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Before advances in scientific discovery, all good/bad manifestations of power beyond human control
were regarded as supernatural
It was thought that disturbed behaviour reflected the displeasure of the gods or possession by
demons
Demonology = the doctrine that an evil being or spirit can dwell within a person and control his/her
mind and body
Exorcism = the ritualistic casting out of evil spirits
o Rites of prayer, noisemaking, forcing the afflicted to drink terrible-tasting brews, flogging,
starvation
Early Biological Explanations
Hippocrates (father of modern medicine) separated medicine from religion, magic and superstition
Insisted that illness had natural causes and should be treated like other more common maladies
Regarded the brain as the organ of consciousness, intellectual life, and emotion
Disordered thinking/behaviour indicate brain pathology
3 categories of psychological disorders: mania, melancholia, and phrentis (brain fever)
Mental health depends on a balance among 4 humors (fluids of the body)
o Blood, black bile, yellow bile, and phlegm *imbalance produces disorders
Predominance of phlegm = sluggish/dull, black bile = melancholia, yellow bile =
irritability/anxiousness, blood = changeable temperament
The Dark Ages and Demonology
Death of Galen said to be the start of the Dark Ages in western European medicine
Monks in the monasteries cared for and nursed the sick (prayed, touched w/relics, potions)
The Persecution of Witches:
o 13th century, recurrent famines and plagues *demonological explanations for disasters
o Witchcraft (instigated by Satan) viewed as heresy and a denial of God
o Torture sometimes led to bizarre delusional sounding confessions
o Pope Innocent VIII mandated witch hunts
o Burning used as method of driving out the demon
o Turns out more healthy individuals than mentally ill individuals were tried and/or prosecuted
as witches
Lunacy Trials:
o Municipal authorities took over some activities of the church, one being care of mentally ill
o 1 purpose of the hospital: mad are kept safe until they are restored of reason
Not described as being possessed
o Trials conducted under the Crown’s right to protect the people with psychological disorders
Trials were to determine a person’s mental health/sanity (13th century, England)
Judgment of insanity allowed the Crown to become guardian of the lunatic’s estate
o Strange behaviour was attributed to physical illness/injury, or emotional shock
o “Lunacy” comes from Swiss physician, attributed odd behaviour to misalignment of the moon
and stars
Development of Asylums
Very few hospitals for people with psychological disorders until the 15th century
Many hospitals for people with leprosy
o As leprosy disappeared, these buildings were no longer used, converted to asylums
Asylums = establishments for the confinement and care of mentally ill
Bethlehem and Other Early Asylums:
o Priory of St. Mary and Bethlehem founded in 1243 *one of first mental institutions
o 1547 Henry VIII devoted the hospital to confinement of people with psychological disorders
o Became a tourist attraction *bought tickets to enter
o Origin of term bedlam (wild uproar or confusion)
o Similar to the Lunatics Tower in Vienna
o Medical treatments were crude and painful
o Benjamin Rush (father of American psychiatry) – believed psyc disorders were caused by
excess blood in the brain, would treat by drawing large quantities of blood from disordered
individuals
Believed he could cure people by frightening them *convince them death is near
Pinel’s Reforms:
o Figure for more humane treatment of people with psychological disorders in asylums
o Pinel was thought to have removed the confining chains worn by patients at La Bicetre
Was really a former patient (Jean-Baptiste Pussin), became an orderly
o Pinel believed that if reason had left a patient because of severe social/personal problems, it
might be restored through comforting counsel and purposeful activity
Moral Treatment:
o Friend’s Asylum (1817 Pennsylvania), Hartford Retreat (1824 Connecticut)
o Mental treatment = people had close contact with attendants, who talked and read to them
and encouraged them to engage in purposeful activity
o Residents lead lives as close to normal as possible
o Engage in purposeful, calming activities (e.g. gardening)
o Talked with attendants
o In general, took responsibility for themselves
o Dorthea Dix – crusader for improved conditions for people with psychological disorders
Campaigned to improve the lives of people with psychological disorders
Efforts lead to 32 public hospitals being built
Staff unable to provide individual attention, ran by physicians not interested in
psychological well-being, only interested in biological aspects of illness
The Evolution of Contemporary Thought
Biological Approaches
Biological Origins in General Paresis and Syphilis:
o By mid 1800s, partially understood anatomy and workings of the nervous system
o Not enough to know if structural brain abnormalities that cause psychological disorders were
present
o Many people with psyc disorders had a syndrome of steady deterioration of mental and
physical abilities and progressive paralysis = general paresis
= Degenerative disorder with psyc symptoms (delusions of grandeur) & physical
symptoms (progressive paralysis)
Established that some people with general paresis also had syphilis
o Louis Pasteur – germ theory of disease = disease is caused by infection of the body by
minute organisms
Demonstrated relation between syphilis and general paresis
Causal link established between infection, damage to certain areas of the brain, and a
form of psychopathology (paresis)
Genetics:
o Galton – originator of genetic research with twins, attributed many behavioural
characteristics to heredity
o Psyche = the mind, divided into 3 principle parts: id, ego and superego
o Id = present at birth, repository of all energy needed to run the psyche, includes basic urges
*aka limbic system
Libido = biological source of the id’s energy (unconscious)
Id seeks immediate gratification = pleasure principle (tension is produced if not
satisfied)
o Ego = begins to develop from the id during the second 6 months of life, conscious, deals with
reality
Operates on the reality principle = mediates between the demands of reality and the
id’s demands for immediate gratification
o Superego = a person’s conscience, develops throughout childhood, arising from the ego
Incorporate parental values as their own
Ego and Superego aka frontal lobe
Defense Mechanisms:
o Discomforts experienced by the ego as it attempts to resolve conflicts and satisfy demands of
the id and superego can be reduced in several ways
o Defense mechanism = a strategy used by the ego to protect itself from anxiety (repression,
denial, projection, regression, rationalization)
Psychoanalytic Therapy:
o Goal of the therapist is to understand the person’s early-childhood experiences, the nature of
key relationships, and the patterns in current relationships
o Therapist listens for core emotional and relationship themes that surface again and again
o Free association = a person reclines on a couch, facing away from the analyst, and is
encouraged to give free rein to his or her thoughts, verbalizing whatever comes to mind,
without censoring anything
o Transference = the person’s responses to his/her analyst that seem to reflect attitudes and
ways of behaving toward important people in the person’s past
Analyst could gain insight into childhood origins of a person’s repressed conflicts
o Interpretation = the analyst points out to the patient the meanings of certain of a person’s
behaviour
Defense mechanisms are a principle focus
Jung and Analytical Psychology:
o Collective unconscious = part of the unconscious that s common to all human beings and
that consists primarily of archetypes = basic categories that all human beings use in
conceptualizing about the world
o Each of us has masculine and feminine traits that are blended
o People’s spiritual and religious urges are as basic as the id urges
o Extraversion vs. introversion
Adler and Individual Psychology:
o Individual psychology = regarded people as inextricably tied to their society, fulfillment is
found in doing things for the social good
o Stressed the importance of working toward goals
o Focus on helping people change their illogical and mistaken ideas and expectations
o Feeling and behaving better depend on thinking more rationally (lead to CBT)
Continuing Influences of Freud and His Followers:
o - Freud conducted no formal research on causes/treatments of psychological disorders
o - Based on anecdotal evidence, not grounded in objectivity
o 1) Childhood experiences help shape adult personality (don’t focus on his psychosexual
stages as much)
o 2) There are unconscious influences on behaviour *people can be unaware of the cause of
their behaviour
o 3) The causes and purposes of human behaviour are not always obvious
The Rise of Behaviourism:
o Dissatisfaction in Freud’s theories bright to a head by John Watson
o Behaviourism = focuses on observable behaviour rather than on consciousness or mental
functioning
o Focus shifted from thinking to learning
o 1) Classical Conditioning:
Ivan Pavlov
Unconditioned stimulus = automatically elicits a response without prior learning
Unconditioned response = response elicited by UCS
Conditioned stimulus = previously neutral stimulus that elicits a conditioned response
after multiple pairings with UCS
Conditioned response = response elicited by CS
Extinction = CR gradually disappears if the CS is no longer followed by the UCS
John Watson and Little Albert
o 2) Operant Conditioning:
Thorndike studied the effects of consequences on behaviour
Law of effect = behaviour that is followed by consequences satisfying to the organism
will be repeated, and behaviour followed by unpleasant consequences will be
discouraged
Skinner – operant conditioning “Principle of reinforcement”
Positive reinforcement = strengthening of a tendency to respond by virtue of the
presentation of a pleasant event called a positive reinforcer
Negative reinforcement = strengthens a response but does so with the removal of an
aversive event
Operant conditioning principles may contribute to persistence of aggressive
behaviour of conduct disorder
o 3) Modeling:
We learn by watching and imitating others (even without reinforcement)
Witnessing someone perform certain activities can increase/decrease diverse kinds of
behaviours (Bandura & Menlove)
Behaviour Therapy:
o Emerged in 1950s – applied procedures base don classical and operant conditioning to alter
clinical problems = behaviour modification
o Systematic desensitization = includes deep muscle relaxation and gradual exposure to a list
of feared situations, starting with those that arouse minimal anxiety and progressing to these
that are the most frightening (used to treat anxiety & phobias)
o A state opposite to anxiety is substituted for anxiety as the person is exposed gradually to
stronger and stronger doses of what he/she fears
o Modeling also included in behaviour therapy
o Operant techniques using rewards have been particularly successful with treating childhood
problems
o Intermittent reinforcement (only rewarding some instances of target behaviour) makes new
behaviour more enduring
The Importance of Cognition:
o Humans don’t just behave, we think and feel too
o The way in which people think about situations can influence behaviour in dramatic ways
Cognitive Therapy:
o Based on the idea that people not only behave, they also think and feel
o Emphasize how people construe themselves and the world is a major determinant of
psychological disorders
o Therapist begins by helping clients become more aware of their maladaptive thoughts
o Change cognition to change feelings and behaviour
o Roots in Beck’s cognitive therapy and Ellis’s Rational Emotive Behavioural Therapy
o REBT = sustained emotional reactions are caused by internal sentences that people repeat to
themselves; these self-statements reflect sometimes unspoken assumptions – irrational
beliefs – about what is necessary to lead a meaningful life
Shared environment factors = those things that members of a family have in common
o E.g. family income, child-rearing practices
Non-shared environment “unique environment” factors = those things believed to be distinct
among members of a family
o E.g. relationships, specific events
Unique/non-shared experiences have much more to do with the development of psychological
disorders
Behaviour Genetics
Behaviour genetics = the study of the degree to which genes and environmental factors influence
behaviour
Genotype = total genetic makeup of an individual, consisting of inherited genes *unobservable
o Genes switch on and off
Phenotype = totality of observable behavioural characteristics
o Changes overtime and is the product of an interaction between the genotype and the
environment
Molecular Genetics
Molecular genetics = seeks to identify particular genes and their functions
Human being has 46 chromosomes (23 pairs), each made up of thousands of genes that contain DNA
Alleles = different forms of the same gene
Polymorphism = a difference in DNA sequence on a gene that has occurred in a population
DNA in genes is transcribed into RNA, sometimes translated into amino acids (to make proteins)
Promoter DNA is recognized by proteins called transcription factors
Focus on difference between people in the sequence of their genes and in the structure of their
genes
Single nucleotide polymorphisms (SNPs) = differences between people in a single nucleotide (A, T,
C, G) in the DNA sequence of a particular gene
Copy number variations (CNVs) = differences between people in gene structure
o Can be present in a single gene or multiple genes
o Abnormal copy of one or more sections of DNA within the gene(s)
o Abnormal copies are additions/deletions
o Found in 5% of human genome (inherited or spontaneous mutation)
o Knockout study = specific gene is taken out of DNA in an animal to observe effect on
behaviour
Gene-Environment Interactions
Gene-environment interaction = a given person’s sensitivity to an environmental event is influenced
by genes
Serotonin transporter gene = gene with a polymorphism such that people have two short alleles,
some have two long alleles and some have one short, one long
o Combination of short-short and short-long + child maltreatment = more likely to be
depressed
Epigenetics = study of how the environment can alter gene expression (“above”/”outside” the gene)
o Marks on DNA control gene expression, the environment can influence them
o Genes predispose individuals to seek out situations that increase the likelihood of developing
a disorder
Evaluating the Genetic Paradigm
Direct replication = using the same measures and definitions of concepts
Indirect replication = including broader measures of related constructs
o Anterior cingulate
o Septal area
o Hippocampus (memory)
o Hypothalamus (metabolism, temperature, perspiration, blood pressure, sleep, appetite)
o Amygdala (Emotion) *emotional psychological problems
Key brain structure for psychopathology researchers due to role in attending to
emotionally salient stimuli & in emotionally relevant memories
Brain development begins in first trimester
Pruning = process of eliminating a number of synaptic connections *fewer and faster connections
Cerebellum and occipital lobe develop the quickest
Frontal lobe develops last
The Neuroendocrine System
Hypothalamic-pituitary-adrenal axis (HPA) = central to the body’s response to stress, and stress
figures prominently in many psyc disorders
Hypothalamus releases corticotropin-releasing factor (CRF) when faced with threat
CRF communicates with the pituitary gland, releases hormone that travels to adrenal gland
Adrenal cortex promotes the release of hormone cortisol – the stress hormone
o Takes 20-40 minutes for cortisol release to peak
o Takes up to an hour for cortisol levels to return to baseline
Autonomic nervous system (ANS) = operates very quickly, without our awareness, beyond voluntary
control
o Innervates the endocrine glands, the hearth, and smooth muscles
o 1) Sympathetic NS = prepares body for fight/flight (heart rate, dilates pupils, inhibits
intestinal activity, increases electrodermal activity)
o 2) Parasympathetic NS = helps calm down the body
o Involved in anxiety disorders (panic, PTSD)
The Immune System/Neuroendocrine System
Psychoneuroimmunology = studies how psychological factors impact the immune system
Immune system contains many cells and proteins that respond when the body is infected/invaded
Natural immunity = body’s first and quickest line of defense against infections
microorganisms/invaders *releases cells on invaders to destroy them
o Results in inflammation/swelling
o Cytokines = help initiate bodily responses to infection (fatigue, fever, activation of HPA axis)
Release of cytokines stimulated by activation of macrophages (cell released)
Specific immunity = cells respond more slowly to infection (lymphocytes t-helper and b cells),
involved in responding to specific pathogens or invading agents
o T-helper cells promote the release of cytokines
o B cells release antibodies
Stress directly effects the immune system (prenatal stress can even affect her offspring)
Interlukin-6 = cytokine that promotes inflammation in response to infection, linked to human
diseases and psyc disorders (MDD)
Exposure to stress also slows process of wound healing
Risk of harmful immune response to stress increases with age
Neuroscience Approaches to Treatment
Use of psychoactive drugs and antidepressants has been increasing *alter neurotransmitter activity
Antidepressants are the 3rd most commonly prescribed medications for any type of health issue
o Based on idea that depressed mood is caused by distortions in the way people perceive life
experiences *distorted thinking
E.g. focus exclusively on negative happenings, ignore positive ones
o Goal: to provide people with experiences, both inside/outside the therapy room, that will
alter their negative schemas, enabling them to have hope rather than despair
o Information processing bias *attention, interpretation, and recall of negative & positive
information biased in depression
o Helps patients recognize and change maladaptive thought patterns
Evaluating the Cognitive Behavioural Paradigm
Some cognitive explanations do not appear to explain much
The thoughts are given causal status negative thoughts cause sadness of depression
Focus is on current determinants of disorder
o Childhood and other historical antecedents given less attention
Are distorted thoughts the cause of result of psychopathology?
