptive behavioral or cognitive changes and impaired thought processes or motor behavior. Substance Use Disorder - The recurrent substance use that results in significant adverse consequences in social or occupational functioning.

Symptoms Related to Impaired Control (Psychological Dependence):

1. Ingestion of large amounts (Impairment of Control) of the substance or over a long period than was originally intended.

2. Desire to cut down with or without unsuccessful efforts to reduce or discontinue.

3. Great deal of time spent obtaining, using or recovering from a use of a substance.

4. Cravings (Habituation): Desires triggered by different cues “Obsession”.

Symptoms Related to Social Impairment: 5. Failure to fulfill major roles, obligations at work, school or

home. 6. Continued use despite social and interpersonal problems

drawn from the effects of the substance. 7. Loss of social, occupational, or recreational activities

because of substance abuse.

Symptoms Related to Risky Abuse: 8. Recurrent substance use in situations in which it is physically

hazardous (E.g. Driving). 9. Continued use despite knowledge of having

recurrent/persistent physical or psychological problems that is likely to be caused by substance (E.g. Kidney Failure Still Drinking Alcohol)


Pharmacological (Physiological Dependence) Criteria: 10. Tolerance: Increased amounts of a substance needed to

achieve the same effects. 11. Withdrawal: An unpleasant and sometimes dangerous

symptom as the addictive substance is removed from the body. Lethargy Nausea Headaches

Polysubstance Abuse - “The rule not the exception” - The simultaneous misuse or dependence upon two or more substances.

Risks Physically dangerous Mixture Results in worse conditions (combination is

greater than the sum of the parts) Associated with greater comorbidity of other psychological

disorders.

Treatment Challenges: Which drug present the more immediate threat to health? Which one is to be treated first?

Alcohol Abuse - “The World’s Number One Psychoactive Substance” - The recurring use of alcoholic beverages despite its negative consequences. - University Students Statistics

86% of students reports having consumed alcohol in the past 12 months

18.5% report to binge drinking Binge Drinking: 5 or more drinks per month or more.

51% report to having blackouts Blackouts: An interval of time for which the person cannot

recall key details or entire events. (Passing out and not being able to remember anything) - Associated to Changes in the Brain Damaging

Etiology of Alcohol Abuse - Genetic Factors

Higher in males concordance rate for developing alcohol abuse. Twin Studies Significant effect for males MZ twins than

females MZ twins - Male MZ twins 26-77% concordance rate.


Many offsprings of alcoholics do not become alcoholics, and many alcoholics are born to non-alcoholic parents (Hodgins & Mackay, 2010)

- Physiological Factors

Strong placebo effects Alcohol Expectancy Theory: Individual’s drinking is determined by

the reinforcements they expect to obtain from it. Positive Reinforcements (The power of alcohol within

people’s own perceptions): - More Fun - More Social - More Relaxed

- Behavioral Disinhibition

People with alcohol problems tend to have greater difficulty controlling impulsive behavior

“Risk-Takers” are more prone (Risk Factor & Predictor) Abstinence vs. Moderation (Defining Treatment Goals) - Abstinence: Helping the individual to stop drinking completely.

Based on the Disease Model = Minnesota Model Cannot control drinking in a controlled way Alcoholism = “Disease” Participants are required to attend AA meetings to

encourage to keep going after treatment and to address the danger of relapse.

- Moderation: Taking the substance in limited small amounts “gradual decrease”. Motivational Interviewing & The Transtheoretical Model of Change - Motivational Interviewing

An approach that can be used with clients who present with varying levels of readiness to change their behaviors.

Lasting change is not likely to occur until individuals can resolve their ambivalence.

OARS Strategy - Open-Ended Questions: Get individuals talking and

make it difficult for them to say one-word replies or short answer replies Elicits “Change Talk”

- Affirmations (Express empathy): Statements and facts that are used to discourage doubts (doubts hinder progress in MI)

Affirmations/Reinforcements:


o Resourcefulness o Previous change attempts o Qualities of individuals that may facilitate

change. - Reflective Listening (Ambivalence is Normal): Saying

statements back with inferred meaning (tone of voice, highlight something important), statements – not questions.

- Summarizing: “Action Process” complex reflection, selective and directive, includes both sides of ambivalence.

