Chapter 1 09/16/2013
Mental Health Issues: Problems are Common
Mental disorders are common in the United States and internationally.
An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a
diagnosable mental disorder in a given year.
When applied to the 2004 U.S. Census residential population estimate for ages 18 and older, this figure
translates to 57.7 million people.
Even though mental disorders are widespread in the population, the main burden of illness is concentrated
in a much smaller proportion — about 6 percent, or 1 in 17 — who suffer from a serious mental illness.
Projected lifetime risk for a mental disorder in US (by age 75) is 55%.
Study of the nature, development, and treatment of psychological disorders
Challenges to the study of psychopathology:
Avoid preconceived notions
Defining Mental Disorder
Emotional pain and suffering
Helplessness and hopelessness of depression
Impairment in a key area (e.g., work, relationships)
Chronic substance abuse results in job loss
Violation of Social Norms
Makes others uncomfortable or causes problems
E.g., checking behavior in anxiety, poor social skills in schizophrenia.
Wakefield's Harmful Dysfunction: failure of internal mechanisms in the mind to function properly
Breuer and Freud (18561939) jointly publishStudies in Hysteria ” in 1895, which serves as the basis
for Freud’s theory.
Freudian or Psychoanalytic theory Human behavior determined by unconscious forces.
Psychopathology results from conflicts among these unconscious forces.
Freud’s Structures of the Mind
Energy of ID
Attempt to satisfy ID’s demands within reality’s constraints
Develops as we incorporate parental and society values
Id, Ego, & Superego continually in conflict
Conflict generates anxiety
Ego generates strategies to protect itself from anxiety
Psychological maneuvers used to manage stress & anxiety
Goals of Psychoanalytic Therapy or Psychoanalysis
Understand earlychildhood experiences, particularly key (parental) relationships
Understand patterns in current relationships
Psychoanalytic Techniques Free Association
Analysis of Transference
Problems with Freudian Theory
Developmental model based on adults.
Model of normal development based on clinical samples.
Nonexperimental – based on clinical interview, observation, case studies.
Difficult to test elements of model.
Continuing Influences of Freud and His Followers
Childhood experiences help shape adult personality
There are unconscious influences on behavior
There are unconscious influences on behavior
The Evolution of Contemporary Thought: Rise of Behaviorism
John Watson (18781958)
Focus on observable behavior
Emphasis on learning rather than thinking or innate tendencies
Three types of learning:
Discovered by Pavlov (18491936)
Substance use (UCS) results in neurotransmitter alterations (UCR)
Environmental cues become associated with physiological responses to drug Environmental cues (CS) now elicit physiological mechanisms (CR) and trigger craving
UCS Trauma (combat exposure, injury)
UCR – Pain, Fear (cognitions, physiology)
Are paired with
Environmental stimuli (exteroceptive) that may all serve as future CS (sights, sounds, smells, etc.)
Internal states may also become CS (e.g., heart rate)
These CS now elicit CR of fear (cognitions, physiology)
Acquisition of Fear – Little Albert Study (Watson & Rayner, 1920)
White Rat + Loud noise (UCS) = Rat (CS)
E. Thorndike (18741949)
Learning through consequences
Law of Effect
Behavior that is followed by satisfying consequences will be repeated; behavior that is
followed by unpleasant consequences will be discouraged
B.F. Skinner (19041990)
Principle of Reinforcement
Behaviors followed by pleasant stimuli are strengthened
Behaviors that terminate a negative stimulus are strengthened
All behavior is learned
Humans are adaptive and behavior (all behavior) serves a purpose.
Look to environment to understand origins of behavior.
Must understand Antecedents (A) of Behavior (B) and Consequences (C).
What preceded a behavior and what followed? Parent is on phone (A) Child throws a tantrum (B) and
parent provides attention (C) or complies with child’s request (C). Parental response is reward and this
Learning by watching and imitating others’ behaviors Can occur without reinforcement to observer.
Classical conditioning can also occur.
Bandura & Menlove (1968)
Modeling reduced children’s fear of dogs
Bandura – modeling of violence.
Acquisition of fear through observation.
Behavior Therapy or Behavior Modification
Used to treat phobias and anxiety
Combines deep muscle relaxation and gradual exposure to the feared condition or object
Starts with minimal anxiety producing condition and gradually progresses to most feared
Rewarding a behavior only occasionally more effective than continuous schedules of reinforcement
Importance of Cognitions
Limitations of Behavior Therapy
How we think or appraise a situation influences our feelings and behaviors
Emphasize how people think about themselves and their experiences can be a major determinant of
Focus on understanding maladaptive thoughts
Change cognitions to change feelings and behaviors
REBT (RationalEmotive Behavior Therapy) Chapter 2: Current Paradigms in Psychopathology
I. The Genetic Paradigm
II. The Neuroscience Paradigm
III. The Cognitive Behavioral Paradigm
IV. Factors That Cut Across the Paradigms
V. DiathesisStress: An Integrative Paradigm
Notion of a Paradigm
Goal: Study abnormal behavior scientifically
Science aims for objectivity
Paradigm (Thomas Kuhn)
Perspective or conceptual framework from within which a scientist operates
We can never be totally objective; subjective factors interfere
No one paradigm sufficient to completely explain psychopathology
Current Paradigms: Genetic
Heredity plays a role in most behavior
Carriers of genetic information (DNA)
Impacted by environmental influences
e.g., stress, relationships, culture
Relationship between genes and environment is bidirectional
Nature via nurture (Ridley, 2003)
Important Genetic Terms
Proteins influence whether the action of a specific gene will occur
Multiple genes influence a trait or phenotype.
Heritability Chapter 2: Current Paradigms in Psychopathology
Extent to which variability in behavior is due to genetic factors
Heritability estimate ranges from 0.00 to 1.00
Group, rather than individual indicator
Pleiotropy: One Gene Can Affect Multiple Traits
The termpleiotropy is derived from the Greek worpleio, which means "many," an tropic, which
means "affecting." Genes that affect multiple, apparently unrelated, phenotypes are thus called pleiotropic
2013 genetic study involving over 60,000 individuals ( Lancet )
Identification of risk loci with shared effects on five major
psychiatric disorders: a genomewide analysis
CrossDisorder Group of the Psychiatric Genomics Consortium*
Aimed to identify specific variants underlying genetic effects shared between the five disorders:
autism spectrum disorder, attention deficithyperactivity disorder, bipolar disorder, major depressive
disorder, and schizophrenia.
Pathway analysis supported a role for calcium channel signaling genes for all five disorders. Variation in
calciumchannel activity genes seems to have pleiotropic effects on psychopathology.
De novo mutations
Increasing paternal, but not maternal, age related to risk for schizophrenia.
Events and experiences that family members have in common
Events and experiences that are unique to each family member
Study of the degree to which genes and environmental factors influence behavior
Genetic material inherited by an individual
Phenotype Chapter 2: Current Paradigms in Psychopathology
Expressed genetic material
Observable behavior and characteristics
Depends on interaction of genotype and environment
Identifies particular genes and their functions
Different forms of the same gene
Difference in DNA sequence on a gene occurring in a population
SNPs (Single Nucleotide Polymorphisms)
Identify differences in sequence of genes
CNVs (Copy Number Variations)
Identify differences in structure of genes; can be additions or deletions in DNA within
Removing specific genes in animals to observe effect on behavior
One’s response to a specific environmental event is influenced by genes
Study of how the environment can alter gene expression or function
Crossfostering adoptee method
Rats born to mothers with low parenting skills who were raised by mothers with high parenting skills
showed lower levels of stress reactivity (Francis et al., 1999)
Environment (mothering) was responsible for turning on (or turning up) the expression of a particular gene
Reciprocal GeneEnvironment Interaction
Genes predispose individuals to seek out situations that increase the likelihood of developing a disorder.
Adolescent girls with genetic vulnerability for depression more likely to experience events that can trigger
depression (Silberg et al., 1999)
Dependent life events influenced by genes (Kendler and Baker, 2007) Chapter 2: Current Paradigms in Psychopathology
Evocative effects: Genetically influenced behavior EVOKE responses from others, creating an
First Law : All human behavioral traits are heritable.
Second Law : The effect of being raised in the same family is smaller than the effect of genes.
Third Law . A substantial portion of the variation in complex human behavioral traits is not accounted for
by the effects of genes or families.
Nonshared environment and the Gloomy Prospect
After accounting for genes and shared environment, approx. 50% of differences in siblings is left
Unexplained portion of variance termed “nonshared environment”
So, (2nd Law) part of family environment thatshared by sibs does not matter.
