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PSY340H5 Final: Lecture Notes

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Hywel Morgan

1 ASSESSMENT AND DIAGNOSIS What is Abnormal Behaviour?  Statistical criteria o Gathering large amounts of data  Creating bell curve  Middle is 'normal'  Tails are 'abnormal' o Abnormal behaviour is behaviour that deviates 1 standard deviation from the mean  Standard deviation is subjective o Limited to behaviours that are most common o Disregards behaviours that are most favourable, includes unfavourable behaviours  Cultural norms o Behaviours differ from culture to culture, environment to environment o Some behaviours are so extreme that it is viewed as abnormal in most cultures (eg. Schizophrenia)  Developmental norms o Milestones- behaving in certain ways at certain ages o Certain ages come along with certain levels of cognitive development/function o What could be considered normal at the age of 5 would be considered abnormal at 50 o Different ages, different expectations o Fast development= positively viewed (+ vice versa)  Frequency, intensity, duration o Occurring all of the time (frequency) o There is a lot of it (intensity) o It occurs over a long period of time (duration) o It is dysfunctional (abnormal) o Eg. Drinking so much coffee that you cannot make it one day without drinking it Etiological Models of Abnormal Behaviour  Medical-disease/diathesis models: almost exclusively focuses on internal variables o Genetic models  Certain genes can make a person more susceptible to certain disorders  If someone close to you in your family has a psychopathology, you are 50% likely to develop the same disorder  Strongly suggests the genetic components to disorders o Biochemical models  Genetic component of disorders influences what neurotransmitter is produced/released  Biochemical models of almost every disorder have been created o Neurophysiological models  Theory that different parts of the brain have different functions which make them specialized o Psychoanalytic models  Freud- compartmentalization of behaviour  Believed that psychological illness was mental illness  Environmental models: almost exclusively focuses on external variables o Sociocultural models- group  Family 2  SES  Urban vs. rural  Affiliation  All influence normal and abnormal behaviour o Learning models- individualistic  Abnormal behaviour is viewed primarily as determined by learning  Environmental interaction shapes who you are based on what you've learned  Norms are learned and developed from others  Sometimes done through process of elimination  Behaviour modeled after others  Skinner- most influential in this field  Useful because it suggests straightforward treatment- relearn behaviour that is wrong  Problems with model  No consideration of internal processes  Views people as passive (product of environment) o Humanistic models- environmental  Comes from philosophy  You are born with the tools and skills you need- adapt skills to need  Stresses experience and reaction  No interest in unconscious cognitive functioning or how the behaviour was learned  Just assumes application is incorrect  Focus on individual as a whole  Can be intangible and abstract (major flaw) Assessment  Assessment must be made first, in order for a diagnosis to occur  An ongoing procedure  Assessment is usually sought out when someone asks you to go for treatment  Referral: doctor/psychologist/social worker/nurse can say 'this looks like a problem'- not a diagnosis but an acknowledgement of an issue being present  Clinical methods o Clinical observations  Therapist-client interaction  Observation of client's behaviour can give therapist insight as to how further treatment sessions will go  A lot of information can be gathered by someone who comes in for a formal assessment  Eg. Limps, grooming, attitudes, etc.  