Factors That Cut Across the Paradigms
Emotion, sociocultural, and interpersonal factors
Emotion and Psychopathology
Emotions influence how we respond to problems and challenges in our environment
Help us reorganize our thoughts and actions
85% of psyc disorders include disturbances in emotional processing
Emotions = short-lived states, lasting for a few seconds/minutes/hours
o Expressive, experiential and physiological components
o Expressive/behavioural – facial expressions
o Experiential/subjective – how someone reports he/she feels at a given moment
o Physiological – changes in the body (autonomic NS)
Moods = emotional experiences that endure for a longer period of time
Ideal affect = the kinds of emotional states that a person ideally wants to feel
Sociocultural Factors and Psychopathology
Sociocultural factors: gender, culture, ethnicity, SES *may increase vulnerability to psychopathology
Environmental factors can trigger, exacerbate, or maintain the symptoms that make up the different
disorders
Some disorders affect men and women differently (depression 2x common in women as men)
Poverty is a major influence on psychological disorders
Interpersonal Factors and Psychopathology
Quality of relationships (family, marital, social support)
Trauma, serious life events, and stress
Object relations theory = stresses the importance of long-standing patterns in close relationships,
particularly within the family, that are shaped by the ways in which people think and feel
o Object refers to another person (in most versions)
Attachment theory = the type/style of an infant’s attachment to his/her caregivers can set the stage
for psychological health or problems later in life
o John Bowlby & Mary Ainsworth
o Securely attached – likely to grow up psychologically healthy
o Anxiously attached – likely to experience psychological difficulties
Relational self = the self in relation to others
o People will describe themselves differently depending on what other close relationships they
have been asked to think about
o Female sexual interest/arousal disorder (instead of hypoactive sexual desire disorder and
female sexual arousal disorder)
o Autism spectrum disorder (autism and Asperger’s)
Ethnic and Cultural Considerations:
o Many different cultural influences on risk factors for certain psyc disorders, symptoms
experienced, willingness to seek help, treatments available
o DSM-5 includes a list that cross-references the DSM diagnoses with the International
Statistical Classification of Diseases and Related Health Problems (ICD) codes
o Added features to enhance cultural sensitivity
o Includes a section on culture-related diagnostic issues
o Clinicians are cautioned not to diagnose symptoms unless they are atypical and problematic
within a person’s culture
o Includes 9 cultural concepts of distress
Dhat syndrome – (India) severe anxiety about the discharge of semen
Shenjing shuairuo – (China) syndrome characterized by fatigue, dizziness, headaches,
pain, poor concentration, sleep problems and memory loss
Taijin kyofusho – (Japan) fear that one could offend others through inappropriate eye
contact, blushing, perceived body deformation, one’s own foul body odor
Ataque de nervios – (Latino culture) intense anxiety and fear of screaming and
shouting uncontrollably
Specific Criticisms of the DSM
Too Many Diagnoses?
o Contains more than 300 different diagnoses
o Seems as though too many problems have been made into psyc disorders
o Some argue that the system includes too many minute distinctions based on small
differences in symptoms
o Classification may emphasize trivial similarities relevant info may be overlooked
o Comorbidity = the presence of a second diagnosis *norm rather than the exception
Could be a sign that we are dividing syndromes too finely
45% of people diagnosed with 1 disorder will meet criteria for a second disorder
o Many risk factors seem to trigger more than one disorder
o Why not lump childhood conduct disorder, adult antisocial personality disorder, alcohol use
disorder, and substance use disorder into “externalizing disorders”
o Research Domain Criteria = roadmap for research that will lead to the development of a new
classification system that is based on neuroscience and genetic data rather than just clinical
symptoms
Categorical Classification Versus Dimensional Classification:
o Categorical classification = classification requiring the presence of a certain amount of
specific symptoms that fall under a diagnosis category (DSM-5)
Forces clinicians to define one threshold as “diagnosable”
o Dimensional system = describes the degree of an entity that is present
Dimensional approach for personality disorders is included in the appendix
o Unspecified – used when a person meets many but not all of the criteria for a diagnosis
Used to be called NOS
Reliability of the DSM in Everyday Practice:
o Reliability for diagnosis was poor prior to DSM-III
o Difficult for mental health professionals to always agree on a diagnosis
o List different life events, participants are asked to indicate whether or not these events
happened to them in a specified period of time
o Issue: high variability in how people view these events
o Issue: difficulties with recall
o Low test-retest reliability
Personality Tests:
2 most common types of psyc tests: personality tests & intelligence tests
Self-Report Personality Inventories:
o Personality inventory = the person is asked to complete a self-report questionnaire including
whether statements assessing habitual tendencies apply to him/her
o Administered to analyze how certain kinds of people tend to respond
o Standardization = process of establishing statistical norms for a test
o Minnesota Multiphasic Personality Inventory (MMPI) = designed to detect a number of psyc
problems based on responses to certain items in a similar manner as individuals with a
particular diagnosis
MMPI-32 is much more reliable, has adequate criterion validity
Specific subscale to detect lying & faking “good”/”bad”
Projective Personality Tests:
o Projective test = a psych assessment tool in which a set of standard stimuli
(inkblots/drawings) ambiguous enough to allow variation in responses is presented to the
person
o Because the stimulus materials are unstructured/ambiguous, the person’s responses will be
determined by unconscious processes and will reveal true attitudes/motivations = projective
hypothesis
o Used when the subject is assumed to be unwilling or unable to express true feelings in asked
directly
o Thematic Apperception Test (TAT) = a person is shown a series of black and white pictures
1@ a time, and asked to tell a story related to each
Not very reliably scored, low construct validity
o Rorschach Inkblot Test = person is shown 10 inkblots, one at a time, and asked to tell what
the inkblots look like *most well-known
Exner scoring system, concentrates on perceptual and cognitive patterns in a person’s
responses
Responses viewed as a sample of how subject perceptually/cognitively organizes real-
life situations
Norms of this scoring system based on a small sample
Validity with assessing certain issues, not with others
Intelligence Tests
Alfred Binet
Intelligence test (IQ) = used to assess a person’s current mental ability
Based on the assumption that a detailed sample of a person’s current intellectual functioning can
predict how well he/she will perform in school
Most common: Wechsler Adult Intelligence Scale & Stanford-Binet
Regularly updated and standardized
Other uses:
o Diagnose learning disorders and identify areas of strength/weakness
o Assess whether a person has intellectual disability
Being in a scanner can generate anxiety on its own, it’s a scary experience
Cultural and Ethnic Diversity and Assessment
Cultural Bias in Assessment
A measure developed for one culture/ethnic group may not be equally reliable and valid with a
different group **not simply a matter of language translation
Cultural assumptions/biases may cause clinicians to over/under estimate psyc problems
Strategies for Avoiding Cultural Bias in Assessment
Students need to learn how culture/ethnicity may impact assessment
But that it may not impact assessment in every individual case
o Randomized controlled trials (RCTs) = studies in which clients are randomly assigned to
receive active treatment of a comparison
IV is treatment, DV is patient outcome
Defining the Treatment Condition: The Use of Treatment Manuals:
o Treatment manuals = detailed books on how to conduct a particular psyc treatment
o Provide specific procedures for therapist to follow at each stage of treatment
o Help therapist achieve greater uniformity in how they conduct therapy
Defining Control Groups:
o No-treatment control group = allows researchers to test whether the mere passage of time
helps as much as treatment does
o Placebo = a pretend treatment, uses the power of suggestion, allows researchers to control
for expectations of a symptom relief
o Active-treatment control group = researchers compare new treatment against a well-tested
treatment
o Double-blind procedure = psychiatrists and patient are not told whether the patient received
active medication or placebo *reduces bias in evaluating outcomes
o Placebo effect = a physical or psyc improvement that is due to the patient’s expectations of
help rather than to any active ingredient in a treatment
Defining a Sample:
o Often there is a failure to include people from diverse cultural/ethnic backgrounds
o People from minority groups are about half as likely to receive mental health treatment
Assessing How Well Treatments Work in the Real World:
o Efficacy = whether a treatment works under the purest of conditions
o Effectiveness = how well the treatment works in the real world
The Need for Dissemination of Treatment Outcome Findings:
o Dissemination = the process of facilitating adoption of efficacious treatments in the
community
Most typically by offering clinicians guidelines about the best available treatments
along with training on how to conduct those treatments
Analogue Experiments:
o Analogue experiment = investigators attempt to create/observe a related phenomenon (an
analogue) in the laboratory to allow more intensive study
o Can obtain results with good internal validity, less external validity
o Single-Case Experiments:
Single-case experiments = experimenter studies how one person responds to
manipulations of the IV *high internal validity
Lack of external validity
Just because treatment works for one person doesn’t mean it will work for
another
Reversal design (ABAB design) = participant’s behaviour must be carefully measured
in a specific sequence (baseline, treatment intro, reinstatement of baseline,
reintroduction of treatment)
No control group, but time period of baseline serves as control aspect
Integrating the Findings of Multiple Studies
Meta-analysis = thorough literature search, followed by putting together all the results into a
common scale, using effect size
Criticism: sometimes include studies of poor quality
Unlikely that there is a single gene that explains mood disorders – due to high heterogeneity
GWAS studies for responsible genes have been inconclusive
o DRD 4.2 gene influences dopamine function, related to MDD
Have identified several genetic polymorphisms related to bipolar disorder
Polymorphism of serotonin transporter gene is related to MDD
o Greater risk for depression after a stressful life event with this polymorphism
o Having at least one short allele associated with elevated reactivity to stress
Neurotransmitters:
o Norepinephrine, dopamine and serotonin are related to mood disorders
o People with depression are less responsive than others to drugs that increase dopamine
levels
o It is thought that the functioning of dopamine might be lowered in depression
o Dopamine is involved in the reward system of the brain = guides pleasure, motivation, and
energy in the context of opportunities to obtain rewards
o Drugs that increase dopamine levels are found to trigger manic symptoms in bipolar
individuals *overly sensitive dopamine receptors
o To lower serotonin levels, deplete levels of tryptophan *major precursor or serotonin
Causes temporary depressive symptoms in those with family history for depression or
depressive symptoms
o Bipolar disorder may be related to diminished sensitivity of serotonin receptors
o Medication alters levels immediately but takes 2-3 weeks for relief
o New modes focus on sensitivity of post-synaptic receptors
Brain Function: Regions Involved in Emotion
5 primary brain structures most studied in depression: amygdala, anterior cingulate, dorsolateral
prefrontal cortex, hippocampus, and the striatum
Amygdala – helps assess how salient/emotionally important a stimulus is
o People with MDD have more intense reactions to stimuli with emotion
MDD associated with greater activation of anterior cingulate and diminished activation of the
hippocampus & dorsolateral prefrontal cortex when viewing negative stimuli
MDD – diminished activation of striatum – specifically when receiving positive feedback
o Nucleus accumbens – central component of rewards system, plays a key role in motivation to
pursue rewards
Bipolar I – elevated responsiveness in the amygdala, increased activity of anterior cingulate,
diminished activity of hippocampus and dorsolateral prefrontal cortex
o High activation of striatum***
The Neuroendocrine System: Cortisol Dysregulation
HPA axis overactive during MDD *stress reactivity **overactive amygdala
Overactive amygdala sends signals to HPA axis, triggers release of cortisol (stress hormone)
Cortisol increases immune system activity to help body prepare for threats
Cushing’s syndrome = causes over-secretion of cortisol, frequent depressive symptoms
80% of people hospitalized for depression show poor regulation of HPA system
Social Factors in Depression: Childhood Adversity, Life Events, and Interpersonal Difficulties
Often interpersonal factors precede onset of depression
Childhood adversity: parental death, physical abuse, sexual abuse increases risk that later the
individual will develop depression *depressive symptoms likely will be chronic
Child abuse linked to anxiety even more strongly than to depression
Common stressful life events for triggering depressive symptoms include: losing a job, a key
friendship or a romantic relationship
Lack of social support is common amongst depressed individuals *lessens ability to handle stress
Expressed emotion = a family member’s critical or hostile comments toward or emotional over-
involvement with the person with depression
o High EE strongly predicts relapse in depression
Excessive need for reassurance has been found to be predictive of depression
Low social competence among elementary school children is a predictor of depression, poor-
interpersonal problem solving skills among adolescents
Marital conflict can predict depression
Psychological Factors in Depression
Neuroticism:
o Neuroticism = a personality trait that involves the tendency to experience frequent and
intense negative affect *predicts the onset of depression
o Explains part of genetic vulnerability to depression
o Also associated with anxiety
Cognitive Theories:
o Pessimistic and self-critical thoughts are major causes of depression
o Beck’s Theory:
Depression is associated with a negative triad = negative views of the self, their
world, and the future (hopelessness)
In childhood, people with depression acquired negative schemas through experiences
Negative schema is activated whenever the person encounters situations similar to