What does matter is the individual environments of children, their peers, and aspects of parenting they do
What qualifies an environmental event as nonshared?
Objective : if experienced by only one sibling
Effective : if it makes siblings different rather than similar, regardless if experienced by one or both
Differences in environments should be measurable. True?
Turkheimer & Waldron (2000) reviewed 43 studies of measured differences in environments among
Upwards of 50% of the variance was defined as “nonshared”
Median percentage accounted for by objectively defined nonshared events is less than 2%.
Plomin & Daniels (1987): One gloomy prospect is that the salient environment might be unsystematic,
idiosyncratic, or serendipitous events such as accidents, illness or other traumas
Turkheimer: Nonshared environmental variability predominates b/c of unsystematic effects of all
environmental events, compounded by the equally unsystematic processes that expose us to environmental
events in the first place.
Thus, the field faces formidable challenges. Individual environmental events influence outcomes in a
Current Paradigms: Neuroscience
Examines the contribution of brain structure and function to psychopathology Chapter 2: Current Paradigms in Psychopathology
Mental disorders are linked to aberrant processes in the brain.
Three major components:
Neurons and neurotransmitters
Brain structure and function
The Neuron: Basic Unit of the Nervous System
Cells of the nervous system
Four major parts
Dendrites or cell body stimulated
Travels down axon to terminal
Gap between neurons
Chemicals that allow neurons to send a signal across the synapse to another neuron
Receptor sites on postsynaptic neuron absorb neurotransmitter
Reabsorption of leftover neurotransmitter by presynaptic neuron
Neurotransmitters and Psychopathology
Serotonin and Dopamine
Implicated in depression, mania, and schizophrenia
Implicated in anxiety and other stressrelated disorders Chapter 2: Current Paradigms in Psychopathology
GammaAminobutyric Acid (GABA)
Inhibits nerve impulses
Implicated in anxiety
Excessive or inadequate levels
Excessive number or sensitivity of postsynaptic receptors
Second Messengers help neurons adjust receptor sensitivity after periods of high activity
Agonist drugs stimulate neurotransmitter receptor sites
Antagonist drugs dampen neurotransmitter receptor sites
Brain Structure and Function
two cerebral hemispheres
connected by corpus collosum
sulci (fissures) define regions or lobes of the cerebrum (gray matter):
frontal (reasoning, problem solving, emotion regulation)
Brain Slice Through Medial Plan
white matter interior
Myelinated (sheathed) nerve fibers
Sensory relay station (except olfactory)
Pons and medulla oblongata
Responsible for balance, posture, equillibrium
Subcortical Structures of the Brain
Limbic System (outdated term):
Often implicated in psychopathology
Involved in the expression of emotions Chapter 2: Current Paradigms in Psychopathology
Amygdala is key brain structure for psychopathology researchers due to role in attending to emotionally
salient stimuli and in emotionally relevant memories
The HPA Axis of the Neuroendocrine System
HPA axis involved in stress
Hypothalamus triggers release of corticotropinreleasing hormone (CRF)
Pituitary gland releases adrenocorticotrpic hormone (ACTH)
Adrenal cortex triggers release of cortisol, the stress hormone
Takes 2040 minutes for cortisol to peak
Takes up to 1 hour for cortisol levels to return to baseline
Neuroscience Approaches to Treatment
Psychoactive drugs alter neurotransmitter activity
A neuroscience view does not preclude psychological interventions
Evaluating the Neuroscience Paradigm
Reductionism, “Localizationism”, the new “Phrenology”
View that behavior can best be understand by reducing it to its basic biological components
Ignores more complex views of behavior
Mental events are not the sort of thing that has a spatial location.
What we can do is localize in space a portion of the tissue that seems differentially associated with mental
Voodoo Correlations – many voxels, many correlations (circular reasoning).
Current Paradigms: Cognitive Behavioral
Roots in learning principles and cognitive science
Behavior is reinforced by consequences
Escape or avoidance
Sensory stimulation Chapter 2: Current Paradigms in Psychopathology
Access to desirable objects or events
To alter behavior, modify consequences
Relaxation plus exposure
Imaginal or in vivo
Important treatment for anxiety disorders
Behaviorism criticized for ignoring thoughts and emotions
A mental process that includes:
Perceiving, recognizing, conceiving, judging, and reasoning
Organized network of previously accumulated knowledge
We actively interpret new information
Role of attention in psychopathology
Anxious individuals more likely to attend to threat or danger
Role of the Unconscious
Contemporary theorists have attempted to study the unconscious scientifically
The unconscious may reflect efficient information processing rather than being a repository for troubling
Cognitive Behavior Therapy (CBT)
Attends to thoughts, perceptions, judgments, selfstatements, and unconscious assumptions
Change a pattern of thinking
Changes in thinking can change feelings, behaviors, and symptoms Chapter 2: Current Paradigms in Psychopathology
Beck’s Cognitive Therapy
Initially developed for depression
Depression caused by distorted thoughts
Nothing ever goes right for me!
Attention, interpretation, and recall of negative and positive information biased in depression
Help patients recognize and change maladaptive thought patterns
Evaluating the CBT Paradigm
Focus is on current determinants of disorder
Childhood and other historical antecedents given less attention
Are distorted thoughts tcause or theresult of psychopathology?
Causal status unclear
Current Paradigms: Factors That Cut Across the Paradigms
Affect vs. Mood
Most psychopathology includes disturbances of one or more component
e.g., flat affect in schizophrenia
What is your Ideal Affect?
Happiness vs. Calmness
Factors That Cut Across the Paradigms
Gender, race, culture, ethnicity, and socioeconomic status
May increase vulnerability to psychopathology
e.g., women more likely to experience depression than men Chapter 2: Current Paradigms in Psychopathology
Some disorders specific to certain cultures
in Japanese culture
Interpersonal Factors and Psychopathology
Object relations theory
Longstanding patterns of relating to others
Type and style of infant’s attachment to caregivers can influence later psychological functioning
Individuals will describe themselves differently depending upon which close relationships are told to think
Interpersonal Therapy (IPT)
Impact of current relationships on psychopathology
Unresolved grief; Role transitions; Role disputes; Social deficits
Current Paradigms: DiathesisStress
Integrative model that incorporates multiple causal factors
Genetic, neurobiological, psychological, and environmental
May be biological or psychological
Increases one’s risk of developing disorder
May occur at any point after conception
Psychopathology unlikely to result from one single factor Chapter 3: Diagnosis & Assessment 09/16/2013
I. Cornerstones of Diagnosis and Assessment
II. Classification and Diagnosis
III. Psychological Assessment
IV. Neurobiological Assessment
Diagnosis and Assessment
The classification of disorders by symptoms and signs.
Advantages of diagnosis:
Facilitates communication among professionals
Advances the search for causes and treatments
Cornerstone of clinical care
Consistency of measurement
Similarity of scores across repeated test administrations or observations
Similarity of scores on tests that are similar but not identical
Extent to which test items are related to one another
How well does a test measure what it is supposed to measure?
Extent to which a measure adequately samples the domain of interest, e.g., all of the symptoms of a
Criterion validity Chapter 3: Diagnosis & Assessment 09/16/2013
Extent to which a measure is associated with another measure (the criterion)
Two measures administered at the same point in time
Ability of the measure to predict another variable measured at some future point in time
Construct validity (Cronbach & Meehl, 1955)
A construct is an abstract concept or inferred attribute
Involves correlating multiple indirect measures of the attribute
1. e.g., selfreport of anxiety correlated with increased HR, shallow breathing, racing thoughts
Important for validating our theoretical understanding of psychopathology
Method for evaluating diagnostic categories
Classification and Diagnosis
Diagnostic and Statistical Manual
of Mental Disorders (DSM) published by American Psychiatric Association
First edition published in 1952
Current edition: DSMIV (5 edition, 2013)
A Short History of the DSM
The DSM1 (1952), 106 disorders across several major categories, reflecting a psychodynamic perspective
DSM II (1968), 182 disorders, similar framework as DSM1; like DSM1, it lacked specification of specific
symptoms of many disorders; distinguished among disorders at broader levels of neurosis, psychosis, and
DSMIII (1980) and DSMIIIR (1987), which focused on standardization of diagnostic categories by linking
them to specific criteria or symptom clusters, expressed in colloquial language; included 265 diagnoses in
DSMIII and 292 in DSMIIIR, which changed some of the diagnostic criteria
DSMIV (1994) and DSMIVTR (2000), 297 disorders, relatively minor changes
DSM5 (2013) 347 diagnoses
Diagnostic Criteria and Names Changed
Disorders added, criteria and names changed to better align with research.