When to use “Change Talk” o Pros associated with change o Cons associated with present behavior o Intentions to change o Discrepancy between where individual

ideally wants to be and their current tasks o Transitioning between tasks at the end of

assessment or session (Certain specific time points)

- The Transtheoretical Model of Change

A theoretical framework for understanding the process of behavioral change.

A theory that can be applied to everything Stages of Change:

Precontemplation: Not ready for change, individuals feel that they don’t have a problem, cons > pros with change.

Contemplation: Thinking about changing behaviors, but not committed to change ambivalent. Weighing pros and cons.

Preparation: Decided to change and developing a plan for change with therapist, changing environment.

Action: Actively working at changing their problem behavior, thought records, actively doing in order to reduce behavior.

Maintenance: Working to maintain changes and prevent relapse.

“Spiral Method”, not linear: Movement can occur forwards or backwards in treatment.

People can enter at any stage Relapse is common (normal), often a maintenance issue. Interventions to “match” individuals’ stage of change

Matching and moving up the spiral Miss-matches behavior doesn’t improve at all


Always encouraging treatment for change Integrating Motivational Interviewing and Transtheoretical Together - Used in all stages of change - In assessments and different types of interventions - Motivation Interviewing = therapeutic. Harmful Reduction Model - Range of public health policies designed to reduce the harmful consequences associated with various, sometimes illegal, human behaviors.

Minimizes the bad effects There is harm but it’s not trying to reduce the usage, but rather the

harm that comes after taking the substance. Focuses of reducing the consequences of substance use

E.g. Need Exchange Programs

Often implemented along with: Counseling Education Outreach Programs


Schizophrenia and Psychotic Disorders Schizophrenia - A complex condition that is characterized by heterogeneity. - The tendency for people with the disorder to differ from each other in:

Symptoms Family Background Response to Treatment The Ability to Live Outside the Hospital

- It is also characterized by delusions, hallucinations, and disorganized speech. - One of the most serious psychological disorders. - Adverse Changes in:

Thoughts Perception Emotion Motor Behavior Feelings of Depersonalization

Typical Characteristics of Schizophrenia – Positive and Negative Symptoms (Broadly Divided): - Positive Symptoms: More obvious symptoms of psychosis

Delusions: A system of implausible beliefs that persist despite evidence that contradicts them.

Persecutory Delusions: The most common and are fixed false beliefs that others aim to obstruct, harm or kill individual.

Hallucinations: Misinterpretations of sensory perceptions that occur while a person is awake and conscious and in the absence of corresponding stimuli.

People hear, see, smell and feel things that are not really present.

Perception of certain stimuli doesn’t match the outside world.

Hearing voices is the most common hallucinations among patients with schizophrenia.

Disorganized Speech and Thought Disorder: Loosening of associations and logical connections between ideas quick shifts from topic to another “incoherent” (least common of the positive symptoms)

Exaggerated Dispositions of Typical Behavior - Negative Symptoms: Absence or loss of typical behaviors.

Flat Affect: Limited emotional expression.


Avolition: Lack of energy, limited ability to persist in what are usually daily routines (grooming and hygiene).

Loss of apathy and motivation

Alogia: Can take two forms: Poverty of Speech and Poverty of Content of Speech.

Poverty of Speech: Amount of speech is greatly reduced. Poverty of Content of Speech: Amount is adequate but

speech communicates little information (vague and repetitive)

Anhedonia: The inability to experience pleasure. Motor Symptoms & Catatonic Behavior:

Motor Symptoms: Ranges from agitation to immobility (movement orientation)

Catatonic Behavior: “Contortions” holding unusual postures and resisting efforts by others to change these postures.

Changes for DSM-V: - DSM-IV-TR:

2 or more of the following for a significant period of time during a 1-month period. (Note: Only 1 required if delusions are bizarre or if hallucinations involve running commentary 2 or more voices)

Delusions Hallucinations Disorganized Speech Grossly Disorganized or Catatonic Behavior Negative Symptoms (Affective Flattening, Alogia or

Avolition)

Subtypes of Schizophrenia: Paranoid: Prominent usually thematically (disordered)

related delusions or auditory hallucinations and the absence of markedly impaired cognitive functioning or affect - Most common - Least disabling - Later onset than other subtypes - Best prognosis

Disorganized: Characterized by disorganized speech and

behavior as well as notably flat and inappropriate affect.