This is how most information is gathered from children (most children are nonverbal) o The interview  Asking of questions (verbally)  Expectation of a response  Questions regarding how you are thinking (cognition) and how you are feeling (emotion)  Structured vs. unstructured  Structured  Specific set of questions  Designed to cover all aspects of psychopathology  Extensive and thought to be exhaustive  Designed through research to be exhaustive 3  Specific responses are needed  Used to weed out other disorders  Rapport- poor in structured  Good because you get everything  Unstructured  Known why individual is coming to therapy  Informal discussion  "tell me about yourself"  Pursuing lines of questioning that are of interest to diagnosis/therapist  Conversation vs. bombardment of questions  Client engagement= really good for rapport  Non exhaustive so things can be missed  Both are used in combination o Psychological tests  Psychologists excel in this line of assessment  Thousands of psychological tests are devised every year  Only do testing and assessment, no treatment  Assessment is ongoing  Not great for rapport  There is a right and wrong answer to the questions  2 types of testing  Cognitive/intellectual tests  Right and wrong answers  Projective tests  Concrete thinking= inability to think abstractly  Allow for active interpretation  Eg. Rorschach Inkblot Test  Multiple answers/interpretations are allowed  Systems have been formatted to analyze interpretations  Exner system- encyclopedia for responses that could be given  Drawn scenarios can also be interpreted via story telling- eg. TAT (thematic apperception test)  Allows for projection onto drawing(s)  MMPA- Minnesota Multiphasic Personality Inventory  Standard- specific answers expected  List of questions  Determines if the truth is being told or not (malingering= not telling the truth) o Behavioural assessment  Going out into the field and assess behaviour  Interaction with others is observed  Can be done with and without client knowing observation is occurring Diagnosis  Most contentious issue in psychology- can be beneficial (appropriate treatment selected) or harmful (stigmatizing)  Introduction o English speaking language currently uses DSM o 7 versions of DSM: 1-3, 3 revised, 4, 4 text revised, 5 4 o DSM only had 2 categories (mental retardation and childhood schizophrenia) o DSM-IV has 12 categories and changed childhood schizophrenia to Autism o Categorical differences in child disorders is the biggest changes amongst DSM versions o ICD: International Classification of Diseases compatible with DSM  Reports on diseases need to be made using ICD codes (law)  For statistical purposes  Diagnosis can be made using DSM but needs to be reported in ICD code  What makes a good classification system? o Categories are clearly defined (symptom overlap can occur)  NOS= not otherwise specified (in DSM-IV but eliminated in DSM-5) o Categories exist- symptoms occur together regularly o System is reliable (produces same result over and over while being consistent over time and person)  Reliability of DSM exists but the diagnosis generally occurs in that particular place, in that particular time o System has validity (measures what it should o Clinical utility- does it have usefulness?  Clinically derived systems o DSM IV  Factor analysis o Which systems correlate with one another most strongly? o Finding similarities between variables  Advantages and disadvantages of diagnosis LEGAL VS. ETHICAL ISSUES Legal Issues  People in social conflict o Ex. If someone wants to hurt another, it's a legal issue but things like suicide are not a legal issue- ethical gray area  If you are aware of someone's suicidal ideations, it is your ethical (not legal) obligation to stop it  Knowing someone wants to murder another is both an ethical and legal issue  Power of mental health professionals o Commitment- mental health professionals have the power of custody if you are suffering from suicidal ideation or homicidal thoughts o Can last indefinitely Canadian Legal System  Constitutional law- federal government (1982) o You have the right to be taken care of by all Canadians o If you are unable to take care of yourself, we other Canadians will take care of you  Statutory law o How the constitutional law is interpreted o Interpretations between provinces and territories may differ o Eg. Different provinces have different committal days, in Ontario, you cannot be forced into treatment, Where in Quebec you can be forced  Common law o Universal throughout North America except in Quebec (follow civil law in that province) o If a judge/jury claims "it's that" that's what will be (precedent)- judge and jury need to come to the same conclusion 5 o Consists of judge and jury assessing statutory law interpretation of constitutional law o Parens patrie- responsibility and authority to care  Responsibility to yourself, others and those suffering o Involuntary commitment- both civil and criminal  Rules in Ontario for civil commitment  Must be suffering from a mental disorder  Unwilling/incapable of consent  Be at risk of harming self or others  Tarasoff case- Regents v. Tarasoff (1976)  Created law stating that the risk to others must be disclosed to authorities and potential victim must be informed (duty to warn) o Requires you to report self abuse or harming another person  Privilege: doctors, psychologists and clergies have the duty under law not to bring harm to their client Psychologist's Environment (ethics)  Clinical  Research  Teaching ANXIETY DISORDERS What is Anxiety?  