those that originally caused the schema to form
Cause cognitive biases = tendencies to process info in certain negative ways
Depression associated with a tendency to stay focused on negative info once it is
initially noticed
o Hopelessness Theory:
Hopelessness theory = most important trigger of depression is hopelessness *the
belief that desirable outcomes will not occur and that there is nothing a person can
do to change this
Attributions = the explanations a person forms about why a stressor has occurred:
1) Stable (permanent) vs. unstable (temporary) causes
2) Global vs. specific causes
Stable and global Attributional style more likely linked to depression
o Rumination Theory:
Rumination = tendency to repetitively dwell on sad experiences and thoughts, or to
chew on material again and again
Most detrimental form: to brood regretfully about why a sad event happened
Tendencies to ruminate have been found to predict onset of MD episodes
Women tend to ruminate more than men
Rumination increases negative moods, particularly when people focus on negative
aspects of their mood and their self
Evolutionarily adaptive to focus on negative events in order to solve problems
Social and Psychological Factors in Bipolar Disorder
Most people who experience a manic episode will also experience a major depressive episode
Depression in Bipolar Disorders:
o Electromagnetic coil placed against scalp, pulses of magnetic energy used to increase activity
in dorsolateral prefrontal cortex (30 mins, for 5-10 days)
o Can help relieve treatment resistant depression
o Star-D sequenced treatment alternatives to relieve depression
Comparing Treatments for Major Depressive Disorder:
o Combining psychotherapy and antidepressant use raises odds of recovery by 10-20%
o Antidepressants work more quickly than psychotherapy
Medications for Bipolar Disorder:
o Mood-stabilizing medications = medications that reduce manic symptoms
o Lithium = naturally occurring chemical element, first mood stabilizer identified
o Most medicated patients still experience mild manic/depressive symptoms
o 40% of people relapsed while taking lithium, 60% while taking a placebo
o Lithium levels are toxic if too high *ingestions requires regular blood tests
o 2 other types of medications for acute mania: *also help relieve depression
Anticonvulsant (antiseizure) medication (divalproex sodium)
Antipsychotic medication (olanzapine)
Recommended for those who don’t respond to lithium
o Patients often begin with lithium alongside psychotherapy (lithium takes a long time to start
working)
A final note on treatment:
o Deep brain stimulation = involves implanting electrodes into the brain, applying small
current to the electrodes, can manipulate activity to those brain regions
o Studies done with patients who have not responded to other forms of treatment
o 10-20% better chance at recovery when combining medication w/therapy
o Medication takes 2-3 weeks to kick in
o CT can be as effective as medications for severe depression, more effective than medication
at preventing relapse
Suicide
Suicidal ideation = thoughts of killing oneself, more common than attempted/completed suicide
Most suicide attempts do not result in death
Suicide attempt = behaviour intended to kill oneself
Suicide = involves behaviours that are intended to cause death and actually do so
Non-suicidal self injury = involves behaviours meant to cause immediate bodily harm but are not
intended to cause death
Epidemiology of Suicide and Suicide Attempts
9% report ideation (worldwide), 2.5% have made at least 1 attempt
Suicide rates are underestimated – often circumstances of some deaths are ambiguous
Every 20 minutes someone in the US dies from suicide
Men (adolescent males especially) are 4 times more likely to kill themselves than women
Women are more likely to make suicidal attempts that do not result in death
Men choose to shoot/hang themselves, women are more likely to use pills
Suicide rate increases in old age *white males over 50 have highest rate in US
Being divorced or widowed increased risk 4 or 5 fold
6% of undergrads, 4% grad students seriously contemplate attempting
o 1 in 12 make a plan, ½ don’t tell anyone
Risk Factors for Suicide
Psychological Disorders:
Associated with twice the average rate of medical costs, higher risk of cardiovascular disease, twice
the risk of suicidal ideation and attempt
Clinical Description of Anxiety Disorders
1) Symptoms interfere with important areas of functioning or cause marked distress
2) Symptoms are not caused by a drug or a medical condition
3) Symptoms persist for at least 6 months or at least 1 month for a panic disorder
4) The fear and anxieties are distinct from the symptoms of another anxiety disorder
Specific Phobias
Specific phobia = a disproportionate fear caused by a specific object or situation
Recognizes fear is excessive, goes to great lengths to avoid feared object/situation
May elicit intense disgust
Must be severe enough to cause distress/interfere with job or social life *avoidance
Common: Claustrophobia and Acrophobia (fear of heights)
Specific phobias are highly comorbid
Criteria:
o Marked and disproportionate fear consistently triggered by specific objects or situations
o The object or situation is avoided or else endured with intense anxiety
o Symptoms persist for at least 6 months
Social Anxiety Disorder
Social anxiety disorder = a persistent, unrealistically intense fear of social situations that might
involve being scrutinized by, or even exposed to, unfamiliar people
Labeled as social phobia in DSM-IV-TR
Feel as though all eyes are watching them, others waiting to evaluate them and record embarrassing
acts
Avoid social situations, feel social discomfort and experience symptoms for longer time than people
who are shy
Common fears: public speaking, speaking up in meetings or classes, meeting new people, talking to
people in authority
Those with broader array of fears more likely to experience comorbid depression and alcohol abuse
Often work in occupations far below their talents
1/3 meet the criteria for avoidant personality disorder
Generally begins during adolescence when peer relationships become particularly important
Tends to be chronic without treatment
Critera:
o Marked and disproportionate fear consistently triggered by exposure to potential social
scrutiny
o Exposure to the trigger leads to intense anxiety about being evaluated negatively
o Trigger situations are avoided or else endured with intense anxiety
o Symptoms persist for at least 6 months
Panic Disorder
Panic disorder = characterized by recurrent panic attacks that are unrelated to specific situations and
by worry about having more panic attacks
Panic attack = a sudden attack of intense apprehension, terror and feelings of impending doom,
accompanied by at least 4 other symptoms
Physical symptoms: shortness of breath, head palpitations, nausea, upset stomach, chest pain,
feelings of choking and smothering, dizziness, light headedness, faintness, sweating/chills, heat
sensation, numbness/tingling and trembling
Behavioural inhibition = tendency to become agitated and cry when faced with novel toys, people,
or other stimuli
May be inherited and set the stage for later development of anxiety disorders
Strong predictor of social anxiety disorder
Neuroticism = personality trait defined by tendency to experience frequent/intense negative affect
o Predicts onset of anxiety disorders and depression, 2x as likely with high levels
Cognitive Factors
Sustained Negative Beliefs About the Future:
o Believe that bad things are going to happen
o Safety behaviours = behaviours that maintain feared beliefs (e.g. stop all physical activity if
believe they will die from fast heart rate)
o Believe only their safety behaviours are what have kept them alive
Perceived Lack of Control:
o May be promoted by childhood traumatic events, punitive parenting or abuse
o Often develop after serious life events that threaten the sense of control over one’s life
o More than 70% report serious life event before onset of disorder
Attention to Threat:
o Pay more attention to negative cues in environment than those w/o anxiety disorder
o Heightened attention to threatening stimuli *automatically and quickly
o Stay focused on threatening object longer than others do
Etiology of Specific Anxiety Disorders
Etiology of Specific Phobias
2-factor model of behavioural conditioning (classical and operant)
Specific phobias seen as a conditioned response that develops after a threatening experience and is
maintained by avoidant behaviour
Phobias could be conditioned by direct trauma, modeling, or verbal instruction
People may forget conditioning experiences that lead to phobia
Only certain kinds of stimuli and experiences will contribute to the development of a phobia
o Could have evolutionary/adaptability basis
o Prepared learning = evolution may have prepared our fear circuit to learn fear of certain
stimuli very quickly and automatically
Etiology of Social Anxiety Disorder
Behavioural Factors: Conditioning of Social Anxiety Disorder:
o 2-factor conditioning model
o Negative social experience can lead to conditioned fear of stimulus, person avoids those
situations/stimuli
o Safety behaviours: avoiding eye contact, disengaging from conversation, standing apart from
others
Cognitive Factors: Too Much Focus on Negative Self-Evaluations:
o Unrealistically negative beliefs about the consequences of their behaviour
o Attend more to how they are doing in social situations and their own internal sensations than
most people do
o Overly negative in evaluating their social performance
o Attend more to internal cues than external
Etiology of Panic Disorder
Neurobiological Factors:
o Locus coeruleus = major source of norepinephrine in the brain
o Surges of norepinephrine are a natural response to stress, associated with increased activity
of sympathetic nervous system
Faster heart rate, other fight or flight responses
o W/anxiety disorder, show more dramatic biological response to drugs that trigger release of
norepinephrine
o Drugs that increase activity in locus coeruleus can trigger panic attacks, decrease (clonidine
and antidepressants) decrease risk of panic attacks
Behavioural Factors: Classical Conditioning
Panic attacks are often triggered by internal bodily sensations of arousal
Panic attacks are classically conditioned responses to situations that trigger anxiety or internal bodily
sensations of arousal
Interoceptive conditioning = classical conditioning of panic attacks in response to bodily sensations
Cognitive Factors in a Panic Disorder:
o Focus on catastrophic misinterpretations of somatic changes
o Panic attacks develop when a person misinterprets bodily sensations as signs of impeding
doom (increased heart rate = heart attack)
o Anxiety sensitivity index = measures the extent to which people respond fearfully to their
bodily sensations
Can predict onset of panic attacks in longer-term studies
Putting it All Together: A Gene that Influences Neurobiological and Psychological Risk Factors for
Panic Disorder:
o Polymorphism in gene guiding neuropeptide S function – NPSR1 gene – tied to increased risk
of panic disorder
o Neuropeptide S related to anxiety-like behaviours in mice
o NPSR1 gene related to increased amygdala response to threat stimuli, larger cortisol
response to stressor, higher anxiety sensitivity scores
Etiology of Agoraphobia
Related to genetic vulnerability and life events
Fear-of-fear hypothesis = agoraphobia is driven by negative thoughts about the consequences of
experiencing anxiety in public
Etiology of GAD
Tends to co-occur with other anxiety disorders
People who meet diagnostic criteria are much more likely to experience episodes of MDD
Seems to involve general tendency to experience general distress more than a specific pattern of
intense fear
Related to a more amorphous profile of general distress
Worry is reinforcing because it distracts people from more powerful negative emotions and images
Worry does not involve powerful visual images and doesn’t produce the physiological changes that
accompany emotion
More of a repetitive self-talk about bad things that might happen
Worrying decreases psycho-physiological arousal
Maltreatment predicts a 4 fold risk of developing GAD *worry distracts from remembering trauma
People with GAD may be avoiding emotions
People who have a hard time accepting ambiguity are more likely to worry and develop GAD
Treatment of Anxiety Disorders
Most individuals visit a family doctor for treatment and are prescribed benzodiazepines
Commonalities Across Psychological Treatments
o Thought Suppression:
People with OCD try harder to suppress their obsessions than other people and may
actually make the situation worse
Feelings of responsibility for what occurs
Etiology of BDD:
o People with BDD can accurately see and process their physical features
o They are detailed oriented and this influences how they look at facial features, examine one
feature at a time instead of examining the whole
o Become engrossed in considering a small flaw
o Consider attractiveness to be more important than others, self-worth is dependent upon it
Etiology of Hoarding Disorder:
o Evolutionary perspective – would be adaptive to store any resources
o Behavioural model: related to poor organizational abilities, unusual beliefs about
possessions, and avoidance behaviours
o Slow at sorting objects into categories, find it anxiety-provoking
o Demonstrate an extreme emotional attachment to possessions *especially to animals
o Avoidance (of anxiety from organizing clutter) helps maintain the clutter
Treatment of the OC and Related Disorders
Medications:
o Antidepressants most commonly used
o Clomipramine used for OCD (50% reduction in symptoms) *youth and adults
o Antidepressants more helpful than placebos for BDD *using clomipramine and fluoxetine
(continue to experience mild symptoms)
o Hoarding symptoms respond less to medication treatment than other OCD symptoms
Psychological Treatment:
o Exposure and response prevention (ERP) = exposure treatment to address compulsive rituals
people with OCD use to ward off threats
o OCD:
Hold belief that compulsive behaviours will prevent awful things from happening
ERP – exposure themselves to situations that elicit the compulsive act and refrain
form performing the compulsive ritual
Not performing the ritual exposes the person to the full force of the anxiety
provoked by the stimulus
The exposure promotes the extinction of the conditioned response (the
anxiety)
Uses exposure hierarchy, highly effective *more than clomipramine
25% of clients refuse ERP treatment
Cognitive – challenging beliefs about what will happen if one doesn’t engage in
rituals, also use exposure to test beliefs
o BDD:
ERP – exposure to feared activity e.g. interact with people who could be critical of
their looks, response prevention avoid looking in the mirror
Supplemented with strategies to address cognitive features
o Hoarding Disorder:
Adaptation of ERP – focuses on getting rid of objects
Response prevention – halting the rituals engage in to reduce anxiety e.g. counting or
sorting possession
Etiology of PTSD
2/3 of people with PTSD have a history of an anxiety disorder
PTSD related to genetic risk for anxiety disorders *high activity in fear circuit areas (amygdala),
childhood trauma, tendencies to attend selectively to cues of threat
Neuroticism and negative affectivity predict the onset of PTSD
Related to Mowrer’s 2-factor model of conditioning (classical conditioning and operant conditioning)