Undifferentiated: Seen in individuals that meet the criteria of: Delusions, Hallucinations, Disorganized Speech, Catatonic Behavior and Negative Symptoms – but without sufficient characteristics to satisfy the criteria for the paranoid, disorganized, or catatonic subtypes.

Residual: Diagnosed in the case of an individual with at least one prior episode of schizophrenia and with negative symptoms (flat affect, poverty of speech, or avolition) as well as attenuated positive symptoms, which may include eccentric behavior, mildly disorganized speech, or odd beliefs.

Catatonic: Acute psychomotor disturbance, which may present immobility and extreme negativism and rigidity.

- DSM-V:

2 or more of the following for a significant period of time during a 1-month period. At least one of these should include 1-3

1. Delusions 2. Hallucinations 3. Disorganized Speech 4. Catatonic Behavior 5. Negative Symptoms

Changes for DSM-V:

Removal of subtypes Clinician-rated dimensions of psychosis symptom severity

Early Identification - Warning Signs: - Behavioral (Changes in Person):

Strange posturing Less sleep needed than usual Self-harm/Self-mutilation Excessive writing without meaning Deterioration of personal hygiene Hyperactivity or inactiveness, or alternating between the two Agitation Staring without blinking or blinking incessantly Severe sleep disturbances Drug or alcohol abuse (coping mechanism)

- Thinking and Speech:

Things around them seem to be changed in some way Rapid speech that is difficult to interrupt


Irrational statements Preoccupation with religion or with the occult Peculiar use of words or odd language structures Unusual sensitivity to stimuli (noise, light, colors and textures) Memory problems Severe distractibility

- Social:

Sensitivity and irritability when touched by others Refusal to touch people or objects directly (gloves) Deterioration of social relationships Severe social withdrawal, isolation and reclusive Unexpected aggression Suspiciousness

- Emotional:

Inappropriate laughter Inability to cry, excessive crying Feelings of depression and anxiety Inability to express joy Euphoric mood

- Personality

Reckless behaviors that are out of character Significantly prolonged drops in motivation or speech Shift in basic personality

Proposed Changes for DSM-V - Attenuated Psychotic Symptoms Disorder

All six of the following: A. Characteristic Symptoms: At least 1 of the following in

attenuated from with intact reality testing, but of sufficient severity and/or frequently that is not discounted or ignored:

I. Delusions II. Hallucinations

III. Disorganized Speech

B. Frequency/Currency: Symptoms meeting A must be present in the past month and occur at an average frequently of at least once per week in the past month.

C. Progression: Symptoms meeting A must have begun in or significantly worsened in the past year.


D. Distress/Disability/Treatment Seeking: Symptom of A are distressing and disabling.

E. Symptoms meeting A: Not explained by any DSM-V diagnosis, including substance-related disorder.

F. Clinical Criteria: Never been met for any DSM-V psychotic disorder.

Attenuated Psychosis Syndrome - Precursor to Schizophrenia

People don’t have to be so ill to be diagnosed. Added as an example of an “other specified schizophrenia spectrum

and other psychotic disorder” Also included as a condition for further study.

Etiology - Genetics

Biologically predisposed Adoption studies provide strong evidence for a genetic

contribution: 1. Children of biological parents with schizophrenia who were

reared by foster/adoptive parents will have higher rates of schizophrenia vs. children whose biological parents did not have schizophrenia.

2. Studies of relatives of adopted children with schizophrenia higher rates of schizophrenia among biological relatives

Negative symptoms stronger genetic component

- Dopamine

One of the neurotransmitters Original Belief = Schizophrenia is related to an excess in dopamine. Current Thinking = Schizophrenia is related to oversensitive

dopamine receptors due to the reuptake of dopamine. Why Dopamine?

Anti-psychotic medications function by blocking post-synaptic dopamine receptors

Amphetamine used can cause symptoms consistent with paranoid schizophrenia – they release dopamine into the synaptic cleft and prevent their inactivation

Dopamine Strongly related to positive symptoms - Amphetamines worsen positive symptoms and lessen

negative ones - Induce delusions, hallucinations.


- Anti-psychotics reduce positive symptoms and their effect on negative symptoms is less clear.

Disagreement between drug action and changes in behavioral symptoms. - Anti-psychotics Block dopamine receptors - Therapeutic gains Reduce receptor activity

Below normal Resulting in symptoms like Parkinson’s disease.