Added, for example:
Mild neurocognitive disorder
Disruptive Mood Dysregulation Disorder (DMDD,
Premenstrual Dysphoric Disorder (PMDD) Chapter 3: Diagnosis & Assessment 09/16/2013
Binge Eating Disorder
Schizophrenia subtypes (e.g., Paranoid) removed.
ADHD revised to adapt criteria to adults.
Bereavement Exclusion removed from MDD
Attempts to ensure that MDD is not overlooked.
Substance Use Disorder
Combines old categories of abuse and dependence into single continuum rating
Autism Spectrum Disorder
Replaces Autistic Disorder, Asperger’s Disorder, Pervasive Developmental Disorder.
Areas for Further Study
Conditions that require further research:
Attenuated Psychosis Syndrome
Internet Gaming Disorder
Categorical Versus Dimensional Systems of Diagnosis
Presence/absence of a disorder
Either you are anxious or you are not anxious.
Rank on a continuous quantitative dimension
Degree to which a symptom is present
How anxious are you on a scale of 1 to 10?
Ethnic and Cultural Considerations
Different cultures and communities exhibit or explain symptoms in various ways.
Revised criteria to better apply across cultures.
For example, the criteria for social anxiety disorder now include the offending others ” to reflect
the Japanese concept in which avoiding harm to others is emphasized rather than harm to oneself.
Focus on influence of culture on disorder presentation
Criticisms of the DSM Chapter 3: Diagnosis & Assessment 09/16/2013
Too many diagnoses?
Should relatively common reactions be pathologized?
Presence of a second diagnosis
45% of people diagnosed with one disorder will meet criteria for a second disorder
Reliability in everyday practice
Extent to which clinicians agree on the diagnosis
Construct Validity of Diagnostic Categories
Construct validity of highest concern
Diagnoses are constructs
For most disorders, no lab test available to diagnose with certainty
Strong construct validity predicts wide range of characteristics
Possible etiological causes (past)
Clinical characteristics (current)
Predict treatment response (future)
Criticisms of Classification
Stigma against mental illness.
Treated differently by others
Difficulty finding a job
Categories do not capture the uniqueness of a person.
The disorder does not define the person.
She is an individual with schizophreninot a “schizophrenic
Classification may emphasize trivial similarities
Relevant information may be overlooked.
Techniques employed to: Chapter 3: Diagnosis & Assessment 09/16/2013
Describe client’s problem
Determine causes of problem
Arrive at a diagnosis
Develop a treatment strategy
Monitor treatment progress
Conducting valid research
Ideal assessment involves multiple measures and methods
Interviews, personality inventories, intelligence tests, etc.
Informal/less structured interviews
Interviewer attends thow questions are answered
Is response accompanied by appropriate emotion?
Does client fail to answer question?
Good rapport essential to earn trust
Empathy and accepting attitude necessary
Reliability lower than for structured interviews
All interviewers ask the same questions in a predetermined order
Structured Clinical Interview for Axis I of DSM (SCID)
Good interrater reliability for most diagnostic categories
Assessment of Stress
Subjective experience of distress in response to perceived environmental problems
Bedford College Life Events and Difficulties Schedule (LEDS)
Evaluates stressors within the context of each individual’s circumstances
SelfReport Stress Checklists
Faster way to assess stress Chapter 3: Diagnosis & Assessment 09/16/2013
Testretest reliability low
Selfreported Personality Inventories
Minnesota Multiphasic Personality Inventory (MMPI)
Yields profile of psychological functioning
Specific subscales to detect lying and faking “good” or “bad”
Rorshach Inkblot Test andThematic Apperception Test (TAT)
Responses to ambiguous stimuli reflect unconscious processes
Norming to allow comparisons with representative samples (e.g., how is sex or age related to typical
responses?) and determine deviation from typical functioning in appropriate comparison group.
Criteria Keying = how well does an item differentiate groups, or identify a clinical condition
Projective Testing Concerns
Questions regarding reliability.
Some procedures have been developed to improve but infrequently used in practice.
Questions concerning validity.
Despite empirical limitations, oddly remain popular in some clinical settings.
Capture “realistic” interaction (e.g., video family discussion)
Role play (simulate social interaction or necessary skill) Chapter 3: Diagnosis & Assessment 09/16/2013
Questions of external validity – evidence suggests useful and valid.
In vivo observation
e.g., school visit to observe child in classroom
Individuals observe and record their own behavior
e.g., moods, stressful events, thoughts, etc.
Concerns – accuracy due to memory, selfpresentation
Ecological Momentary Assessment (EMA)
Collection of data in real time using diaries or smart phones .
The act of observing one’s behavior may alter it
Desirable behaviors tend to increase whereas undesirable behaviors decrease.
But, evidence also suggests such assessment has validity.
Autonomic NS: Sympathetic and Parasympathetic
Sympathetic NS: Mobilizing resources, Fight or flight.
Study of bodily changes that accompany psychological characteristics or events
Heart rate measured by electrodes placed on chest
Electrodermal responding (skin conductance) Chapter 3: Diagnosis & Assessment 09/16/2013
Sweatgland activity measured by electrodes placed on hand
Brain’s electrical activity measured by electrodes placed on scalp
Brain Assessment: Function and Structure
EEG MEG fMRI
fMRI Activiation and Connectivity
MultiMethod Assessment Multiple Levels of Analysis
Constructs are often defined at multiple levels.
Emotion is action disposition involving
Cognition I am going to die ”)
Behavior (frowning, crying, stuttering)
Psychophysiology (sympathetic NS activation: heart rate, blood pressure, sweat)
Important to assess across domains
May give different inResponse desynchrony . Chapter 4: Research Methods 09/16/2013
Chapter 4: Research Methods in the Study of Psychopathology
I. Science and Scientific Methods
II. Approaches to Research on Psychopathology
III. Integrating the Findings of Multiple Studies
Science and Scientific Methods
Science = “to know”
The systematic pursuit of knowledge through observation
Scientists gather data to test theories
Set of propositions developed to explain what is observed
A good theory is falsifiable
Allows for disconfirmation
Specific predictions about what will occur if a theory is correct
Detailed biographical description of an individual
Educational and work background
Information about peer and romantic relationships
Personality and adjustment issues
Current difficulties and prior experiences in therapy
Rich description, especially helpful for rare disorders
Limitations Chapter 4: Research Methods 09/16/2013
Paradigm may influence observations
Cannot rule out alternative explanations
Cannot prove hypothesis
Do variable X and variable Y vary together?
Are they related in a systematic way?
Do people who experience more stress have more headaches?
Variables measured but not manipulated
Cannot determine cause or effect
Correlation Coefficientr. )
Varies from 1.0 to +1.0
e.g., 1.0, 0.65, 0.33, 0, +0.22, +0.70, +1.00
The higher the absolute value, the stronger the relationship
(0.9 > +0.6; +0.9 > .08)
Higher scores on Variable X associated withhigher scores on Variable Y
Higher scores on Variable X associated withlower scores on Variable Y
Statistical and Clinical Significance
Probability ≤ .05
Can be influenced by number of participants
Larger samples increase likelihood of significance
Clinical significance Chapter 4: Research Methods 09/16/2013
Is the association meaningful as well as statistically significant?
Problems of Causality
Correlation does not imply causality
Variable X may cause Variable Y
Variable Y may cause Variable X
Variable Z causesboth Variable Xand Variable Y
Longitudinal vs. Crosssectional Designs
Studies participants over time
Examines whether causes are present before disorder develops
Include only those who are at greatest likelihood of developing a disorder
Reduces the cost of longitudinal research
Causes and effects measured at the same time
Third variable may produce changes in two correlated variables
Study of the distribution of disorders in a population and possible correlates
Three features of a disorder
The National Comorbidity Survey–Replication Chapter 4: Research Methods 09/16/2013
Largescale national survey
Used structured interviews to collect information on the prevalence of several diagnoses (Kessler et al.,
Correlational Research: Behavioral Genetics
Methods to determine genetic predisposition (concordance) to psychopathology
Firstdegree relatives (parents, children, siblings)
50% shared genes
Seconddegree relatives (aunts, uncles, grandparents)
25% shared genes
Sample of individuals with psychopathology
Monozygotic (MZ) or identical twins
100% shared genes
Dizygotic (DZ) or fraternal twins
50% shared genes
Cooccurrence or similarity of diagnosis
Study of adoptees who havebiological parents with psychopathology
Study of adoptees who haveadoptive parents with psychopathology
Correlational Research: Molecular Genetics
Examine the relationship between a specific allele and a trait or behavior in the population Chapter 4: Research Methods 09/16/2013
Genomewide association studies (GWAS)
Examines the entire genome of a large group of people to identify variations between people
Provides information aboucausal relationships
Independent variable (manipulated variable)
Dependent variable (measured variable)
Can evaluate treatment effectiveness
Differences between groups
Basic Features of Experimental Design
The investigator manipulates an independent variable.