Nature of the Trauma: Severity and the Type of Trauma Matter:
o PTSD rates are doubled with soldiers who have a second tour of duty
o More prisoners of war develop PTSD than those only wounded in war
o Traumas caused by humans are more likely to cause PTSD than natural disasters
Neurobiology: The Hippocampus:
o PTSD uniquely related to the function of the hippocampus
o Hippocampus volume is smaller in those with PTSD
o Smaller than average hippocampus volume precedes the onset of the disorder
o Plays role in ability to locate autobiographical memories in space, time and context, and in
organizing our narratives of those memories
o Decreased hippocampus volume could explain deficit in verbal memory
Coping:
o People who cope with trauma by trying to avoid thinking about it are more likely to develop
PTSD
o Dissociation = feeling removed from one’s body or emotions or being unable to remember
the event *may keep the person from confronting the event
o Symptoms of dissociation after trauma are predictive of development of PTSD
o High intelligence and strong social support may help cope with severe trauma more
adaptively
Treatment of PTSD and ASD
Medication Treatment of PTSD:
o SSRIs receive strong support as a treatment
o Relapse is common if medication is discontinued
Psychological Treatment of PTSD:
o Exposure treatment
o Client is asked to face his worst fears, by working up an exposure hierarchy
o Extinguish fear response or help challenge the idea that the person could not cope with
anxiety/fear generated by those stimuli
o Exposure focused on memories/reminders of trauma
o In-vivo – returning to scene of the crime
Imaginal exposure = the person deliberately remembers the event
o Virtual reality technology sometimes used
o More effective that medication
o Cognitive processing therapy designed to help victims of rape and sexual abuse dispute
tendencies towards self-blame
Psychological Treatment of ASD:
o Short-term CBT include exposure therapy
o Decreases chances of ASD developing into PTSD (reduced to 32% compared to 58%)
o Exposure more effective than cognitive restructuring in preventing development of PTSD
Often comorbid with anxiety and depression, use antidepressants to lessen *have no effect on DID
itself
2. Somatic Symptom and Related Disorders (previously known as somatoform disorders)
1) Somatic symptom disorder: excessive thought, distress, and behaviour related to somatic
symptoms
2) Illness anxiety disorder: unwarranted fears about a serious illness in the absence of any significant
somatic symptoms
3) Conversion disorder: neurological symptoms that cannot be explained by medical disease or
culturally sanctioned behaviour
4) Malingering: intentionally faking psychological or somatic symptoms to gain from those symptoms
5) Factitious disorder: falsification of psychological or physical symptoms, without evidence of gains
from those symptoms
Defined by excessive concerns about physical symptoms or health
Hypochondriasis = chronic worries about developing a serious medical illness **not a DSM-5
diagnosis
Seek frequent medical treatment, hospitalizations and surgery are common
Conditions are remarkably varied
Health concerns are cause of excessive anxiety or involve too much expenditure of time and energy
*very subjective criteria
Diagnosis of these disorders often is found to be stigmatizing
New to DSM-5: somatic symptom disorder does not have to be medically unexplained
Tend to develop in early adulthood, wax and wane over time, recovery can occur naturally
Tend to co-occur with anxiety disorders, mood disorder, substance use disorders & personality
disorders
More common in women than in men
I. Somatic Symptom Disorder (SSD)
DSM-5 Criteria
1) At least one somatic symptom that is distressing or disrupts daily life
2) Excessive thought, distress and behaviour related to somatic symptoms or health concerns, as
indicated by at least one of the following:
o Health-related anxiety, disproportionate and persistent concerns about the seriousness of
symptoms, excessive time and energy devoted to health concerns, duration of at least 6
months
3) Specify if predominant pain
Diagnosed regardless of whether symptoms can be explained medically
DSM-5 label “Psychological Factors Affecting Other Medical Conditions” used when psychological
factors are the cause of symptoms
May begin/intensify after some conflict or stress
Might seem that the person is using the symptom to avoid some unpleasant activity or to get
attention/sympathy
Experience symptoms as completely physical
3x as common as illness anxiety disorder
II. Illness Anxiety Disorder (IAD)
DSM-5 Criteria:
1) Preoccupation with and high level of anxiety about having or acquiring a serious disease
2) Excessive illness behaviour (e.g. checking for signs of illness, seeking reassurance) or maladaptive
avoidance (avoiding medical care)
3) No more than mild somatic symptoms are present
Depression and anxiety related to increased activity in ACC and also related to increase in somatic
symptoms & pain
o Emotional pain can also activate the ACC and anterior insula
No support for genetic influence (concordance rates in MZ twins don’t differ from DZ twins)
II. Cognitive Behavioural Factors that increase awareness and distress over somatic symptoms:
Focus on mechanisms that could contribute to the excessive focus on and anxiety over health
concerns
Once a somatic symptom develops, 2 cognitive variables appear important:
o Attention to body sensations & interpretation (attributions) of those sensations
Use version of emotion Stroop task – people with somatic symptom-related disorders had more
difficulty ignoring words related to physical health
Believe symptoms are a sign of an underlying long-term disease
2 behavioural consequences:
o Person may assume the role of being sick and avoid work, exercise and social tasks, these
avoidant behaviours in turn can intensify symptoms by limiting other healthy behaviours
o Person may seek reassurance from doctors and from family members, this help-seeking
behaviour may be reinforced if it results in the person getting attention/sympathy
III. Psychodynamic Perspective
Unconscious psychological factor cause
Blindsight = not consciously aware of visual input (implicit component still often intact)
o Failure to be explicitly aware of sensory information
IV. Social & Cultural Factors
Decrease in incidence of conversion disorder since last half of 19 th century
o Higher incidence may have been due to more repressed sexual attitudes or low tolerant for
anxiety symptoms
More prevalent: in rural areas, in individuals of lower SES, in non-Western cultures
Treatment
Most people with these disorders usually want medical care, not mental health care
Most somatic and pain concerns have both physical and psychological components
Interventions in Primary Care
Teach primary care teams to tailor care for people with osmatic symptom-related disorders
Goal: to establish a strong doctor-patient relationship to bolster the patient’s sense of trust/comfort
so the patient will feel more reassured about his/her health
Informing physicians when a patient appears to be an intensive user of health care services so they
can minimize the use of diagnostic tests and medications
Cognitive Behavioural Treatment
1) Help people identify and change the emotions that trigger their somatic concerns
2) Help people change their cognitions regarding their somatic symptoms
3) Help people change their behaviours to stop playing the role of a sick person and to gain more
reinforcement for engaging in other types of social interactions
Treating anxiety and depression will help reduce somatic symptoms *antidepressant: Tofranil =
effective even at low dosages that do not alleviate depression symptoms
Psychoeducation programs help patients recognize links between negative moods and somatic
symptoms
Train people to pay less attention to their body
Help people identify and challenge negative thoughts about their bodies
Help people resume healthy activities and build a lifestyle that has been damaged by too much focus
on illness-related concerns
Family therapy to change patient’s reliance on playing the role of a sick person
CBT helps reduce distress about symptoms, less able to reduce the actual symptoms
Internet based CBT not strong enough to reduce health anxiety
Mindfulness helps reduce health anxiety
Treatment for Somatic Symptom Disorder with Pain
Hypnosis helps reduce pain levels, influences brain regions involved in experiencing and interpreting
pain
Acceptance and commitment therapy (ACT) – variant of CBT, the therapist encourages the client to
adopt a more accepting attitude towards pain, suffering and moments of depression and anxiety,
and to view these as a natural part of life
o Coached not to struggle intensely to avoid these situations
Antidepressants can also be helpful (low doses can reduce pain)
CHAPTER 9: Schizophrenia
= A disorder characterized by disordered thinking, in which ideas are not logically related; faulty
perceptions and attention; a lack of emotional expressiveness; and disturbances in behaviour, such
as a disheveled appearance
Withdraw from other people and everyday reality, experience delusions and hallucinations
Substance use rates are high, suicide rates are high *12x more likely to die of suicide
Mortality rates are as high, or higher than people who smoke
1% life prevalence, affects men more than women
Diagnosed more frequently among some groups: African Americans *may reflect diagnostic bias
Sometimes begins in childhood, usually appears in late adolescence/early adulthood *earlier in men
than women
o Late onset (30s) = more severe
3 domains of symptoms: positive, negative, and disorganization
DSM-5 Criteria:
1) Two or more of the following symptoms for at least 1 month: one symptom should be either 1, 2,
or 3
o 1. Delusions, 2. Hallucinations, 3. Disorganized speech, 4. Disorganized/catatonic behaviour,
5. Negative symptoms (diminished motivation or emotional expression)
2) Functioning in work, relationships of self-care has declined since onset
3) Signs of disorder for at least 6 months;
o Or, if during a prodromal or residual phase, negative symptoms or 2+ symptoms 1-4 in less
severe form
Positive Symptoms
= Comprise excesses and distortions, and include hallucinations and delusions
Acute episodes are characterized by positive symptoms
Delusions:
o = Beliefs contrary to reality and firmly held in spite of disconfirming evidence
o Precursory delusions (“CIA planted a listening device in my head”) *found in 65%
o Forms:
Thought insertion = belief that thoughts that are not his/her own have been placed in
his/her mind by an external source
Thought broadcasting = belief that thoughts are broadcasted or transmitted, so that
others know what one is thinking
Belief that an external force controls one’s feelings or behaviours
Genetically heterogeneous genetic factors may vary from case to case, not likely caused by 1
gene
People with schizophrenia in their family histories have more negative symptoms that no family
history
o Negative symptoms may have stronger genetic component
Incidence of schizophrenia highest if both biological parents were diagnosed (27.3%), (7% if one
parent)
Risk for MZ twins is 44.3%, 12,08% for DZ
Even with adopted children whose biological parent had schizophrenia, there is still a heightened risk
for developing
Familial high-risk study = begins with 1 or 2 biological parents with schizophrenia, follow their
offspring longitudinally to identify how many develop schizophrenia
6x more likely to develop by age 40 if have a parent with schizophrenia
Predisposition is not transmitted by a single gene
Multiple common genes associated with schizophrenia and bipolar
1) DTNBP1 & NGR1 – associated w/schizophrenia, 2) COMT & BDNF – associated w/cognitive deficits
associated w/schizophrenia
o DTNBP1 codes for a protein ‘dysbindin’ – impacts dopamine and glutamate NTM systems
o COMT associated with cognitive control processes relying on the prefrontal cortex
o BDNF – linked to cognitive functioning in people with and without schizophrenia
(polymorphism Val66Met)
o ***These genes do not appear in GWAS
SNPs associated with schizophrenia are also associated with bipolar disorder
Genome-wide scans: identification of several gene mutations
The Role of Neurotransmitters
Dopamine theory:
o Drugs effective in treating schizophrenia reduce dopamine activity (antipsychotic drugs)
o Side effects resembling symptoms of Parkinson’s disease *caused by low dopamine in
particular area of brain
o Antipsychotic drugs block postsynaptic dopamine receptor D2, in the mesolimbic pathway
o Amphetamines amplify dopamine activity, can produce state closely resembling
schizophrenia
o Only related to positive and disorganized symptoms of schizophrenia
o Dopamine neurons in prefrontal cortex (mesocortical pathway) may be underactive & fail to
inhibit dopamine neurons in subcortical brain areas **negative symptoms
Antipsychotics do not have major effect on dopamine neurons in prefrontal cortex
o Take several weeks for antipsychotics to lessen positive symptoms, although receptors are
rapidly blocked
o To be effective, must reduce DA to below normal levels
New drugs related to serotonin, block D2 receptors, also block serotonin receptor 5HT2
GABA transmission in prefrontal cortex is disrupted in those with schizophrenia
Glutamate may also play a role *low levels in cerebrospinal fluid ***medication targeting glutamate
shows promise
o Also low levels of enzyme needed to produce glutamate
Elevated AA homocysteine – interacts with NMDA receptor in pregnant women whose child
develops schizophrenia
PCP drug can induce positive and negative symptoms in people without schizophrenia
Antipsychotic drugs = used to treat symptoms of schizophrenia (aka neuroleptics produce side
effects similar to symptoms of a neurological disease)
First generation antipsychotics:
o Reduce positive and disorganized symptoms (also reduce agitation & violent behaviour), little
or not effect on negative symptoms
o Block dopamine D2 receptors
o 30% do not respond favourably to first generation, 50% quit after 1 year, 75% quit before 2
years because of side effects
o Side effects: sedation, dizziness, blurred vision, restlessness, sexual dysfunction, dystonia
(rigidity), dyskinesia (abnormal muscle motion), akasthesia (inability to remain still)
o Extrapyramidal side effects = resemble the symptoms of Parkinson’s disease (tremors,
shuffle, drooling)
o Tardive dyskinesia = mouth muscles involuntarily make sucking, lip-smacking and chin-
wagging motions
Mainly in older people with schizophrenia who had been treated with 1 st generation
drugs
o Neuroleptic malignant syndrome = (1% of cases) sometimes fatal, severe muscular rigidity
develops, accompanied by fever
Second generation antipsychotics:
o Approval of clozapine – therapeutic gains in those who didn’t respond well to 1st generation
medication, produce fewer side effects, less relapse and treatment noncompliance *impacts
serotonin receptors
Side effects: impair immune system functioning, agranulocytosis (lower amount of
WBC), seizures, dizziness, fatigue, drooling, weight gain *fewer motor side effects
o Olanzapine and risperidone – produce fewer side effects
o Equally as effective in reducing positive and disorganized symptoms, slightly more effective in
reducing negative symptoms and improving cognitive deficits
o Less treatment noncompliance
o No differences in relapse *reduces relapse?