An unpleasant emotional state ranging from mild unease to intense fear  A certain amount of anxiety, however, is normal and serves to improve performance o Motivates you to complete the task o Eg. Test anxiety motivates you to study  Anxiety arouses you to action- it gears you up to face a threatening situation o It makes you study harder for that exam o Keeps you on your toes when making a speech o In general, it helps you cope  Different from fear o Fear or panic is a basic emotion that involves activation of the "fight-or-flight" response (to direct threat- eg. Riding a roller coaster)  Physiological responses are very similar  Most mammals pick flight  Some pick flight or freeze o Anxiety is a general feeling of apprehension about possible danger (feeling threatened- direct or indirect)  Low levels can be adaptive  Maladaptive anxiety o High levels diffuse negative emotion  Frequency  Intensity  Duration o Sense of uncontrollability o Shift in attention to state of self-preoccupation Symptoms  Excessive worry o Uncontrollable sequence of negative thoughts of danger 6 o Pathological worry  High quantity and negative, unrealistic content o Causes impairment and marked distress o Inability to cope  Epidemiology o Gender- higher prevalence in females  Women withdraw socially when anxious/depressed  Men get angry/aggressive when sad o Age- lower prevalence in the elderly o Cross cultural studies  Similar prevalence  Different symptom patterns  Etiology o Social factors  Stressful (dangerous) life events  #1 most important cause of psychopathology= death of someone close to you  #2= divorce  Good things like marriage, birth, etc. can cause psychopathology  Cumulative stress can also lead to ADs  Childhood abuse/neglect  Insecure attachment o Biological factors  Strong genetic component  Family and twin studies  Two genetic factors identified  GAD/major depression  Panic disorder/phobias  Neuroanatomy  Thalamus-amygdala circuit  Too much stress causes too much amygdala activation  GABA (anxiety medications inhibit GABA function)  OCD- caudate nucleus/orbital prefrontal cortex/anterior cingulate cortex  Prefrontal lobe= produces anxiety  Amygdala= reads anxiety DSM-V  Generalized Anxiety Disorder (most common) o Chronic high level of anxiety with no threat whatsoever o Intense anxiety that lasts over a long time and doesn't go away (really hard to treat since it doesn’t go away) o Most commonly used one is Adivan o Issue with medication is that they are extremely addictive and easily adapted to  Phobias o Fear of something that no fear should occur from o Irrational fear o Persistent and irrational fear of an object or situation that presents no realistic threat  Panic Attack/Panic Disorder o Doesn’t involve frequency or duration as much as intensity o Requires large amounts of intensity o Large amounts of onset anxiety to the point where it is believed that one is dying of a heart attack o Viewed that the anxiety is unable to be controlled 7 o Characterized by overwhelming amounts of anxiety that occurs suddenly and unexpectedly o Extreme form of panic attack= depersonalization o Tend to be recurrent Agoraphobia o Fear of going out into public o Comorbid with panic disorders o Common disorder where people have the fear of being with people/being in public o When forced to interact with other- panic attack occurs o Fear of public places and usually a complication with panic disorders Specific Phobias o Eg. Fear of snakes, fear of spiders, etc. Social Anxiety Disorder o Was not on DSM-IV o Fear of social situations, not only interactions with people Hoarding (on DSM-V) o Fear of letting go of objects, regardless of their use or value OCD, PTSD and ASD are no longer under anxiety disorders (still in DSM-V)  OCD o The need to complete ritualistic and repetitive behaviours o Obsessive- have to o Compulsive- ritual o If behaviours aren't performed, extreme anxiety begins o Persistent, uncontrollable intrusions of unwanted thoughts and urges to