- Expressed Emotion

Communication style in families Family experiences alone doesn’t cause schizophrenia

Expressed Emotions: Within families, over-involvement and negative

interpersonal communication (hostility, critical attitudes, etc.) directed at the family member with schizophrenia. - May play a role in relapse - Not specific to schizophrenia contribution factor

environmental predisposition. - Congenital and Developmental Considerations

In Utero Viral exposure (influenza, rubella) Complication during birth (prolonged labor, preterm

delivery, low birth weight, fetal distress, and breathing difficulties)

Multiple factors coming together. Treatments - Medication

Chlorpromazine = First anti-psychotic, had severe side effects Risperidone & Olanzapine = Newer anti-psychotics with fewer side

effects. - Psychological

Cognitive Behavior Therapy: Symptom focused, helps with negative symptoms.

Family Therapy: Support and reduce negative emotional expression. Social Skills Training: Skills-based, purpose to help with functional

disabilities associated with schizophrenia.


Personality Disorders - Inflexible and maladaptive personality traits causes impairments - Personality is non-responsive to context - Restricted range of traits relative to people without a personality disorder DSM-IV-TR – Criteria for Defining Personality Disorders - Criterion A: Manifested in multiple areas - Criterion B: Enduring, rigid, consistent - Criterion C: Causes clinically significant distress - Criterion D: Stability and long duration - Criterion E: Cannot be accounted for by another disorder DSM-V – Personality Clusters - Cluster A: Odd and Eccentric

Paranoid Pervasive suspicious of other Schizoid Emotional detachment Schizotypal Eccentric behavior and social isolation

- Cluster B: Dramatic, Emotional or Erratic

Antisocial Disregard for others, rule-breaking impulsive Borderline Labile mood, unstable relationships Histrionic Attention-seeking, dramatic emotional displays Narcissistic Grandiosity, egocentricity

- Cluster C: Anxious and Fearful

Avoidant Sensitivity to criticism, avoidance of intimacy despite desire for affection

Dependent Cannot function independently, forfeits own needs Obsessive-Compulsive Inflexibility, need for perfection

Diagnostic Issues: - Axis I vs. Axis II

High co-morbidity with Axis I disorder Insurance often does not cover treatment for Axis II disorder In DSM-V, Axes removed but diagnostic criteria unchanged

- Comorbidity and Overlap

Comorbidity: Co-occurrence of two or more distinct disorders within the same person.

Overlap: Similarity of symptoms between two or more disorders Criteria for personality disorders are vague and require

inference by the clinician. Thus, there are problems with overlap.


- Egosyntonic vs. Egodystonic Symptoms Egosyntonic = Do not view functioning as problematic

Generally Axis I disorders Egodystonic = Causes the individual distress

Generally Axis II disorders Implication for treatment?

Motivation - Gender Issues

Sex role stereotypes might be influencing diagnoses Reluctance to diagnose males with histrionic personality disorder and

females with antisocial personality disorder (APD) May be under diagnosed in females differences in

prevalence and expression of aggression between males and females.

Histrionic Personality Disorder: Patterns of excessive emotions and attention seeking in early adulthood.

Antisocial Personality Disorder: Symptoms of violence, pervasive pattern of disregard for, or violation of the rights of others.

- Reliability

Inter-rater reliability (agreement between diagnosticians) is improving, but still low.

Improves with: Structured interviews Comprehensive assessments

Etiology of Personality Disorders - Psychodynamic View

Disturbances in parent-child relationships Particularly with problems related to separation-individuation

resulting in difficulties dealing with other people or an inadequate sense of self.

- Relative to people without personality disorder, people with personality disorders are more like to have lose a parent through death, divorce or abandonment.

- Attachment Theory

Children develop a style of interacting with others based on how their parents relate to them

If parents and child bond is poor, the child will: - Lack of confidence in interpersonal relationships - Fear of rejection


- Lack of skills necessary to develop and sustain intimate relationships

- Biological Factors

Genetics Brain dysfunction (pre-frontal cortex)

- Cognitive Behavior Theory

Attribute personality disorders to rigid and inflexible. Families that invalidate child’s emotional experiences and

oversimplify their problems Children learn to magnify their emotions and problems to get deserved attention.