o Can also produce extrapyramidal side effects
o Less often given to African-Americans
Medical review: 2nd generation not more effective, did not produce fewer unpleasant side effects,
nearly ¾ stopped taking before study ended
o Can lead to serious side effects: pancreatitis, weight gain, diabetes
Psychological Treatments
Psychosocial treatments are recommended alongside medication (Patient Outcome Research Team
“PORT” recommendation)
o Skills training, CBT, family-based treatment
Social skills training = designed to teach people with schizophrenia how to successfully manage a
wide variety of interpersonal situations
o (Discussing medications with psychiatrist, ordering meals in a restaurant, filling out a job
application, saying no to drug dealers, reading bus schedules)
o Involves role-playing and other group exercises the practice skills (in therapy and real social
situations)
o Help achieve fewer relapses, better social functioning, higher quality of life
o May also be effective in reducing negative symptoms
Family therapies:
o Developed to try and decrease expressed emotion within the family (hostility, critical
comments and emotionally overinvolved)
o 1) Education about schizophrenia – about genetic/neurobiological factors, cognitive problems
associated, symptoms, and signs of relapse
o 2) Information about antipsychotic medication – importance of taking, effects and side
effects
o 3) Blame avoidance and reduction – encourage family members not to blame themselves of
their ill relative
o 4) Communication and problem-solving skills – express feelings in constructive, empathic,
nondemanding manner
o 5) Social network expansion – encouraged to expand social contacts
o 6) Hope – hope for improvement, not to return to hospital
CBT:
o Encouraged to test out delusional beliefs
o Helped to attach nonpsychotic meaning to paranoid symptoms to reduce intensity and
aversive nature
o Helps reduce negative symptoms *recognize & challenge expectations associated w/negative
symptoms
Cognitive Remediation Therapies:
o Improvement in basic cognitive processes hold promise for improving social and emotional
lives of schizophrenics
o Try to normalize attention and memory
o Cognitive remediation training/cognitive enhancement therapy (CET) = seek to enhance
basic cognitive functions such as verbal learning ability
Effective in reducing symptoms and improving cognitive abilities, linked to good
functional outcomes
o Can include computer-based training in memory, problem solving and attention
o Enriched supportive therapy (EST) = includes supportive and educational elements
Psychoeducation:
o Educate patients about their illness, symptoms, time course, triggers, treatment strategies
o Reduces relapse and rehospitalization
Case Management:
o Case managers – familiar with the mental health system, able to connect people with
schizophrenia to whatever services they required
o Often provided direct clinical services
o Multidisciplinary team that provides services in the community (medication, treatment for
substance abuse, help in dealing with stressors, psychotherapy, vocational training,
assistance in obtaining housing and employment
o Has not shown improvement in social functioning
Residential Treatment:
o “Halfway houses” – alternative for those who do not need to be in the hospital but are not
well enough to live on their own or with family
o Protected living units
o Vocational rehabilitation – learn skills to help secure employment and return to the
community
o Staff may include psychiatrists/clinical psychologists
o Often include group meetings
DSM-5 Criteria:
1) Problematic pattern of use that impairs functioning
2) 2 or more symptoms within a 1 year period:
o Failure to meet obligations, repeated use in situations where it is physically dangerous
o Repeated relationship problems, continued use despite problems caused by substance
o Tolerance, withdrawal, substance taken for longer time or in greater amounts than intended
o Efforts to reduce or control use do not work, much time spent trying to obtain the substance
o Social/hobbies/work activities given up or reduced, craving to use the substance is strong
Severity: Mild = meet 2-3 criteria, Moderate = meet 4-5 criteria, Severe = meet 6+ criteria
Marijuana is most popularly used illegal drug
Alcohol is the most used substance
DSM-IV-TR had 2 categories: substance abuse and substance dependence, DSM-5 only has substance
USE
o DSM-5 now includes gambling disorder in chapter on substance-related and addictive
disorders
Addiction = a severe substance use disorder with 6+ symptoms
o Using more than intended amounts, trying unsuccessfully to stop, physical/psyc problems
made worse by drug, problematic relationships
o Physiological dependence = presence of either tolerance or withdrawal
o W/o physiological dependence = absence of tolerance and withdrawal
Tolerance and withdrawal often part of severe substance use disorder
Tolerance = indicated by: 1) larger doses of the substance being needed to produce the desired
effect, or 2) the effects of the drug becoming markedly less if the usual amount is taken
Withdrawal = negative physical and psychological effects that develop when a person stops taking
the substance or reduces the amount
o Muscle pain, twitching, sweats, vomiting, diarrhea, insomnia
Drug and alcohol use disorder are among most stigmatized disorders
I. Alcohol Use Disorder
Generally show more severe symptoms: tolerance, withdrawal
Delirium tremens (DTs) = person becomes delirious when alcohol level in blood suddenly drops, as
well as tremulous and has hallucinations that are primarily visual and may be tactile as well
Often associated with other drug use, 80-85% are smokers
Nicotine and alcohol are cross-tolerant can induce tolerance for the rewarding effects of the other
Nicotine influences the way alcohol works in the brain’s dopamine pathways associated with reward
Prevalence
8.5% meet criteria for DSM-IV-TR categories of alcohol dependence/abuse (rates are declining)
Binge drinking = having 5+ drinks in a short period of time *common among college-age students
(39.5%)
Heavy-use drinking = having 5 drinks on the same occasion five or more times in 30-day period
(12.7%)
More men than women have problems with alcohol
European American and Hispanic adolescents/adults more likely to binge drink than African
American
o Least likely among Asian American and African American
Most prevalent among Native Americans and Hispanics
Comorbid with personality disorders, mood disorders, schizophrenia, and anxiety disorders (and
other drug use)
6.8% have another psyc disorder
Short-Term Effects of Alcohol
Alcohol being metabolized by enzymes enter small intestine and is absorbed into blood
Broken down in liver, can metabolize 1 ounce or 100-proof (50%) liquor per hour
Women achieve higher blood alcohol concentrations after adjustments for body weight
Alcohol stimulates GABA receptors (reduces tension)
Increases levels of serotonin and dopamine *pleasurable effects
Inhibits glutamate receptors *causes cognitive effects (slowed thinking, memory loss)
Long-Term Effects of Prolonged Alcohol Abuse
Impairs digestion of food and absorption of vitamins
Deficiency of B-complex vitamins can cause amnestic syndrome = severe loss of memory for recent
and long-past events
Alcohol use plus reduction in protein intake leads to developed or cirrhosis of the liver
o Liver cells become engorged with fat and protein, impeding their function
Damage to: endocrine glands, brain, pancreas, heart failure, erectile dysfunction, hypertension,
stroke, capillary hemorrhages (redness in face)
Fetal alcohol syndrome = growth of fetus is slowed, production of cranial, facial and limb
abnormalities as a result of heavy alcohol consumption while pregnant
Benefits: physiological (increases coronary blood flow), psychological (less-driven lifestyle and
diminished hostility)
Low-moderate consumption of red wine may lower bad cholesterol and raise god cholesterol
II. Tobacco Use Disorder
Nicotine = addicting agent of tobacco *activates neural pathways that stimulate dopamine neurons
in mesolimbic area
Prevalence and Health Consequences
18% prevalence rate
Smoking is the single most preventable cause of premature death in the US
People in US who are most likely to smoke are those with a psyc disorder
Consequences: emphysema, cancer of larynx/esophagus/pancreas/bladder/cervix/stomach,
pregnancy complications, SIDS, periodontitis, cardiovascular disorders
Harmful ocmponents: nicotine, carbon monoxide, tar
Similar rates among adolescent males/females, higher among Hispanic and white adolescents than
African/Asia American **African Americans retain nicotine in their blood longer (metabolize it more
slowly) *less likely to quit, more likely to get lung cancer **smoke more menthol (inhaled more
deeply and longer)
o Mutations ADH2 and ADH3 genes linked with alcohol use disorders
People who are more sensitive to effects of nicotine are more likely to get addicted (dopamine
release, inhibit reuptake)
o Gene SLC6A3 related to reuptake regulation of dopamine
One form of the gene related to lower likelihood of smoking, greater likelihood of
quitting and greater sensitivity to smoking cues
o CYP2A6 gene contributes to body’s ability to metabolize nicotine *less likely to become
dependent
Slower metabolism = stays in brain longer
Ability to tolerate large quantities of alcohol may be an inherited diathesis
o Asians have lower rates of alcohol abuse
o Deficient enzymes (ADH or alcohol dehydrogenase)
Neurobiological Factors
Dopamine pathways in the brain are linked to pleasure and reward ***particularly mesolimbic
pathway is affected
o Possible deficiency in DA receptor DRD2
Vulnerability model – do problems in the dopamine system increase vulnerability to substance
dependence
Toxic effect model – dopamine system problems are the consequence of substance dependence
Support for both models for cocaine use
People take drugs to avoid bad feelings associated with withdrawal *explains frequency of relapse
Insensitive-sensitization theory – considers both the craving for drugs and the pleasure that comes
with taking the drugs
o Dopamine system linked to pleasure/liking, becomes supersensitive to the drug and to cues
associated with it (needles, spoons, rolling paper)
o Sensitivity to cues induces craving
o Overtime, liking decreases and wanting remains intense
More craving is associated with more usage, even when trying to quit
Brain imaging studies show that cues for a drug activate the reward & pleasure areas of the brain
involved in drug use
Greater activation in basal ganglia, inferofrontal gyrus, and pre-motor areas = better at inhibiting a
response when needed
Self-reports of liking and wanting are important for predicting drinking behaviour
Short Term Over Long Term:
o People with substance use disorders often value the immediate, impulsive pleasure and
reward that comes from taking a drug more than the delayed reward (e.g. monthly paycheck)
o Delay discounting – can compute extent to which people discount the value of larger, delayed
rewards
o People on opiates, nicotine, cocaine and alcohol discount delayed rewards more steeply than
others
o Valuing delayed rewards is associated with prefrontal cortex activation
o Valuing immediate rewards is associated with amygdala and nucleus accumbens activation
Psychological Factors
Mood Alteration:
o Drug use is reinforced because it enhances positive moods or diminishes negative ones
o Alcohol use reduces anxiety and stress *also lessens positive emotions in response to
anxiety-provoking situations
o Heroin substitutes = drugs chemically similar to heroin that can replace the body’s craving for
it
Methadone – addicting on its own
Synthetic narcotics are cross-dependent with heroin = by acting on the same CNS
receptors, they become a substitute for the original dependency
Less severe withdrawal reactions
Side effects: insomnia, constipation, excessive sweating, diminished sexual
functioning
Stigma associated with going to methadone clinics
o Opiate antagonists = drugs that prevent the use from experiencing the heroin high
Naltrexone
Gradually weaned from heroin, receiving increasing doses of naltrexone
Molecules occupy receptors to which opiates usually bind, without stimulating them
Requires frequent visits to a clinic (motivation required)
o Buprenorphine – partial opiate agonist (less addictive than heroin), also contains naloxone
(opiate antagonist)
Less intense high
Do not need to go to clinic to receive *prescribed
Effective at relieving withdrawal symptoms
o Drug replacement therapy does not seem to be effective for cocaine use disorders
o Vaccine to prevent the high associated with cocaine, contains tiny amounts of cocaine
attached to harmless pathogens
Body responds by developing antibodies
Not all users develop enough antibodies to keep cocaine from reaching the brain
o Methamphetamine Treatment Project – Matrix treatment – 16 CBT group sessions, 12
family education sessions, 4 individual therapy sessions, 4 social support sessions
Positive short-term results, long-term results were equally comparable to treatment
as usual (TAU)
Prevention
Half of adult smokers began before age 15, nearly all before age 19
Top priority to discourage youth
Family interventions
Statewide comprehensive tobacco control programs: increasing taxes on cigarettes, restricting
advertising, conducting public education campaigns, creating smoke free environments
New health warnings including graphic images on packaging
School programs:
o Peer-pressure resistance training *learn to say no
o Correction of beliefs and expectations – believe it is more prevalent than it actually is
o Inoculation against mass media messages – media makes smoking look positive
Truth campaign – aims to share health and social consequences of smoking
o Peer leadership
People with bulimia are distinct from anorexia because they do not lose an excessive amount of
weight
Binges occur in secret, triggered by stress and negative emotions they arouse, continue until
uncomfortably full
o Often involves soft, sweet foods that can be rapidly consumed: ice cream, cake
o More likely to binge while alone, during morning/afternoon
o Avoiding a craved food can lead to a binge the next day
o Likely to occur after negative social interaction
Severity: (Compensatory behaviours) Mild = 1-3/week, Moderate = 4-7/week, Severe = 8-13/week,
Extreme = 14+/week
Must occur at least once a week for 3 months
Self-esteem depends heavily on maintaining normal weight
More accurate than normal population in reporting height/weight
DSM-IV-TR included subtypes which were removed
Begins in late adolescence/early adulthood, 90% are women, 1-2% prevalence among females
Many are somewhat overweight before onset
Comorbid with: depression, personality disorders, anxiety disorders, substance use disorders,
conduct disorder
o Increase likelihood in both directions, except bulimia usually precedes substance use
disorders
Higher suicide rates than normal population (lower than anorexia)
Physical Consequences
Typically have a normal BMI but amenorrhea can still occur
Frequent purging can lead to K depletion, loss of electrolytes, irregular heartbeat
Vomiting can lead to tearing of stomach tissue and throat tissue, loss of dental enamel
Swollen salivary glands
Mortality rate of 4% for women
Prognosis
Close to75% recover, 10-20% remain fully symptomatic
Earlier intervention linked to better prognosis
III. Binge Eating Disorder (BED)
DSM-5 Criteria:
1) Recurrent binge eating episodes
o 1+/week for 3 months
2) Binge eating episodes include at least 3 of the following:
o Eating more quickly than usual, eating until over full, eating large amounts even if not hungry,
eating alone due to embarrassment about large food quantity, feeling bad after binge
3) No compensatory behaviour is present
Most often are obese (BMI greater than 30), prevalence among 2-25% of obese people
o Many have a history of dieting
Severity (# binges/week): Mild 1-3/week, Moderate = 4-7/week, Severe = 8-13, Extreme = 14+/week
Comorbid with: mood disorders, anxiety disorders, ADHD, conduct disorder, substance use disorder
Risk factors: childhood obesity, critical comments about being overweight, weight-loss attempts in
childhood, low self-concept, depression, and childhood abuse
More prevalent than other eating disorders, 0.2-4.7% prevalence, more common in women (less
gender difference)
Equally prevalent cross-culturally
Physical Consequences
Increased risk of type II diabetes, cardiovascular problems, chronic back pain, headaches
Sleep problems, anxiety, depression, IBS, early onset menstruation for women
Prognosis
25-82% of people recover
Lasts approximately 14.4 years (longer than anorexia/bulimia) or just over 4 years?