Participants are assigned to the conditions by random assignment.
Researcher measures a dependent variable that is expected to vary with conditions of the independent
Differences between conditions on the dependent variable
Extent to which experimental effect is due to independent variable
Participants who do not receive (active) treatment
Standard against which treatment effectiveness is judged
Extent to which results generalize beyond the study
Would results apply to others besides the study participants? Chapter 4: Research Methods 09/16/2013
Experimental Research: Treatment Outcomes
Research designed to answer the question: “Does treatment work?”
Empirically supported treatments
Exclusion of diverse populations
Efficacy and Effectiveness
Need for dissemination
Placebo: "a substance or procedure… that is objectively without specific activity for the condition being
Importance of Placebo or Treatment Comparison
Improvement in condition simply with passage of time.
Impact of assessment.
Nonspecific effects of therapy.
Experiments not always possible in psychopathology
Ethical or practical constraints
Examine related or similar behavior in the lab
Induce temporary symptoms
Recruit participants with similarities to diagnosable disorders
College students who tend to be anxious or depressed
Animal research Chapter 4: Research Methods 09/16/2013
Concerns about external validity.
To what degree does the experimental manipulation model the clinical phenomenon?
Analogue experiment as part of program of research to address questions of causality.
Basic research (animal models) à Human analogue studies à Clinical studies
SingleCase Experimental Research
Examine how individual participants respond to changes in the independent variable.
Reversal (ABAB) Design
The reversal technique not always possible
Initial state may not be recoverable
Integrating Findings from Multiple Studies
Identify relevant studies
Compute effect size
Transforms results to a common scale
Smith et al. (1980)
Metaanalyzed 475 outcome studies
Involved 25,000 subjects
Results: Psychotherapy is effective Chapter 5: 09/16/2013
DSM5 Criteria for Major Depressive Disorder
Sad mood OR loss of interest or pleasure (anhedonia)
Symptoms are present nearly every day, most of the day, for at least 2 weeks
PLUS four of the following symptoms:
Sleeping too much or too little
Psychomotor retardation or agitation
Poor appetite and weight loss, or increased appetite and weight gain
Loss of energy
Feelings of worthlessness or excessive guilt
Difficulty concentrating, thinking, or making decisions
Recurrent thoughts of death or suicide
Major Depressive Disorder (MDD)
Symptoms tend to dissipate over time
Once depression occurs, future episodes likely
Average number of episodes is 4
Sadness plus 3 other symptoms for 10 days
Significant impairments in functioning even though full diagnostic criteria are not met
Persistent Depressive Disorder (Dysthymia)
Chronic depressive disorder
Depressed mood for most of the day more than half of the time for at least 2 years (1 year for
PLUS 2 other symptoms:
Poor appetite or overeating
Sleeping too much or too little
Low energy Chapter 5: 09/16/2013
Trouble concentrating or making decisions
Feelings of hopelessness
Epidemiology and Consequences
Depression is common
Lifetime prevalence (Kessler et al., 2005)
Twice as common in women as in men
Three times as common among people in poverty
Prevalence varies across cultures
1.5% in Taiwan
19% in Beirut, Lebanon
People who move to the U.S. from Mexico have lower rates than people of Mexican descent who were born
in the United States
Etiology of Mood Disorders: Social Factors
4267% report a stressful life event in year prior to depression onset
e.g., romantic breakup, loss of job, death of loved one
Replicated in 12 studies across 6 countries (Brown & Harris, 1989b)
Lack of social support may be one reason a stressor triggers depression
High levels of expressed emotion by family member predicts relapse
Marital conflict also predicts depression
Behavior of depressed people often leads to rejection by others
Excessive reassurance seeking
Few positive facial expressions
Negative self disclosures Chapter 5: 09/16/2013
Slow speech and long silences
Lewinsohn: Depression reflects environmental and behavioral factors associated with:
1) impoverished reward
2) excess punishment.
Environment: Rewarding events may not be available (poverty) or skills may be lacking (ability to obtain
Stress and Depression
Life stress can be characterized by two dimensions:
events that are beyond one's control;
Ex. natural disasters, being in a plane crash, or the death of a loved one
occurs, at least in part, as a result of the individual's own actions.
Ex. financial, marital, or academic difficulties (although these examples could be independent stressors
under certain circumstances)
difficulties with family
Seligman (1974): Dogs exposed to inescapable shocks when same dogs are exposed to escapable shocks
they do not initiate escape responses or were slow and inept at escaping.
Seligman concluded that dogs learned that shock was uncontrollable learned that they were helpless to
avoid shock. Chapter 5: 09/16/2013
Etiology of Mood Disorders: Psychological Factors
Negative triad: negative view of self, world, future
Negative schema : underlying tendency to see the world negatively
Negative schema cause cognitive biases: tendency to process information in negative ways
Most important trigger of depression is hopelessness
Desirable outcomes will not occur
Person has no ability to change situation
Stable and Global attributions can cause hopelessness
A specific way of thinking: tendency to repetitively dwell on sad thoughts (NolenHoeksema, 1991)
Most detrimental is to brood over causes of events
The Social Brain
Social Baseline Theory
The human brain has evolved in a social context.
Baseline assumption of the human brain is access to social resources.
Social proximity and interaction decrease neural costs of responding to environmental demands (load
sharing and risk distribution ).
Being alone is, on average, more effortful.
Perception of Our World Is Influenced by Social Resources
Perception of physical challenges are shaped by:
weight of burden
hills are perceived as steeper. Chapter 5: 09/16/2013
Availability social support also alters perception of challenges – hill seen as less step with warm close
Social Support and Threat: Friends Shrink Foes
Men who were within visual and auditory proximity of their male friends estimated a prospective foe to be
less physically formidable than did men who were alone
Interpersonal and Depression
Those with a history of depression tend to experience higher levels of interpersonal life stress, even when
euthymic, than do those without a history of depression.
Stress causation theory:
the characteristics of the depressed person (symptoms of depression or other predictors of depression) are
thought to play a causal role in generating stress over time
Joiner: Selfpropagating & Erosive
Erosive: “scarring”, passive process where episode erodes personal and psychological resources
SelfPropagating: active behaviors performed by the person
Chronicity: episode duration, relapse (soon), strict recurrence (after symptomfree)
Joiner: Selfpropagating & Erosive
Depressionrelated, initiated, active behaviors
Serve to prolong or exacerbate symptoms or cause recurrence.
Interpersonal Dysfunction; Hammen et al. 2002
812 community women
Formerly Dep, Currently Dep, Never Dep
Less likely to be stably married
Poorer marital satisfaction
Problematic relationship with friends, kids, family
More stress with interpersonal/conflict content
Spouses and boyfriends had greater pathology Chapter 5: 09/16/2013
Depression runs in families
Increased risk to offspring when parent has depression.
Explain about 37% of variance in risk for MDD.
Norepinephrine, Serotonin, Dopamine
low levels = depression
high levels = mania
LEVEL of transmitters is not the whole story.
Tricyclic antidepressants block reuptake of norepinephrine and serotonin by presynaptic neuron thus
increasing their levels.
Monoamine oxidase inhibitors (MAOIs) block degradation of both norepinephrine and serotonin thus
increasing their levels.
Reserpine has side effect of causing depression found to decrease levels of both norepinephrine and
Etiology of Mood Disorders: Neurobiological Factors
Neurotransmitters (NTs): norepinephrine, dopamine, and serotonin
Original models focused on absolute levels of NTs
Low levels of norepinephrine, dopamine, and serotonin
High levels of norepinephrine and dopamine, low levels of serotonin
However, medication alters levels immediately, yet relief takes 23 weeks
New models focus on sensitivity of postsynaptic receptors
Dopamine receptors may be overly sensitive in BD but lack sensitivity in MDD
Depleting tryptophan, a precursor of serotonin, causes depressive symptoms in individuals with personal or
family history of depression Chapter 5: 09/16/2013
Individuals who are vulnerable to depression may have less sensitive serotonin receptors (Sobczak et al.,
5HTT x Environment
Caspi et al. (2003)
Serotonin Transporter (5HTT) Gene
Two alleles (long and short)
Short (s) associate with reduced efficiency of neural transmission in serotonin pathways.