Modeling of maladaptive personality traits. Antisocial Personality Disorder (APD) - 3 or more of the following exemplars of violation of the rights of others:

Nonconformity: Failure to conform to social norms with respect to lawful behaviors

Callousness: Lack of remorse Deceitfulness: Repeated lying, use of aliases, or conning others Irresponsibility: Repeated failure to sustain consistent work

behavior or honor financial obligations Impulsivity Aggressiveness: Repeated physical fights or assaults Recklessness: Disregard for safety of others

Course & Prognosis of Antisocial Personality Disorder (APD) - Long course and a poor prognosis

Average duration of symptoms of APD is 19 years. Treatment of Antisocial Personality Disorder (APD) - High attrition and difficult to develop the therapeutic alliance. - Some promise for early intensive family interventions. - Treatment targets symptom reduction and behavior management rather that “a cure” Psychopathy - Not a DSM diagnosis - Individuals with psychopathy are described as:

Egocentric Deceptive Callous Manipulative Lacking Remorse and Emotional Depth


- Psychopathy related to aggression or violence Information used in predicting reoffending Heinous Violence: Motives of material gain, limited emotional

arousal during offence, may enjoy inflicting violence. Distinguishing Antisocial Personality Disorder (APD) from Psychopathy - The majority of individuals who are psychopathic would qualify for an APD diagnosis, but only a small portion of individuals with APD is psychopathic. Etiology of Psychopathy - Fundamental Psychopathy

Result of biological disposition Affective deficit a result of an inability to experience emotions

- Secondary Psychopathy Result of negative (abuse or extreme neglect) experiences in

childhood Affective deficit as a result of the individual’s ability to detach

self from emotions Borderline Personality Disorders (BPD) - Fluctuations in mood - Unstable sense of self - Instability in relationships DSM-V BPD Criteria - 5 or more required:

1. Frantic Efforts to Avoid Real or Imagined Abandonment: Does not include suicidal or self-harming behaviors

2. A pattern of unstable and intense relationships with extremes of idealization and devaluation

3. Identity Disturbance: Marked, persistent unstable self-image or sense of self.

4. Impulsive in at least 2 areas that are potentially self-damaging: Spending Sex Substance Reckless Driving Binge Eating

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilation


6. Affective instability due to marked reactivity of mood (dysphonia, irritability, anxiety)

7. Chronic feelings of emptiness

8. Inappropriate intense anger or problems controlling anger Frequent displays of temper Constant anger Recurrent physical fights

9. Transient stress-related paranoid ideation or severe dissociation

Etiology of Borderline Personality Disorder (BPD) - History of neglect and sexual abuse common people with BPD - Interpersonal style describer as anxious ambivalence

Intense fears of abandonment occupied with a strong desire for intimacy

Results in seeking out close relationships and then becoming highly anxious and withdrawing as relationship develops

Linehan’s Biosocial Theory of BPD - Biological predisposition to difficulties regulating emotions

Examples: Intense emotional reactions Increased sensitivity to emotional stimuli Increased time to reduce emotional arousal or to “calm down”

- Exposure to a pervasively invalidating environment

Examples: Minimizing Rejecting

Dialectical Behavior Therapy (Linehan) - Blend of CBT and Mindfulness - Skills based. Teach skills in:

Mindfulness Emotion Regulation Interpersonal Effectiveness Distress Tolerance

Better Ways to Classify Personality Disorders? - Theorists

The severity of key traits, or personality dimensions, rather than the presence or absence of specific traits should organize disorders.


Each key trait would be seen as varying along a continuum in which there is no clear boundary between normal and abnormal.

- Dimensional Approach

Approach begins with the notion that individuals whose traits significantly impair their functioning should receive a diagnosis “Personality Disorder Trait Specified (PDTS)”

When assigning this diagnosis, clinicians would further identify and list problematic traits and rate the severity of impairment caused.

According to the proposal, five groups of problematic traits would be eligible for a diagnosis of PDTS:

- Negative Affectivity - Detachment - Antagonism - Disinhibition - Psychoticism

Many clinicians believe the proposed changes give too much

latitude to diagnosticians Still others worry that the proposals are too cumbersome or

complicated Only time and research will determine whether the alternative

system is indeed a useful approach to the classification and diagnosis of personality disorders.

abnormal psychology midterm # 2 review dissociative...

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