Etiology of Eating Disorders
Genetic Factors
Unlikely caused by 1 gene, although they do run in the family
1st degree relatives of women with anorexia are 10x more likely to have the disorder, 4x for bulimia
o Same for men with anorexia, but not bulimia
Higher MZ than DZ concordance rates for anorexia and bulimia
Environmental factors are also very important (higher proportion of bulimia due to environmental
than genetic factors)
Heritable: dissatisfaction with one’s body, strong desire to be thin, binge eating, preoccupation with
weight
Genetic factors may link to negative emotionality and constraint with eating disorders
Neurobiological Factors
Hypothalamus is a key brain structure involved in regulating hunger *not dysfunctional in anorexia
Endogenous opioids reduce pain sensations, enhance mood and suppress appetite
o Released during starvation, related to anorexia, bulimia and BED **increased levels
o Excessive exercise increases opioids *reinforcing
Low levels of beta-endorphin in bulimia *not sure if this is a cause or effect
Serotonin – related to eating and satiety (feeling full) *promotes satiety
o Binges could result from serotonin deficit
o Food restriction interferes with serotonin synthesis
o Low levels of serotonin metabolites in AN and BN = underactive NTM activity
o Show poor response to 5-HT agonists in AN if haven’t been restored to healthy weight
o Linked to comorbid depression
Dopamine – related to reward/pleasure aspects of food
o Linked to motivation to obtain food
o Restrained eaters more sensitive to food cues
o Ventral striatum linked to DA level and reward
More activated in people with AN when looking at images of thin women
o People with AN or BN show greater expression of DA transported gene DAT
o Bingeing on sucrose leads to increased release of DA in the striatum
Cognitive-Behavioural Factors
Focus on distorted body image, fear of fat, loss of control of over eating
Anorexia Nervosa:
o Emphasis on fear of fatness and body image disturbance as motivating factor that reinforced
weight loss
o Onset often follows a period of weight loss and dieting
o Behaviours to achieve thinness are negatively reinforced by reduction of anxiety about
becoming fat
Positively reinforced by comments form others
o Dieting and weight loss positively reinforced by sense of mastery or self-control
o Perfectionism and sense of personal inadequacy may lead a person to become concerned
with appearance
Compare oneself to portrayals in media of thin ideal, being overweight and
comparing to attractive others all lead to greater dissatisfaction in one’s body image
o Criticism from peers and parents about being overweight
o Experience many negative emotions but also positive emotions (e.g. pride) after losing
weight or avoiding treats
Low positive emotion differentiation: may confuse this feeling with happiness or
success
Low positive emotion differentiation predicts eating disorder behaviours (same with
high negative)
Bulimia Nervosa and BED:
o View self-worth in terms of body weight and shape
o Low self-esteem, hope control over body will help feel better generally
o Try to follow strict eating plan, rules are inevitably broken, escalates into binge
o Feelings of disgust and fear build up after binge, leading to compensatory actions
o Purging temporarily reduces anxiety but lowers self-esteem, and cycle repeats
Low SE and high negative affect Dieting to feel better about self Food intake
restricted too severely Diet is broken Binge Compensatory behaviours to
reduce fear of weight gain
o Restraint scale – questionnaire measure of concerns about dieting and overeating
o Bingeing helps regulate amount of negative affect, although tend to experience more
negative affect after binge
o Purging is reinforced by decreasing negative affect
o Concerns about body shape and weight predict restrained eating, which predicts increased
bingeing
o Attention, memory and problem solving are affected with eating disorders
Attention focused on food-related images/words longer
Remember food words more when full w/AN
Sociocultural Factors
BMI of ideal female models has decreased over time, male BMI increased due to increased
muscularity
As cultural standards moved more towards thin ideal, more and more people were becoming
overweight
Over 2/3 of Americans are overweight
Dieting has become more common (29% of men and 44% of women diet)
A 1/3 of women 25-45 report spending over half their lifetime trying to lose weight
Diets are equally effective whether fats, carbs, or proteins are cut as long as number of calories are
reduced
Women are more likely to diet than men
Highest risk for developing eating disorders with high BMI and body dissatisfaction
Sociocultural ideal of thinness leads to people learning to fear being/feeling fat
“Pro-eating disorder” websites – women who visit these sites are more dissatisfied with their bodies,
have more eating disorder symptoms and more likely experienced hospitalizations for eating
disorders
o Viewing these websites has potential to cause unhealthful changes in eating behaviours
Gender Influence:
1) Desire phase = sexual interest or desire, often associated with sexually arousing fantasies or
thoughts
2) Excitement phase = men and women experience increased blood flow to genitalia (produces
erection in male penis & enlargement of breasts & increased lubrication in female vagina)
3) Orgasm phase = sexual pleasure peaks, male ejaculation almost always occurs, in women the
outer walls of the vagina contract (general muscle tension)
4) Resolution phase = relaxation and sense of well-being that usually follows orgasm
o Men – associated refractory period during which further erection isn’t possible
o Women often able to respond again immediately
Many women report that desire and excitement co-occur and cannot be made distinct
Vaginal plethysmograph = used to measure women’s physiological arousal
o Amount of blood flow has little correlation to subjective level or desire/excitement
1. Sexual Dysfunctions (SD)
Clinical Descriptions
Symptoms must last at least 6 months (common to have for just a month)
3 categories:
I. Involving sexual desire, arousal, and interest (low sex drive)
Women: female sexual interest/arousal disorder
o 1) Diminished, absent or reduced frequency of at least 3 of the following:
Interest in sexual activity, erotic thoughts/fantasies, initiation of sexual activity &
responsiveness to partner’s attempts to initiate, sexual excitement/pleasure during
75% of sexual encounters, sexual interest/arousal elicited by any internal or external
erotic cues, genital or non-genital sensations during 75% of sexual encounters
Overall, deficits in sexual interest, biological arousal or subjective arousal
Men: male hypoactive sexual desire disorder
o 1) Sexual fantasies and desires, as judged by clinician, are deficient or absent
Men: erectile disorder
o On at least 75% of sexual occasions:
1) Inability to attain an erections, or
2) Inability to maintain an erection for completion of sexual activity, or
3) Marked decrease in erectile rigidity interferes with penetration or pleasure
o 13-28% rates
o Prevalence increases with age (50% are 60+)
More than 50% seeking treatment report low desire, women more likely than men to report
2-4x more likely if post-menopausal *although older women are less likely to be distressed about it
Women more concerned about lack of subjective desire *previously arousing stimuli no longer
affective
Often have normative biological arousal even with lack of subjective desire
Dysfunction should be persistent and recurrent and should cause clinically significant distress or
problems with functioning
o Diagnosis not made if cause is entirely due to a medical illness (e.g. advanced diabetes) or
other psyc disorder
More women than men report symptoms of sexual dysfunction (43% vs. 31%)
Clinical diagnosis not made unless symptoms cause distress/impairment (only 11-23% of women)
II. Orgasmic disorders
Women: female orgasmic disorder
o On at least 75% of sexual occasions:
Begin by resolving any relationship problems – training in non-sexual communication skills and non-
sexual issues
o Difficulties with in-laws, child rearing
Recommend planning romantic events together to restore closeness and intimacy
Behavioural couples therapy especially effective for women
Sensate focus – reestablish sexual intimacy through contact
Anxiety Reduction and Psychoeducation
Systematic desensitization and in vivo desensitization (begin with psychoeducation, then using small
dilator, then larger)
Psychoeducation – videos showing sexual techniques
For premature ejaculation – expand repertoire of activities
Procedures to Change Attitudes and Thought
Sensate-focus exercises
Help focus on physical sensations
Communication Training
Communicate likes and dislikes to one another
Expressing sexual preferences
**Used when dysfunction is specific to a given relationship and not a concern with previous partners
Directed Masturbation
Developed to enhance a women’s comfort with and enjoyment of sexuality
Women carefully examines her nude body, identify various areas, instructed to touch her genitals,
find areas that produce pleasure
Increase intensity using erotic fantasies, if no orgasm, use vibrator, let her partner do for her as she
was doing
Helpful for treating orgasmic disorders
Other Physical Treatments
Learn sexual positions that increase clitoral stimulation (for female orgasmic disorder)
Squeeze technique (premature ejaculation)
Medications
Testosterone therapy (not approved by FDA for female) – sexual interest/arousal disorder
Psychotherapy is helpful alongside medication
Antidepressants:
o Helpful is depression contributes to diminished sex drive
o Particularly use SSRIs – also helpful in treatment of premature ejaculation
o Some actually interfere with sexual responsiveness, use 2nd medication e.g. buproprion
PDE-5 inhibitors:
o Phosphodiesterase type 5 inhibitor *treatment for erectile disorder
o Relax smooth muscles and allow blow to flow into penis, creating erection during sexual
stimulation but not in its absence
o Taken 1 hour before sex, effects last 4 hours
o Side effects: headaches, indigestions
o May be dangerous with cardiovascular disease (often comorbid)
2. Paraphilic Disorders
= Recurrent sexual attraction to unusual objects or sexual activities lasting at least 6 months
1 category for people whose sexual attractions are focused on causing pain & another for those
focused on children
When termed “disorder” – diagnoses are to be considered only when the sexual attractions cause
marked distress or impairment or when the person engages in sexual activities with a nonconsenting
person
Objects of sexual attraction are described:
o Fetishistic disorder = an inanimate object or non-genital body part
o Transvestic disorder = cross-dressing
o Pedophilic disorder = children
o Voyeuristic disorder = watching unsuspecting others undress or have sex
o Exhibitionistic disorder = exposing one’s genitals to an unwilling stranger
o Frotteuristic disorder = sexual touching of an unsuspecting person
o Sexual sadism disorder = inflicting pain
o Sexual masochism disorder = receiving pain
Lack of structured interviews to reliably assess these disorders
Most people with Paraphilic disorders are heterosexual males
Onset: adolescence (sadism and masochism in early adulthood)
More than 2/3 meet mood disorder criteria, anxiety/substance disorders also common
I. Fetishistic Disorder
1) For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviours
involving the use of nonliving objects or nongenital body parts
2) Causes significant distress or impairment in functioning
3) The sexually arousing objects are not limited to articles of clothing used in cross-dressing or to
devices designed to provide tactile genital stimulation, such as a vibrator
Almost exclusively effects men, fetish sometimes necessary for sexual arousal
Clothing (underwear), leather, articles related to feet (stockings, women’s shoes) are common
fetishes
o Hair, nails, hands, feet are sexually arousing
Feel compulsive attraction to the object, involuntary and irresistible
II. Pedophilic Disorder and Incest
1) For at least 6 months, recurrent and intense, sexually arousing fantasies, urges, or behaviours
involving sexual contact with a prepubescent child
2) Person has acted on these urges or the urges and fantasies cause marked distress or interpersonal
problems
3) Person is at least 16 years old and 5 years older than the child
Generally molest children they know, most don’t engage in violence other than the sexual act
Denies that he is forcing himself on the victim
50% are adolescent males, most are heterosexual
Incest = sexual relations between close relatives for whom marriage is forbidden (subtype of
pedophilic disorder)
o Most common between brother and sister, then father and daughter
o Children of incest can inherit too many recessive genes and lead to serious genetic defect
o Men who commit incest usually abuse their pubescent daughters (vs. pre-pubertal)
o Show greater penile arousal
III. Voyeuristic Disorder
1) For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviours
involving the observation of unsuspecting others who are naked, disrobing, or engaged in sexual
activity
2) Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause
marked distress or interpersonal problems
These fantasies are quite common among men
“Peeping” helps promote sexual arousal and is sometimes essential for it
Does not find it exciting to watch a women who is undressing for his benefit
Excited by anticipation of how the women would react is she knew he was watching
IV. Exhibitionistic Disorder
1) For at least 6 months recurrent, intense, and sexually arousing fantasies, urges, or behaviours
involving showing one’s genitals to an unsuspecting person
2) Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause
clinically significant distress or interpersonal problems
Many masturbate during exposure
Desire to shock or embarrass the observer
Urge to expose triggered by anxiety and restlessness and well as by sexual arousal
Symptoms of anxiety: headaches, palpitations and Derealization
May be repeated often, same place, same time of day *compulsive
Social and legal consequences are far off of mind
Flee and feel remorseful after
V. Frotteuristic Disorder
1) For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviours
involving touching or rubbing against a nonconsenting person
2) Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause
clinically significant distress
Typically occurs on a crowded bus or sidewalk that provide an easy means of escape
Report doing so a dozen times
VI. Sexual Sadism and Masochism Disorders
Sadism Criteria
1) For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviours
involving the physical or psychological suffering of another person
2) Causes clinically significant distress or impairment in functioning or the person has acted on these
urges with a nonconsenting person
Masochism Criteria
1) For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviours
involving the act of being humiliated, beaten, bound, or made to suffer
2) Causes marked distress or impairments in functioning
Manifestations of masochism: physical bondage, blindfolding, spanking, whipping, electric shocks,
cutting, humiliation (being urinated/defecated on, being forced to wear a collar and bark, being put
on display naked), and taking the role of slave and submitting to orders and commands
Most sadists have relationships with masochists, or can take on both roles **masochists outnumber
sadists
Behaviour becoming more acceptable over time
Found in straight and gay relationships
20-30% of sadomasochistic clubs are female
Above average in income and educational status
Alcohol abuse is common among sadists
Etiology of Paraphilic Disorders
Neurobiological Factors
Most paraphilics are male, perhaps androgens (hormones like testosterone) play a role
Androgens regulate sexual desire *high among sexual offenders with Paraphilic disorders
Childhood Sexual Abuse
2/3 of sexual offenders reported a history of sexual abuse
Psychological Factors
Succumbing to sexual urge thought of as impulsive act, often occur in context of alcohol use (unable
to inhibit impulses)
Others report often occur in context of negative moods – sexual activity used as means to escape
Heightened impulsivity and poor emotion regulation
Cognitive distortions and attitudes, lack of empathy for women
Distortion that a women who left her blinds up wants to be looked at, or women who dress
provocatively “ask for it”
Men with pedophilia have lower IQ, higher rates of neurocognitive problems
Treatment
Strategies to Enhance Motivation
Sexual offenders lack motivation to change illegal behaviour
Deny their problem, minimize seriousness, feel confident that they can control it
Blame the victim for being overly seductive
Enhance motivation, bolster hope that client can gain control over urges through treatment,
highlight potential legal consequences
CBT
Aversion therapy to reduce attraction to inappropriate object/activity
Satiation – trained to pair Paraphilic fantasy with another aversive stimulus (masturbating for 55
minutes after orgasm)
Covert sensitization – person imagines situations he finds inappropriately arousing and imagines
feeling sick/ashamed for feeling and acting this way *reduces deviant arousal
Counter distorted thinking that the subjects aren’t really being harmed
Social skills training, training in empathy towards others
Sexual impulse control training
Biological Treatments
Castration – removal of testes
Medications used as supplement to psyc treatment – hormonal agents that reduce androgens
o Reduce arousal to deviant objects
o Long-term use associated with negative side effects
SSRIs commonly used
Balancing Efforts to Protect Public Against Civil Liberties for Those with Paraphilias
Unconstitutional to detain a person on basis of his/her potential for future crimes
High risk for sexual crime can be detained if risk is related to psyc disorder that diminished ability to
control sexual behaviour
Allowed to find out where sexual offenders are living
Most childhood disorders fall under either: a) Neurodevelopmental disorders & b) Disruptive,
impulse-control, and conduct disorders
Defined in 2 broad domains:
o Externalizing disorders = more outward-directed behaviours, such as aggressiveness,
noncompliance, over-activity, and impulsiveness
Includes ADHD, conduct disorder, and oppositional defiant disorder
o Internalizing disorders = more inward-focused experiences and behaviours, such as
depression, social withdrawal, and anxiety
Childhood anxiety, and mood disorders
I. Attention-Deficit/Hyperactivity Disorder (ADHD)
DSM-5 Criteria
1) Either A or B:
o A) 6+ manifestations of inattention present for at least 6 months to a maladaptive degree and
greater than what would be expected given a person’s developmental level (e.g. careless
mistakes, not listening well, not following instructions, easily distracted, forgetful in daily
activities)
o B) 6+ manifestations of hyperactivity-impulsivity present for at least 6 months to a
maladaptive degree and greater than what would be expected given a person’s
developmental level, e.g. fidgeting, running about inappropriately (in adults, restlessness),
acting as if “driven by a motor”, interrupting or intruding, incessant talking
2) Several of the above present before age 12
3) Present in two or more settings
4) Significant impairment in social, academic, or occupational functioning
5) For people age 17 or older, only 5 signs of hyperactivity-impulsivity are needed to meet the
diagnosis
Overestimate their ability to navigate social situations with peers
Vicious cycles – 3 domains: poor social skills, aggressive behaviour, overestimation of one’s social
abilities – predict decline in these abilities at follow-up
Age of onset was changed from under 7 to under 12 & adults only need to show symptoms in 5
domains = more diagnoses
3 specifiers:
o 1) Predominantly inattentive = children whose problems are primarily those of poor
attention
More difficulty with focused attention or speed of information processing
Problems with DA and prefrontal cortex
o 2) Predominantly hyperactive-impulsive = children whose difficulties result primarily from
hyperactive/impulsive behaviour
o 3) Combined = children who have both sets of problems ***majority
More likely to develop conduct problems & oppositional behaviour, be placed in
special classes and have difficulties interacting with peers
Frequently comorbid with conduct disorder *ADHD associated more with off-task behaviour in
school, cognitive and achievement deficits, and a better long-term prognosis
Also comorbid with anxiety and depression (30%), 15-30% have a learning disorder
Hyperactive symptoms predict substance use
8-11% prevalence *increase could be due to factors other than increase in the actual disorder
o Over diagnosis due to assessments that are too brief to properly judge & differing
educational policies
Continue to have substance use, impulsivity, crime and mental health problems in mid
20s
6-9.5% prevalence, more common in boys
Incidence and prevalence of serious law breaking peak at age 17, drop in young adulthood
Etiology
Genetic Factors
Some genetic factors of conduct disorder are shared with other disorders (ADHD, depression) others
are specific to CD
Criminal and antisocial behaviour is accounted for both by genetic and environmental factors
40-50% of antisocial behaviour is heritable
Aggressive behaviour is more heritable than other delinquent behaviour
Age of onset is related to heritability
MAOA gene – located on the X chromosome, releases MAO enzyme which metabolizes NTMs (DA, 5-
HT, NE)
o Maltreated children with low MAOA activity more likely to develop conduct disorder
Brain Function, Autonomic Nervous System, and Neuropsychological Factors
Deficits in brain regions supporting emotions **empathetic responses
o Difficulty perceiving distress and happiness on others, no difficulty perceiving anger
Reduced amygdala and prefrontal cortex activation
Do not learn to associate behaviour with reward/punishment as easily as others (amygdala/ventral
striatum)
ANS abnormalities associated with antisocial behaviour in adolescents
o Low levels of resting skin conductance and heart rate *lower arousal
o May not fear punishment as much
Poor verbal skills, problems with executive functioning, problems with memory
IQ 1 SD lower if developed at early age *not due to low SES or school failure
Psychological Factors
Deficient in moral awareness, lacking remorse for wrongdoings *prominent in antisocial personality
disorder and psychopathy
Interpret ambiguous acts as hostile intent (e.g. being bumped in line)
Peer Influences
1) Acceptance or rejection by peers
o Rejection by peers is causally related to aggressive behaviour *specifically in combination
with ADHD
o Can predict later aggressive behaviour
2) Affiliation with deviant peers
o Increases likelihood of delinquent behaviour
Treatment
Family Intervention
Intervening early has an impact
Family checkup treatment (FCU) = 3 meetings to get to know, assess, and provide feedback to
parents regarding their children and parenting practices
Parent management training (PMT) = parents are taught to modify their response to their children
so that prosocial rather than antisocial behaviour is consistently rewarded
o Parents taught to use positive reinforcement, and time-outs and loss of privileges
o Most efficacious intervention
Multisystemic Treatment (MST)
= Delivering intensive and comprehensive therapy services in the community, targeting the
adolescent, the family, the school, and in some cases, the peer group
Conduct problems influenced by multiple factors
Incorporates behavioural, cognitive, family-systems and case management techniques
Emphasizes individual family strengths
Prevention Programs
Fast Track – designed to help children academically, socially, and behaviourally, focusing on areas
that are problematic in CD including peer-relationships, aggressive and disruptive behaviour, social
information processing, and parent-child relationships
o Treatment for 10 years, more intensive in years 1-5
o Benefits dwindled as children got older
III. Depression and Anxiety in Children and Adolescents
A) Depression
Ages 7-17 show following same symptoms as adults:
o Depressed mood, inability to experience pleasure, fatigue, concentration problems, suicidal
ideation
Show more guilt, lower rates of early-morning wakefulness, early-morning depression, loss of
appetite & weight loss
Recurrent symptoms
Occurs in 2-3% of school-aged children under age 13
By adolescence, rate rises to from 6-16% for girls and 4-7% for boys (2x as common among
adolescent girls)
o Less gender differences in symptoms *no gender difference until adolescence
Comorbid with anxiety
Role of genetic factors (with depressed parent, have 4x risk of developing depression)
Gene-environment interactions predict onset: short-allele of serotonin gene & interpersonal stress
Interpersonal factors especially important in predicting depression in girls
Early adversity predicts depression for ages 15-20 or rejection by parents
Cortisol in people with depression is associated with small volume of hippocampus
Cognitive distortions and negative attributional style (consistent with Beck’s theory and hopelessness
theory)
Attributional style doesn’t appear to be stable until early adolescence *does not predict child
depression
Treatment:
o Treatment for Adolescents with Depression Study (TADS) – efficacy of antidepressants
(Prozac)
Combined treatment of Prozac with CBT most effective, more than either alone
Similar relapse rates for all 3 treatment groups
o Side effects: nausea, diarrhea, sleep problems, agitation, suicidality concerns
o Girls more likely to relapse than boys, especially with comorbid anxiety (both genders)
o CBT in school setting is more effective than family/supportive therapy
o CBT most effective for Caucasian adolescents, those with good coping skills
Prevention:
o Selective – target particular youth based on family risk factors, environmental factors, or
personal factors
More effective
o Universal – targeted toward large groups, typically in schools, seek to provide education and
information about depression
B) Anxiety
Common fears that get outgrown: fear of the dark, imaginary creatures, fear of being separated from
parents
Reported more often in girls than boys
In order to meet criteria, functioning must be impaired *don’t need to regard fear as
excessive/unreasonable
3-5% prevalence in children/adolescents *specific phobias and social anxiety disorder are most
common
Separation anxiety disorder:
o Characterized by constant worry that some harm will befall their parents or themselves when
they are away from their parents
o Often first observed when children begin school
o 1) Excessive anxiety that is not developmentally appropriate about being away from people
to whom one is attached, with at least 3 symptoms that last for at least 4 weeks
Repeated & excessive distress when separated, excessive worry that something bad
will happen to an attachment figure, refusal/reluctance to go to
school/work/elsewhere, refusal/reluctance to sleep away from home, nightmares
about separation from attachment figure, repeated physical complaints when
separated from attachment figure
o Changes: moved into anxiety chapter, age of onset prior to 18 was removed **can be
diagnosed in an adult
Social Anxiety Disorder: 1-7% prevalence, higher rates in adolescents *care more what others think
of them
5% meet criteria for PTSD
o 4 categories of symptoms for children older than 6:
o 1) Intrusively re-experiencing the traumatic event (nightmares, flashbacks, intrusive
thoughts)
o 2) Avoiding trauma-related situations or information and experiencing a general numbing of
responses (detachment)
o 3) Negative changes in cognitions or mood related to traumatic event
o 4) Increased arousal and reactivity, which can include irritability, sleep problems and
hypervigilance
o Separate criteria for younger than 6 *presented in more developmentally appropriate ways
OCD prevalence: from less than 1-4%, similar symptoms as in adulthood
o Common obsessions in children: dirt/contamination, aggression, Adolescence: sex, religion
o More common in boys as children, more common in women as adults
Etiology:
o Heritability estimate of 29-50%
o Parenting practices parental control and overprotectiveness, more than parental rejection
o Social anxiety: over-estimate danger in many situations, under-estimate ability to cope
Anxiety interferes with social interactions, avoid social situations
Behavioural inhibition is an important risk factor
o PTSD:
Requires exposure to trauma (experienced or witnessed)
Risk factors: level of family stress, coping styles of family, past experiences with
trauma
Treatment:
o Major treatment focus is exposure *modified for children by including more modeling and
more reinforcement
o CBT is effective: Coping Cat – focuses on confrontation of fears, development of new ways to
think about fears, exposure to feared situations and relapse prevention
Effective short-term and long-term
o Family CBT more effective than individual CBT when both parents have anxiety disorder, and
both are more effective than psychoeducation
o Combination of CBT and medication (Sertraline *Zoloft) more effective than either alone
*results are more immediate
o Group therapy effective for social anxiety disorder
o For OCD, CBT more effective than medication, and combination *unless severe, then
combination is best
o Other methods: bibliotherapy and computer-assisted therapy
Bibliotherapy – parents given written materials and are the therapist with their
children
Reduces anxiety, but not as effective as CBT
IV. Autism Spectrum Disorder
Not formally included in DSM until 3rd edition, rates have been rising
4 categories from DSM-IV-TR are combined into autism spectrum disorder (ASD)
o 1) Autistic disorder, 2) Asperger’s disorder, 3) Pervasive developmental disorder not
otherwise specified, 4) Childhood disintegrative disorder