Homozygosity for “s” allele of 5HTT gene associated with risk for depression when stress is experienced.
Lowered Reward Responsiveness in MDD
Probabilistic Reward Task
The ability to modulate behavior as a function of reward reinforcement history
Biological Treatment of Mood Disorders
Published studies may overestimate the effectiveness of medication (Turner et al., 2008)
STARD (Rush et al., 2006)
Attempted to evaluate effectiveness of antidepressants in realworld settings
3671 patients across 41 sites
Only 33% achieved full symptom relief with citalopram (the SSRI Celexa)
About 30% of nonresponders achieved remission with a different antidepressant
Research Comparing Treatments for Major Depressive Disorder
Combining psychotherapy and antidepressant medications increase odds of recovery over either alone by
Medications quicker, therapy longer lasting effects
Later studies (Hollon & DeRubeis, 2003)
CT as effective as medication for severe depression
CT more effective than medication at preventing relapse Chapter 6: Anxiety Disorders 09/16/2013
Anxiety vs. Fear
Apprehension about a future threat
Response to an immediate threat
Both involve physiological arousal
Sympathetic nervous system
Both can be adaptive
Fear triggers “fight or flight ”
May save life
Anxiety increases preparedness
“Ushaped” curve (Yerkes & Dodson, 1908)
Absence of anxiety interferes with performance
Moderate levels of anxiety improve performance
High levels of anxiety are detrimental to performance
Autonomic NS: Sympathetic and Parasympathetic
Sympathetic NS: Mobilizing resources, Fight or flight
DSM5 Anxiety Disorders
Social anxiety disorder
Generalized anxiety disorder Chapter 6: Anxiety Disorders 09/16/2013
Disruptive fear of a particular object or situation
Fear out of proportion to actual threat
Awareness that fear is excessive
Must be severe enough to cause distress or interfere with job or social life
Disproportionate fear of a particular object or situation
Common examples: fear of flying, snakes, heights, etc.
Fear out of proportion to actual threat
Awareness that fear is excessive
Most specific phobias cluster around a few feared objects and situations
High comorbidity of specific phobias
DSM5 Criteria for Specific Phobia
Marked and disproportionate fear consistently triggered by specific objects or situations
The object or situation is avoided or else endured with intense anxiety
Symptoms persist for at least 6 months
Note: The DSMIVTR criterion that the person recognizes that the fear is unrealistic is not included in DSM
DSMIVTR includes the duration criterion only for those under age 18
Social Anxiety Disorder
Causes more life disruption than other phobias
More intense and extensive than shyness
Persistent, intense fear and avoidance of social situations
Fear of negative evaluation or scrutiny
Exposure to trigger leads to anxiety about being humiliated or embarrassed socially
Onset often adolescence Chapter 6: Anxiety Disorders 09/16/2013
DSM5 Criteria for Social Anxiety Disorder
Marked and disproportionate fear consistently triggered by exposure to potential social scrutiny
Exposure to the trigger leads to intense anxiety about being evaluated negatively
Trigger situations are avoided or else endured with intense anxiety
Symptoms persist for at least 6 months.
Note: DSMIVTR labels this disorder as social phobia
The DSMIVTR, but not the DSM5, specifies that the person recognizes the fear is unrealistic
DSMIVTR includes the duration criterion only for those under age 18
DSM Panic Attack
The predominant complaint is a discrete period of intense fear or discomfort, in which at least four (or more)
of the following symptoms developed abruptly and reached a peak within 10 minutes.
1. Palpitations, pounding heart, or accelerated heart rate.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feeling of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, lightheaded, or faint.
9. Derealization (feelings of unreality) or depersonalization
(being detached from oneself).
10. Fear of losing control or going crazy.
11. Fear of dying.
12. Paresthesias (numbness or tingling sensations).
13. Chills or hot flushes.
Frequent panic attacks unrelated to specific situations
Panic attack Chapter 6: Anxiety Disorders 09/16/2013
Sudden, intense episode of apprehension, terror, feelings of impending doom
Intense urge to flee
Symptoms reach peak intensity within 10 minutes
Physical symptoms can include:
Labored breathing, heart palpitations, nausea, upset stomach, chest pain, feelings of choking and
smothering, dizziness, sweating, lightheadedness, chills, heat sensations, and trembling
Other symptoms may include:
Fears of going crazy, losing control, or dying
Occur unexpectedly without warning
Panic disorder diagnosis requires recurrent uncued attacks
Causes worry about future attacks
Triggered by specific situations (e.g., seeing a snake)
More likely a phobia
Proposed DSM5 Criteria for Panic Disorder
Recurrent uncued panic attacks
At least 1 month of concern about the possibility of more attacks, worry about the consequences of an
attack, or behavioral changes because of the attacks
From the Greek word “agora” or marketplace
Anxiety about inability to flee anxietyprovoking situations
E.g., crowds, stores, malls, churches, trains, bridges, tunnels, etc.
Causes significant impairment
In DSMIVTR, was a subtype of Panic Disorder
Al least half of agoraphobics do not suffer panic attacks Chapter 6: Anxiety Disorders 09/16/2013
DSM5 Criteria for Agoraphobia
Disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape
or receive help in the event of incapacitation or paniclike symptoms, such as:
Being outside of the home alone; traveling on public transportation; open spaces such as parking lots and
marketplaces; being in shops, theaters, or cinemas; standing in line or being in a crowd
These situations consistently provoke fear or anxiety
These situations are avoided, require the presence of a companion, or are endured with intense fear or
Symptoms last at least 6 months
Generalized Anxiety Disorder (GAD)
Involves chronic, excessive, uncontrollable worry
Lasts at least 6 months
Interferes with daily life
Often cannot decide on a solution or course of action
Restlessness, poor concentration, tiring easily, restlessness, irritability, muscle tension
Relationships, health, finances, daily hassles
Often begins in adolescence or earlier
I’ve always been this way
Proposed DSM5 Criteria for Generalized Anxiety Disorder
Excessive anxiety and worry at least 50 percent of days about at least two life domains (e.g.,
family, health, finances, work, and school)
The worry is sustained for at least 3 months
The anxiety and worry are associated with at least three of the following:
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
5. muscle tension
6. sleep disturbance Chapter 6: Anxiety Disorders 09/16/2013
The anxiety and worry are associated with marked avoidance of situations in which
negative outcomes could occur, marked time and effort preparing for situations that
might have a negative outcome, marked procrastination, difficulty making decisions due
to worries, or repeatedly seeking reassurance due to worries
Note: Italics reflect changes introduced in DSM5.
The DSMIVTR criterion that the person finds it hard to control the worry is not included in DSM5.
The DSMIVTR criteria specify duration of 6 months rather than 3 months.
DSMIVTR criteria specified that the anxiety was about a number of events or activities.
80% of those with anxiety disorder meet criteria for another anxiety disorder
Subthreshold symptoms (do not meet full DSM) very common
Causes of comorbidity
Symptoms used to diagnose the various anxiety disorders overlap:
Social anxiety and agoraphobia might both involve a fear of crowds
Etiological factors may increase risk for more than one anxiety disorder
75% of those with anxiety disorder meet criteria for another psychological disorder
Disorders commonly comorbid with anxiety:
60% with anxiety also have depression
Medical disorders, e.g. coronary heart disease
Gender and Sociocultural Factors
Women are twice as likely as men to have anxiety disorder
Women may be more likely to report symptoms
Men more likely to be encouraged to face fears
Women more likely to experience childhood sexual abuse
Women show more biological stress reactivity
Culturally specific syndromes
Taijin kyofusho Chapter 6: Anxiety Disorders 09/16/2013
Japanese fear of offending or embarrassing others
Inuit disorder in seal hunters at sea similar to panic
Ratio of somatic to psychological symptoms appears similar across cultures (Kirmayer, 2001)
Etiology of Specific Phobias
Mowrer’s twofactor model
Pairing of stimulus with aversive UCS leads to fear (Classical Conditioning)
Avoidance maintained though negative reinforcement (Operant Conditioning)
Etiology of Specific Phobias
Extensions of the twofactor model
Seeing another person harmed by the stimulus
Parent warning a child about a danger
Those with anxiety tend to acquire fear more readily
And to be more resistant to extinction
Etiology of Specific Phobia Behavioral/Learning Model
Not all individuals report trauma
Individuals with trauma NE anxiety disorder.