engage in senseless rituals  PTSD o Anxiety felt around things you shouldn’t o Anxiety is a result of trauma o Leading cause of trauma in society is sexual assault (more common than war)- 1/3 chance of being assaulted  ASD o Anxiety not otherwise specified Different Components Cognitive o Most common and measurable component o Measures for anxiety use cognition  Can be found by asking questions  Scale of 1-10, how anxious do you feel? (Likert Scale)  1=problem, 10=problem  Problem= subjectivity Physiological (somatic) o Measurement of the level of arousal o Eg. Pupil dilation, amount of sweat, heart rate, etc. o Extreme anxiety comes with a lot of physiological arousal o Body is aroused but unsure if anxious or happy Behavioural o Eg. Anxious face, nervous laugh o Very subjective even though visual Panic Attack At least 4 of 13 symptoms 1. Palpitations 8 2. Sweating 3. Trembling/shaking 4. Shortness of breath/smothering 5. Feelings of choking 6. Chest pain/discomfort 7. Nausea 8. Feeling dizzy/light-headed 9. Depersonalization or derealization 10. Fear of losing control/going crazy 11. Fear of dying 12. Tingling/numbness of extremities 13. Chills/hot flashes  Cognitive o "I'm having a heart attack"  Behavioural o Avoidance of places where the person had anxiety symptoms in the past (eg. A certain grocery store) or similar places (eg. All grocery stores) o Avoidance of travel, malls, line-ups o Avoidance of strenuous activities (eg. Exercise)  Panic disorders o Recurrent, unexpected panic attacks o Persistent concern about additional attacks for one month with our without agoraphobia  Most individuals with panic disorders develop agoraphobia Obsessions and Compulsions  Obsessions o Repetitive thoughts, images, impulses o Person realizes their unreasonable nature (not delusional) o Themes of sex, violence, contamination  Compulsions o Behavioural responses to obsessions ("tension reduction") o Rituals (eg. Hand-washing, checking) o Mental acts (counting) Specific Phobias  Persistent, excessive, unrealistic fear of specific objects/situations  Unrealistic (without awareness)  Significant life impairments  Avoidance behaviour Social Phobia  Fear of social situations o Performance anxiety o Interpersonal interactions  Rooted in fear of negative evaluations o Use the cognitive component of anxiety to assess  Agoraphobia: o Fear of public spaces o Can accompany panic disorder Generalized Anxiety Disorder  Excessive, uncontrollable worry  Majority of days for at least 6 months  Affective, cognitive, and somatic symptoms 9  Brain alters the body's physiological by activating the ANS  ANS function: innervates the viscera (smooth muscles), heart, blood vessels, sweat glands, etc. o Also controls "vegetative" functions, homeostasis  Amygdala o Plays central role in anxiety disorders o Part of the limbic system that warns us of danger o "fight-flight-freeze" response o Central= sensing anxiety o Lateral= eliminating anxiety  Hippocampus o Also part of limbic system that encodes information o Anxiety/phobias are generated by memories of painful experiences MOOD DISORDERS Unipolar Disorder (Depression)  Too much sad (intensity is more important than duration)  Anhedonia= cognitive component  Discontinuation of daily functions= physiological component  Major Depression o Fairly common disorder (about as common as Anxiety disorders- frequently occur together) o 1 in 5 people will suffer from MDD at some point in their lives o Eventually goes away (treatment helps it go away faster)  Likely to come back- with or without the help of triggers o Research shows that student-aged people have the highest rates for developing MDD o Most effectively treated with CBT (talking through the rationality of thoughts)  Coupled with pharmacotherapy (SSRIs- serotonin, other medications for dopamine and norepinephrine)  Work for most people but not all  Antidepressants work best coupled with CBT o Psychotherapy has also been used to treat MDD but has been fazed out o A lot of people who have depression believe it is a physical illness (and not depression)  Not uncommon for physical illness to couple depression  Most people see their doctor and don't seek therapeutic help either at all or much later o Psychiatry= medication, drugs o Psychology= therapy o Suicide is sometimes a symptom of depression  People who are depressed are not always suicidal  People who commit suicide are not always depressed  Dysthymic Disorder o Extremely difficult to treat (CBT/pharmacotherapy don’t work) o Doesn't go away o Refers to the people who are pessimistic all the time o Typically not as intense as MDD  Double Depression (bad) o Both MDD and Dysthymic Disorder o Dysthymic Disorder with intermittent bouts of MDD o Hard to treat 10 o Some people can be treated with anti-depressants but research shows they're no better than the placebo affect o Drugs and CBT work better together than alone  Melancholia o Personality trait o Not as severe as MDD of Dysthymic Disorder o Consistent periods of not feeling good (both psychological and physical) o Intermittent o Not considered psychopathological (not in DSM)  Will still be treated by professional  Treatments o Antidepressants take an average of 14 days to kick in, sometimes 1 month  Why is unclear o ECT (Electro-Convulsive Shock Therapy) only used when CBT does not work  For people who are severely depressed  People often exhibit psychosis  Sometimes takes as many as 6-12 sessions  Unknown what mechanism drives ECT  How it changes the brain is unknown but it does seem to trigger a 'reset' switch  Invasive- how it works is unknown + involves inducing a seizure in patients Bipolar Disorder  Too much sadness that alternates with too much euphoria o Periods of normality exist between peaks of euphoria and valleys of depression o More sadness exists in cycle (often gets misdiagnosed for depression)  Antidepressants do not work for bipolar disorder o Some people do react well o Major drug treatment for most people is Lithium  Unclear which neurotransmitters are involved with Bipolar Disorder  Accidentally found that Lithium helps as a treatment  Swings between mania and depression tend to be regular (can be predicted when switch will occur)  Those who change often are called 'rapid cyclers' (not common)- looks like Schizophrenia  Manic Depression (old name for Bipolar Disorder) o Named after the depressive states of Bipolar Disorder o Now referred to as Bipolar Disorder I  Hypomania (cyclothymic disorder) o Now referred to as Bipolar Disorder II o Harder to treat o Less severe o Hypomania is to manic depression as dysthymic disorder is to depression  Extremely uncommon to have the mania without the depression (could be misdiagnosed as a substance abuse disorder) Epidemiology  Depression is more common in women than men o As high as 20% of the population will have depression in their life time  Manic depression occurs equally in both men and women o Much less common than MDD  Hypomania occurs in 1 of every 100 people o Looks the same as depression (could lead to misdiagnosis)  If you have a family member who is depressed, it is very highly likely that you will as well 11 o Genetic component to depression o Similar to Schizophrenia o If you are a twin, your chances of developing MDD or bipolar disorder is approximately 80% SOMATOFORM AND DISSOCIATIVE DISORDERS  Psychologists suggest a misinterpretation of incoming sensory information  Looks like psychosis but is not  Still in touch with reality Somatoform Disorders  Very similar to one another with slightly different symptoms  Appear to be genuine physical illness but have no physical connections to prove reality o "it's all in your head"  Caused by psychological factors o Especially emotional stress  Disorders that cannot be explained by an organic condition  Symptoms o Suggest physical disorder o Cannot be explained physiologically o Often (but not always) described in dramatic ways o Other disorders, such as anxiety disorders, mood disorders, and personality disorders, often co-exist Somatization and Conversion  Marked by a history of diverse physical complaints  Typical #1 complaint is pain  Somatization disorder is seen more often in women than men o Previous thoughts were that it didn't occur in men o Used to be called hysteria (wandering uterus)  Conversion disorder- significant loss of physical function with no apparent organic basis, usually in a single- organ system o Eg. Inability to see  Somatization disorder (Briquet's Disorder) o Many physical complaints o Beginning before age 30 o Must include  4 different pains  2 gastrointestinal symptoms  1 sexual symptom  1 pseudoneurological symptom o Symptoms are unfounded or exaggerated  Conversion disorder o Physical symptoms suggesting neurological problems  Sensory impairment in any modality  Paresthesias and paralysis o Sudden onset, sudden termination, sudden reappearance o Mostly wom
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