Nonrandom distribution of stimuli that are phobic.
Acquisition of fear through observation.
Etiology of Specific Phobia: Behavioral/Learning Model Chapter 6: Anxiety Disorders 09/16/2013
Life Experiences (before, during, after)
Prior positive experiences
Context – control during event
Postevent – trauma after exposure can increase fear of CS inflation effect ), information
Seligman (1971): Organisms may be physiologically predisposed, or biologically prepared, to be sensitive to
the conditioning of certain stimuli (and not others).
Ohman et al. (1985; 1986)
Fear conditioning with:
Fearrelevant stimuli (slides of snakes and spiders)
Fearirrelevant stimuli (slides of flowers and mushrooms)
Fear was conditioned more effectively with fearrelevant stimuli.
Responses conditioned to fearrelevant stimuli more resistant to extinction.
Twin studies suggest heritability
About 2040% for phobias, GAD, and PTSD
About 50% for panic disorder
Relative with phobia increases risk for other anxiety disorders in addition to phobia
Fear circuit overactivity
Medial prefrontal cortex deficits
Poor functioning of serotonin and GABA
Higher levels of norepinephrine Chapter 6: Anxiety Disorders 09/16/2013
Risk Factors: Cognitive
Sustained negative beliefs about future
Bad things will happen
Engage in safety behaviors
Belief that one lacks control over environment
More vulnerable to developing anxiety disorder
Childhood trauma or punitive parenting may foster beliefs
Serious life events can threaten sense of control
Attention to threat
Tendency to notice negative environmental cues
Selective attention to signs of threat
Etiology of Panic
Major source of norepinephrine
A trigger for nervous system activity
Classical conditioning of panic in response to internal bodily sensations
Catastrophic misinterpretations of somatic changes
Interpreted as impending doom
I must be having a heart attack!
Beliefs increase anxiety and arousal
Creates vicious cycle
Anxiety Sensitivity Index
High scores predict development of panic
“Unusual body sensations scare me.”
“When I notice that my heart is beating rapidly, I worry that I might have a heart attack.” Chapter 6: Anxiety Disorders 09/16/2013
Five processes that are involved in maladaptive responses
1. Inflated estimates of threat cost and probability
3. Deficient safety learning
4. Behavioral and cognitive avoidance
5. Heightened reactivity to threat uncertainty
Treatment of the Anxiety Disorders
Psychological treatments emphasize
Face the situation or object that triggers anxiety
Should include as many features of the trigger as possible
Should be conducted in as many settings as possible
Relaxation plus imaginal exposure
Increase belief in ability to cope with the anxiety trigger
Challenge expectations about negative outcomes
Psychological Treatment of Phobias
In vivo (reallife) exposure more effective than systematic desensitization
Social Anxiety Disorder
Role playing or small group interaction
Social skills training
Reduce use of safety behaviors
Cognitive therapy Chapter 6: Anxiety Disorders 09/16/2013
Clark’s (2003) cognitive therapy more effective than medication or exposure
Psychological Treatment of Panic
Panic Control Therapy (PCT; Craske & Barlow, 2001)
Exposure to somatic sensations associated with panic attack in a safe setting
Increased heart rate, rapid breathing, dizziness
Use of coping strategies to control symptoms
PCT benefits maintained after treatment ends
Psychological Treatment of GAD
Cognitive Behavioral methods
Challenge and modify negative thoughts
Increase ability to tolerate uncertainty
Worry only during “scheduled” times
Focus on present moment
Anxiolytics: drugs that reduce anxiety
Selective Serotonin Reuptake Inhibitors (SSRIs)
SerotoninNorepinephrine Reuptake Inhibitors (SNRIs)
Enhances learning during exposure treatment Chapter 6: Anxiety Disorders 09/16/2013
DCS+CBT for Social Anxiety; Hofmann et al. 2013
dCycloserineaugmented and placeboaugmented CBT were associated with similar completion rates
(87% and 82%), response rates (79.3% and 73.3%), and remission rates (34.5% and 24.4%) at the post
treatment assessment; response and remission rates were largely maintained at the followup
Although dcycloserine was associated with a 24%–33% faster rate of improvement in symptom severity
and remission rates relative to placebo during the treatment phase, the groups did not differ in response
and remission rates. Chapter 7: OCD & PTSD 09/16/2013
ObsessiveCompulsive and Related Disorders
ObsessiveCompulsive and Related Disorders
Obsessive Compulsive Disorder (OCD)
Repetitive thoughts and urges (obsessions)
Repetitive behaviors and mental acts (compulsions)
Body Dysmorphic Disorder
Repetitive thoughts and urges about personal appearance
Repetitive thoughts about possessions
ObsessiveCompulsive Disorder (OCD)
Intrusive, persistent, and uncontrollable thoughts or urges
Experienced as irrational
Contamination, sexual and aggressive impulses, body problems
Impulse to repeat certain behaviors or mental acts to avoid distress
e.g., cleaning, counting, touching, checking
Extremely difficult to resist the impulse
May involve elaborate behavioral rituals
Compulsive gambling, eating, etc. NOT considered compulsions, since pleasurable
DSM5 Criteria for ObsessiveCompulsive Disorder
Obsessions (recurrent, intrusive, persistunwanted thoughtsurges , or imagesthat the person
tries to ignore, suppress, or neutralize) or
Compulsions (repetitive behaviors or thoughts that a person feels compelled to perform to prevent distress
or a dreaded event othat a person feels driven to perform in response to an obsession )
The obsessions or compulsions are time consuming (e.g., require at least 1 hour per day) , or
cause clinically significant distress or impairment
Some Common Obsessions
Contamination Chapter 7: OCD & PTSD 09/16/2013
Ideas about germs and illnesses
Harm and Violence
Unwanted impulse to harm a loved one
Intrusive images of violent injuries
Religion and sex
Unwanted blasphemous thoughts and images
“Unacceptable” sexual thoughts
Perception that lack of symmetry = bad, wrong
Doubts about having discarded something important
Stove, door, car
Repeating routine actions
Praying, “cancelingout” bad thoughts
ObsessiveCompulsive Disorder (OCD)
Develops either before age 10 or during late adolescence/early adulthood
More common in women
1.5 times more common than in men
OCD often chronic
Only 20% complete recovery
75% have comorbid anxiety disorder
66% have major depression
33% have hoarding symptoms
Substance abuse is common Chapter 7: OCD & PTSD 09/16/2013
Etiology of ObsessiveCompulsive and Related Disorders: Neurobiological
Heritability estimates of 3050%.
Hyperactive regions of the brain:
Etiology of OCD: Behavioral and Cognitive Factors
Compulsions negatively reinforced by the reduction of anxiety
Lack of a satiety signal
Subjective feeling of knowing or completion
Knowing that you have thought enough or cleaned enough
Individuals with OCD have a yadasentience deficit
Attempts to suppress intrusive thoughts
Trying to suppress thoughts may make matters worse
Paradoxical Effect of Thought Suppression
Trying not to think about a thought leads to preoccupation of thought.
Beliefs à OCD Symptoms in nonclinical sample, N=5,015
PC = Perfectionism and Intolerance of Uncertainty
ICT = Importance and Control of Thoughts
RT = Inflated Responsibility
And Overestimation of Threat Chapter 7: OCD & PTSD 09/16/2013
Etiology of Hoarding Disorder
Adaptive to stockpile vital resources
Poor organizational abilities
Unusual beliefs about possessions
Treatment of the ObsessiveCompulsive and Related Disorders
SSRIs (Serotonin reuptake inhibitors)
Tricyclic antidepressants: Anafranil (clomipramine)
Exposure plus response prevention (ERP)
Not performing the ritual exposes the person to the full force of the anxiety provoked by the stimulus
The exposure results in the extinction of the conditioned response (the anxiety)
Challenge beliefs about anticipated consequences onot engaging in compulsions
Usually also involves exposure
Learning Theory View of OCD
Obsessions evoke anxiety/distress
Compulsions and avoidance behavior reduce obsessional distress
Compulsions and avoidance are negatively reinforced by the immediate reduction in distress they engender
Performance of compulsions and avoidance prevents the natural extinction of obsessional distress
Behavioral Therapy for OCD Includes:
Procedures that evoke obsessional anxiety
Exposure (e.g., floors, driving over bumps in the road)
Procedures that eliminate the contingency between performing compulsions and anxiety reduction
Response prevention (refrain from washing or checking rituals) Chapter 7: OCD & PTSD 09/16/2013
Cognitive Therapy for OCD Includes:
Intrusive unpleasant thoughts are universal
Modify mistaken beliefs about intrusive thoughts
Behavioral experiments to test out new beliefs about obsessional thoughts
Drop safety behaviors that prevent the correction of mistaken beliefs
CognitiveBehavioral Therapy (CBT) for OCD Includes:
Exposure in vivo:
Prolonged confrontation with anxiety evoking stimuli (e.g., contact with contamination
Prolonged imaginal confrontation with feared disasters (e.g., hitting a pedestrian while driving)
Refraining from rituals (e.g., leaving the kitchen without checking the stove)
Psychoeducation and discussions of mistaken cognitions
Efficacy of ERP: Controlled Trials
Randomized controlled trials indicate that ERP is more effective than the following:
Progressive muscle relaxation
Anxiety management training
Posttraumatic Stress Disorder (PTSD)
Extreme response to severe stressor
Anxiety, avoidance of stimuli associated with trauma, emotional numbing
Exposure to a traumatic event that involves actual or threatened death or injury Chapter 7: OCD & PTSD 09/16/2013
e.g., war, rape, natural disaster
Trauma leads to intense fear or helplessness
Symptoms present for more than a month
Women and PTSD
Rape most common type of trauma (Creamer et al., 2001)
Four categories of symptoms:
Intrusively reexperiencing the traumatic event
Nightmares, intrusive thoughts, or images
Avoidance of stimuli
e.g., refuse to walk on street where rape occurred
Other signs of mood and cognitive changes
Memory loss, negative thoughts and emotions, selfblame, blaming others, withdrawal
Increased arousal and reactivity
Irritability, aggressiveness, recklessness or selfdestructiveness, insomnia, difficulty concentrating,
hypervigilance, exaggerated startle response
Tends to be chronic
Higher risk of suicide and selfinjuries, illness
PTSD: DSMIVTR vs. DSM5
Experience of intense emotion at the time of the trauma is removed in DSM5
Definition of traumatic events is narrower
Exposure to media accounts does not qualify as trauma
Specific symptoms must begin after the trauma (difficulties in sleeping, concentrating, etc.)
DSM5 criteria require avoidance symptoms to be present for a diagnosis of PTSD
Numbing symptoms are considered along with the many other possible signs of changes in cognition and
Posttraumatic Stress Disorder
A. The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or
threatened sexual violence, as follows: (1 required)
B. The traumatic event is persistently reexperienced in the following way(s): (1 required)
C. Persistent effortful avoidance of distressing traumarelated stimuli after the event:(1 required)
D. Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2
required) Chapter 7: OCD & PTSD 09/16/2013
E. Traumarelated alterations in arousal and reactivity that began or worsened after the traumatic event: (2
More than 1 month duration.
Criterion A: stressor
The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or
threatened sexual violence, as follows: (1 required)
1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved
actual or threatened death, it must have been violent or accidental.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of
professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to
details of child abuse). This does not include indirect nonprofessional exposure through electronic
media, television, movies, or pictures.
Criterion B: intrusion symptoms
The traumatic event is persistently reexperienced in the following way(s): (1 required)
1. Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom
in repetitive play.
2. Traumatic nightmares. Note: Children may have frightening dreams without content related to the
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to
complete loss of consciousness. Note: Children may reenact the event in play.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to traumarelated stimuli.
Criterion C: avoidance
Persistent effortful avoidance of distressing traumarelated stimuli after the event:(1 required)
Traumarelated thoughts or feelings.
Traumarelated external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood
Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)
1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head
injury, alcohol or drugs). Chapter 7: OCD & PTSD 09/16/2013
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am
bad," "The world is completely dangerous.").
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting
4. Persistent negative traumarelated emotions (e.g., fear, horror, anger, guilt or shame).
5. Markedly diminished interest in (pretraumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity
Traumarelated alterations in arousal and reactivity that began or worsened after the traumatic event: (2
1. Irritable or aggressive behavior.
2. Selfdestructive or reckless behavior.
4. Exaggerated startle response.
5. Problems in concentration.
6. Sleep disturbance.
The National Comorbidity Survey Replication (NCSR),
Interviews of a nationally representative sample of 9,282 Americans aged 18 years and older.
Lifetime prevalence of PTSD among adult Americans to be 6.8%.
The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%.
The twelve month prevalence was 1.8% among men and 5.2% among women
Operation Enduring Freedom/ Operation Iraqi Freedom
Prevalence of PTSD among previously deployed Operation Enduring Freedom and Operation Iraqi
Freedom (Afghanistan and Iraq) service members. Among the 1,938 participants, the prevalence of current
PTSD was 13.8%.
Marital status and social support posttrauma may confer some protection (but PTSD may also erode
Prior trauma and life adversity my increase risk, sensitizing people to later trauma.
Prior clinical states such as depression or catastrophic thinking may increase risk.
Cognitions and reactions around trauma Chapter 7: OCD & PTSD 09/16/2013
Perceived life threat, fear of death, losing control
Peritraumatic emotional distress
Altered sense of time, “blanking out”, feeling disconnected. (measurement a challenge)
Trauma event itself
Trauma severity (more = greater risk)
Injury, combat, rape or molestation
Psychological Treatment of PTSD
Exposure to memories and reminders of the original trauma
Either direct (in vivo) or imaginal
Virtual eality (VR) effective
More effective than medication or supportive therapy
Treatment can be difficult at first
Possible increase in symptomatology
Enhance beliefs about coping abilities
Adding CT to exposure does not improve treatment response
Treatment of ASD may prevent PTSD
Shows benefits even 5 years after the traumatic event
Selective serotonin reuptake inhibitors (SSRIs) are the most typically prescribed pharmacological
Two such medications, sertraline and paroxetine, were approved by the Food and Drug Administration for
the treatment of this disorder. Chapter 8: Dissociative & Somatic Symptom Disorders
Some aspect of cognition or experience becomes inaccessible to consciousness
Sudden disruption in the continuity of:
Dissociation and Memory
How does memory work under stress?
Traumatic events are repressed
Extreme stress usually enhances rather than impairs memory
Interference memory formation
Not accessible to awareness later
Inability to recall important personal information
Usually about a traumatic experience
Not ordinary forgetting
Not due to physical injury
May last hours or years
Usually remits spontaneously
DSM5 Criteria for Dissociative Amnesia
Inability to remember important personal information, usually of a traumatic or stressful nature, that is too
extensive to be ordinary forgetfulness Chapter 8: Dissociative & Somatic Symptom Disorders
The amnesia is not explained by substances, or by other medical or psychological conditions
Specify dissociative fugue subtype if:
the amnesia includes inability to recall one’s past, confusion about identity, or
assumption of a new identity, and
sudden, unexpected travel away from home or work
Note: Changes from DSMIVTR are italicized
Memory Deficits and Dissociation
Memory deficits inexplicit but notimplicit memory
Involves conscious recall of experiences
e.g., senior prom, mom’s birthday party
Underlies behaviors based on experiences that cannot be consciously recalled
e.g., playing tennis, writing a check
Distinguishing other causes of memory loss from dissociation:
Memory fails slowly over time
Is not linked to stress
Accompanied by other cognitive deficits
Inability to learn new information
Memory loss after a brain injury
Perception of self is altered
Triggered by stress or traumatic event
No disturbance in memory
No psychosis or loss of memory
Often comorbid with anxiety, depression
Typical onset in adolescence Chapter 8: Dissociative & Somatic Symptom Disorders
Lose sense of self
Unusual sensory experiences
Limbs feel deformed or enlarged
Voice sounds different or distant
Feelings of detachment or disconnection
Watching self from outside
Floating above one’s body
World has become unreal
World appears strange, peculiar, foreign, dreamlike
Objects appear at times strangely diminished in size, at times flat
Incapable of experiencing emotions
Feeling as if they were dead, lifeless, mere automatons
DSM5 Criteria for Depersonalization/ Derealization Disorder
Depersonalization: Persistent or recurrent experiences of detachment from one’s mental processes or body,
as though one is in a dream, despite intact reality testing, or
Derealization: persistent or recurrent experiences of unreality of surroundings
Symptoms are not explained by substances, another dissociative disorder, another psychological disorder,
or by a medical condition
Note: Changes from DSMIVTR are italicized
Memory can be Fragile & Inventive
Studies on false memories and beliefs have compellingly shown that misleading information can lead to the
creation of recollections of entire events that have not occurred (Loftus, 2005).
Subjects have been led to believe that when they were children, they had been lost in the shopping mall for
an extended period of time before being reunited with their parents.
Subjects falsely remembered even more unusual or upsetting events, such as
spilling a punch bowl at a wedding (Hyman, Husband, & Billings, 1995),
having a ride in a hotair balloon (Wade, Garry, Read, & Lindsay, 2002),
or even having been hospitalized as a child ( Raymaekers , 2005 ). Chapter 8: Dissociative & Somatic Symptom Disorders
Participants given list of 4 events from childhood
3 provided by older relative,
1 was false story about getting lost.
"You, your mom, Tien and Tuan, all went to the Bremerton KMart. You must have been five years old at the
time. Your Mom gave each of you some money to get a blueberry ICEE. You ran ahead to get into the line
first, and somehow lost your way in the store. Tien found you crying to an elderly Chinese woman. You
three then went together to get an ICEE."
Interviewed about each memory
68% remembered and elaborated on true memory.
25% “remembered” false story and elaborated on story.
Even after debriefing some persisted in “recalling”: "..I totally remember walking around in those dressing
rooms and my mom not being in the section she said she'd be in. You know what I mean?".
False belief can have behavioral consequences
Participants given false feedback that they had “got sick after eating egg salad” as a child.
Evaluated for taste preference.
Evaluated for taste preference 4 months later.
Vulnerability to False Memory
Misinformation affects some people more than others.
Age = Younger children more susceptible.
The more one has selfreported lapses in memory and attention, the more susceptible one is to
Fantasy proneness or suggestability.
Where does misinformation come from?
Witnesses talk to each other.
Interrogation with leading questions or suggestive techniques.
Dissociative Identity Disorder (DID)
Two or more distinct and fully developed personalities (alters)
Each has unique modes of being, thinking, feeling, acting, memories, and relationships Chapter 8: Dissociative & Somatic Symptom Disorders
Primary alter may be unaware of existence of other alters
Most severe of dissociative disorders
Recovery may be less complete
Typical onset in childhood
Rarely diagnosed until adulthood
More common in women than men
Often comorbid with:
PTSD, major depression, somatic symptoms
Has no relation to schizophrenia
No thought disorders or behavioral disorganization
DSM5 Criteria Dissociative Identity Disorder (DID)
A. Disruption of identity characterized by two or more distinct personality states (alters)
or an experience of possession, as evidenced by discontinuities in sense of self,
cognition, behavior, affect, perceptions, and/or memories. This disruption may be
observed by others or reported by the patient
B. At least two of the alters recurrently take control of behavior
C. Inability of at least one of the alters to recall important personal information
D. Symptoms are not part of a broadly accepted cultural or religious practice , and are not
due to drugs or a medical condition
Dissociative Identity Disorder (DID)
No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006)
Major increases in rates since 1970s
Diagnostic criteria more explicit
Appearance of DID in popular culture
The Three Faces of Eve
Book and movie received much attention
Epidemiology of DID
Prevalence Chapter 8: Dissociative & Somatic Symptom Disorders
Rare but highly variable
1990’s prevalence = 0.4 to 1.3? (oddly high)
Other estimates = 1 in a million
Has increased media attention (1970’s books and movies) led to “inflated” estimates and invalid diagnosis?
Etiology of Dissociative Identity Disorder (DID): Two Major Theories
DID results from severe psychological and/or sexual abuse in childhood
DID a form of roleplay in suggestible individuals
Occurs in response to prompting by therapists or media
No conscious deception
“a syndrome that consists of rulegoverned and goaldirected experiences and displays of multiple role
enactments that have been created, legitimized, and maintained by social reinforcement” (Lilienfeld)
Evidence raised in theory debate
DID can be roleplayed
Hypnotized students prompted to reveal alters did so (Spanos, Weekes, & Bertrand, 1985)
DID patients show only partial implicit memory deficits
Alters “share” memories (Huntjen et al., 2003)
DID diagnosis differs by clinician
A few clinicians diagnose the majority of DID cases
For many, symptoms emerge after therapy begins
Treatment of Dissociative Identity Disorder (DID)
Most treatments involve:
Empathic and supportive therapist
Integration of alters into one fully functioning individual
Improvement of coping skills
Psychodynamic approach adds:
Use of hypnosis Chapter 8: Dissociative & Somatic Symptom Disorders
Can actually worsen symptoms
Somatic Symptom Disorders
Excessive concerns about physical symptoms or health
‘Soma’ means body
In DSMIVTR physical symptoms have no known physical cause
Nearly impossible to know actual cause
DSM5 removes requirement that symptoms not be medically caused
Three major somatic symptom disorders:
Complex somatic symptom disorder
Illness anxiety disorder
Functional neurological syndrome
Proposed DSM5 Criteria for Complex Somatic Symptom Disorder
At least one somatic symptom that is distressing or disrupts daily life
Excessive thoughts, feelings, and behaviors related to somatic symptom(s) or health concerns, as indicated
by at least two of the following: healthrelated anxiety, disproportionate concerns about the medical
seriousness of symptoms, and excessive time and energy devoted to health concerns
Duration of at least 6 months
Specify: predominant somatic complaints, predominant health anxiety, or predominant pain
Complex Somatic Symptom Disorder
DSMIVTR separates the diagnoses of Pain Disorder (in which the primary symptom involved pain) and
Somatization Disorder (which involves multiple somatic symptoms from various body systems)
DSM5 merges these two diagnoses into Complex Somatic Symptom Disorder
DSM5 places more emphasis on distress and behavior accompanying somatic symptoms, rather than the
number or range of somatic symptoms
Proposed DSM5 Criteria for Illness Anxiety Disorder
Preoccupation with andhigh level of anxiety about having or acquiring a serious disease
Excessive behaviors (e.g., checking for signs of illness, seeking reassurance) or
maladaptive avoidance (e.g., avoiding medical care or ill relatives)
No more than mild somatic symptoms are present
Not explained by other psychological disorders Chapter 8: Dissociative & Somatic Symptom Disorders
Preoccupation lasts at least 6 months
Note: Illness anxiety disorder is a new diagnosis in the DSM5, but it has some parallels with the DSMIV
TR diagnosis of hypochondriasis. Criteria that differ from the DSMIVTR diagnosis of hypochondriasis are
italicized. The DSMIVTR criteria for hypochondriasis specify that the preoccupation must continue despite
Functional Neurological Disorder
Conversion Disorder in DSMIVTR
Sensory or motor function impaired but no known neurological cause
Vision impairment or tunnel vision
Partial or complete paralysis of arms or legs
Seizures or coordination problems
Loss of smell
Functional Neurological Disorder
Believed disorder only occurred in women
Attributed it to a wandering uterus
Originally known as Hysteria
Greek word for uterus
Coined term conversion
Anxiety and conflicconverted into physical symptoms
Famous case of Anna O.
Proposed DSM5 Criteria for Functional Neurological Disorder
One or more neurologic symptoms affecting voluntary motor function, sensory functicognition, or
The physical signs or diagnostic findings are internally inconsistent or incongruent with
recognized neurological disorder
Symptoms cannot be explained by a medical condition
Symptoms cause significant distress or functional impairment or warrant medical evaluation Chapter 8: Dissociative & Somatic Symptom Disorders
Note : DSMIVTR criteria for Conversion Disorder specify that symptoms are related to conflict or stress
and are not intentionally produced
Functional Neurological Disorder
Onset typically adolescence or early adulthood
Often follows life stress
Prevalence less than 1%
More common in women than men
Often comorbid with:
Other Somatic symptom disorders
Major depressive disorder
Substance use disorders
Etiology of Somatic Symptoms Disorders: Neurological Factors
No support for genetic influence
Concordance rates in MZ twin pairs do not differ from DZ twin pairs
Why are some people more aware and distressed by bodily sensation?
Anterior insula and anterior cingulate hyperactive
Somatic symptoms influenced by emotions and stress
Etiology of Somatic Symptoms Disorders: Cognitive Behavioral Factors
Two important cognitive variables:
Attention to bodily sensations
Automatic focus on physical health cues
Attributions (interpretation) of those sensations
Overreact with overly negative interpretations
Two important consequences:
Sick role limits healthy life alternatives
Helpseeking behaviors reinforced by attention or sympathy
Etiology of Functional Neurological Disorders: Psychodynamic Perspective Chapter 8: Dissociative & Somatic Symptom Disorders
Unconscious psychological factor cause
Not consciously aware of visual input
Failure to be explicitly aware of sensory information