o All shared similar clinical features and etiologies, only varied in severity
o DSM-5 – different clinical specifiers relating to severity and extent of language impairment
Social and Emotional Disturbances
Rarely approach others, look through/past people, turn their backs on others, few initiate play,
usually unresponsive when being approached
People with psyc disorders are at risk for dying before age 65
o Heavy drinkers: die from cirrhosis between 55-64 years old
o Anxiety/mood: cardiovascular disease
o Worsened immune function overall
3. Neurocognitive Disorders in Late Life
Most elderly do not have cognitive disorders
Dementia = deterioration of cognitive abilities
Delirium = a state of mental confusion
I. Dementia
= Deterioration of cognitive abilities to the point that functioning becomes impaired
o Impaired social and occupational functioning
Most common symptom: difficulty remembering things, especially recent events
Lose control of impulses, use coarse language, tell inappropriate jokes, shoplift, make sexually
inappropriate remarks
Difficulty dealing with abstract ideas, emotional disturbances common (depression, flatness of
affect, sporadic outbursts)
Delusions and hallucinations can occur
Language disturbances – vague patterns of speech
Become withdrawn and apathetic
Course may be progressive, static or remitting *mostly develops slowly, can detect subtle
cognitive/behavioural defects before
Mild cognitive impairment = the early signs of decline noted before functional impairment is
present
1) DSM mild neurocognitive disorders are similar to mild cognitive impairment
2) DSM major neurocognitive disorders are similar to dementia
Difference based on ability to live independently
Not all people with mild cognitive impairment develop dementia (10% will), 1% of adults develop
dementia w/o MCI
Criteria for Mild Neurocognitive Disorder (Mild cognitive impairment)
1) Modest cognitive decline from previous levels in one or more domains based on the following:
o Concerns of the patient, a close other or clinician
o Modest neurocognitive decline (between the 3rd and 16th percentile) on formal testing or
equivalent clinical evaluation
2) The cognitive deficits do not interfere with independence in everyday activities (e.g. paying bills or
managing medications), even though greater effort, compensatory strategies, or accommodation
may be required to maintain independence
3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to
another psychological disorder
Criteria for Major Neurocognitive Disorder (Dementia)
1) Significant cognitive decline from previous levels in one or more domains based on both of the
following:
o Concerns of the patient, a close other, or clinician
o Substantial neurocognitive impairments (below the 3rd percentile on formal testing) or
equivalent clinical evaluation
2) The cognitive deficits interfere with independence in the everyday activities
3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to
another psychological disorder
Perceptual disturbances are frequent, mistake unfamiliar for familiar, visual hallucinations, delusions
in 25% of older adults (poorly worked out, fleeting and changeable)
Mood/activity swings, disordered thoughts, erratic, shift between emotions
Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, incontinence
of urine and feces
Become lethargic/unresponsive
Have lucid intervals – alter and coherent *daily fluctuations help distinguish from AD
Symptoms worsen during sleepless nights
More common among young children and older adults (nursing homes and hospitals)
6-12% nursing home residents developed delirium in 1 year
Often misdiagnosed, especially if lethargy is present or if person has dementia
High mortality rate if left untreated, 1/3 die within a year
Increased risk for further cognitive decline
Etiology
Caused by medical conditions: drug intoxications, withdrawal reactions, metabolic and nutritional
imbalances (diabetes, thyroid dysfunction, kidney/liver failure, congestive heart failure,
malnutrition), dehydration, infections, fevers, neurological disorders, stress of major injury
One of most common triggers is hip surgery
Usually has more than one cause
Physical declines of late life, increased susceptibility to chronic diseases, many medication
prescribed, greater sensitivity to drugs = increased vulnerability for elderly
Treatment
Recovery if underlying cause is treated promptly
Atypical antipsychotic medication
Treatment takes 1-4 weeks for condition to clear, longer in older people
Preventative strategies:
o Clocks of hospital patients in field of vision, helps stay oriented
o Shades open during the day, lights turned off at night
o Minimal sleep disruptions
o Stress-free, hydration
Risk factors: sleep deprivation, immobility, dehydration, visual/hearing impairment
High risk of delirium among those with dementia
o 5) Suspiciousness or paranoia
o 6) Inappropriate or restricted affect
o 7) Odd or eccentric behaviour or appearance
o 8) Lack of close friends
o 9) Social anxiety and interpersonal fears that do not diminish with familiarity
Recurrent illusions (inaccurate sensory perceptions), flat/constricted affect, aloof from others
Most do not develop delusions or schizophrenia (some do)
Similar genetic vulnerability as for schizophrenia – enlarged ventricles, less temporal grey matter
(also cognitive and neuropsychological deficits)
60% heritable
5. Clinical Description and Etiology of the Dramatic/Erratic Cluster
Highly inconsistent behaviour, inflated self-esteem, rule breaking behaviour, exaggerated emotional
displays
Most well-known
IV. Antisocial PD (APD) and Psychopathy
1) Age at least 18
2) Evidence of conduct disorder before age 15
3) Pervasive pattern of disregard for the rights of others since the age of 15 as sown by at least 3 of
the following:
o Repeated law breaking, deceitfulness/lying, impulsivity, irritability/aggressiveness, reckless
disregard for own safety & that of others, irresponsibility as seen in unreliable
employment/financial history, lack of remorse
Used interchangeably with psychopathy by public *antisocial behaviour is important for both, but
they differ in important ways
Psychopathy is not included in DSM-5
Antisocial PD:
o Core feature: pervasive pattern of disregard for the rights of others
o Presence of conduct disorder, little regard for truth, lack of remorse for misdeeds
o Men are 5x more likely to meet criteria, ¾ meet criteria for another disorder *substance
abuse is common
o ¾ convicted felons meet criteria
o Poverty of emotion:
Negative – lack of shame/remorse/anxiety, doesn’t learn from mistakes
Positive – merely an act to manipulate others, superficially charming
Psychopathy:
o Predates APD diagnostic criteria
o “Mask of Sanity” – Hervey Cleckley
o Criteria focuses on person’s thoughts and feelings *poverty of emotions (positive and
negative)
o No sense of shame, positive feelings for others is an act
o Superficially charming
o Impossible to learn from mistakes due to lack of anxiety
o Impulsive rule-breaking behaviour
o Boldness, meanness, and impulsivity
o Assessed using Psychopathy Checklist-Revised (PCL-R)
o Symptoms do not need to show before age 15 *will not obtain high scores on PCL-R if have
APD
Etiology
Most research done on those convicted as criminals, use different measures (APD vs. psychopathy)
Interactions of Genes and the Social Environment:
o Role of social environment is key in APD: parenting qualities of negativity, inconsistency and
low in warmth
o Poverty and exposure to violence also predict antisocial behaviour
o Those with CD, if impoverished, 2x more likely to develop APD
o Polymorphism of MAO-A gene predicts psychopathy in males who had experienced
childhood abuse or maternal rejection
o Anti-social behaviour is 40-50% heritable
Psychological Risk: Insensitivity to Threat and to Others’ Emotions:
o Psychopaths are unable to learn from experience, immune to anxiety that keeps us from
breaking the law/lying
o Deficits in experience of fear and threat, lower than normal levels of skin conductance
o Deficits in developing conditioned fear responses *no increased amygdala activity for CS
o Even more unresponsive to threat when trying to obtain a reward
o Inattentiveness to threats when pursing a goal – deficits in regions of prefrontal cortex
involve in attending to negative information during goal pursuit
o Lack of empathy – especially difficult to recognize fear in others
V. Borderline PD (BPD)
Presence of 5+ of the following signs of instability in relationships, self-image, and impulsivity from
early adulthood across many contexts:
o 1) Frantic efforts to avoid abandonment
o 2) Unstable interpersonal relationships in which others are either idealized or devalued
o 3) Unstable sense of self
o 4) Self-damaging, impulsive behaviours in at least two areas, such as spending, sex, substance
abuse, reckless driving, and binge eating
o 5) Recurrent suicidal behaviour, gestures or self-injurious behaviour
o 6) Marked mood reactivity
o 7) Chronic feelings of emptiness
o 8) Recurrent bouts of intense or poorly controlled anger
o 9) Curing stress, a tendency to experience transient paranoid thoughts and dissociative
symptoms
Very common in clinical settings, very hard to treat, associated with recurrent periods of suicidality
Core features: impulsivity and instability in relationships and mood, emotional reactivity
Emotions are intense, erratic, shift abruptly *passionate idealization to contemptuous anger
Overly sensitive to small signs of emotions in others
No clear/coherent sense of self
Cannot bear to be alone (fear of abandonment), chronic depression and emptiness
Psychotic and dissociative symptoms when stressed
2/3 engage in self-mutilation
Likely to have comorbid PTSD, mood disorders, substance related disorders, eating disorders = more
likely to last longer
Etiology
Neurobiological Factors:
o Highly heritable (60%)
o Lower serotonin function – general dysregulation
Must be decided before it can be determined whether a person is responsible for the crime which
he/she is accused
Pate v. Robinson – the defense attorney, prosecutor, or judge may raise the question of the
psychological disorder whenever there is reason to believe that the accused person’s mental
condition might interfere with his/her upcoming trial
In absentia “not present” = a centuries old principle of English common law that refers to the
person’s mental state, not his/her physical presence
o Trial can be delayed, accused person placed in hospital with hopes of restoring adequate
mental function
Being deemed mentally ill doesn’t necessarily mean cannot stand trial
Being judged incompetent to stand trial has consequences for individual:
o Bail is automatically denied, person usually kept in hospital for pretrial examination
(supposed to receive treatment to become competent to stand trial), person may lose
employment, undergo trauma from being separated from family/friends/familiar
surroundings
Jackson v. Yates – deaf and mute man with intellectual disability, deemed unlikely to ever be
competent to stand trial
o If deemed not ever competent, state must either institute civil commitment or release the
defendant
o Cannot be committed to process of determining competency that exceeds longest possible
sentence
o Most people deemed competent in about 6 months
Can proceed in trial with “synthetic sanity” due to medication
Cannot forced defendant to take medication, until 2003***new ruling, can be used only if
alternative treatments had failed
Medications are often the most effective means of restoring competency
Insanity, Intellectual Disability, and Capital Punishment
Should someone who is sentenced to death have to be legally sane at the time of the execution?
Daryl Atkins – intellectual disability and capital punishment – lacked understanding of consequences
of actions, not morally culpable for acts as a person of normal intelligence *capital punishment
would be unconstitutional
o Ruled that capital punishment of those with intellectual disability constitutes cruel and
unusual punishment (8th amendment prohibits)
o State of Virginia defined intellectual disability as IQ of 70 or less along with difficulties in self-
care and social interaction ***varies from state-to-state
Supreme Court 2014 – intellectual disability cannot be determined solely on the basis of IQ score,
must also include assessments of adaptive functioning over the lifetime
2. Civil Commitment
Governments have a duty to protect their citizens from harm
Right and obligation to protect us both from ourselves, parens patriae, “power of the state” & from
others, the police power of the state
A person can be committed to a hospital against his/her will if judgment is made that he/she is:
o 1) Mentally ill and, 2) A danger to self (suicidal or unable to provide for basic physical needs)
or to others
o Dangerousness to others is more often the principle criterion in court rulings
Civil commitment is supposed to last only as long as the person remains dangerous
Formal and informal commitment procedures:
o Modest neurocognitive decline (between the 3rd and 16th percentile) on formal testing or
equivalent clinical evaluation
2) The cognitive deficits do not interfere with independence in everyday activities (e.g. paying bills or
managing medications), even though greater effort, compensatory strategies, or accommodation
may be required to maintain independence
3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to
another psychological disorder
Criteria for Major Neurocognitive Disorder (Dementia)
1) Significant cognitive decline from previous levels in one or more domains based on both of the
following:
o Concerns of the patient, a close other, or clinician
o Substantial neurocognitive impairments (below the 3rd percentile on formal testing) or
equivalent clinical evaluation
2) The cognitive deficits interfere with independence in the everyday activities
3) The cognitive deficits do not occur exclusively in the context of delirium and are not due to
another psychological disorder
0.4% prevalence of dementia in 2000
Prevalence increases with age, 1-2% ages 60-69, increases to 20% in ages 85+
Types:
o Alzheimer’s – most researched
o Frontotemporal dementia – affects frontal and temporal lobes
o Vascular dementia – caused by cerebrovascular disease
o Dementia with Lewy Bodies – presence of Lewy bodies
Alzheimer’s Disease
Brain tissue irreversibly deteriorates, death usually occurs within 12 years
6th leading cause of death in US
Most common symptom is memory loss, may begin with absentmindedness and gaps in memory for
new material
Interferes with daily living
Apathy is a common symptom before cognitive symptoms are noticeable, 1/3 develop depression,
problems with language and word finding, visual-spatial abilities decline – disorientation = confusion
with respect to time, place or identity
Unaware of own cognitive problems initially, become agitated
Personality loses its sparkle/integrity “not him/herself anymore”
Become oblivious to surroundings
Plaques = small, round beta-amyloid protein deposits outside the neurons
o Mostly in frontal cortex, may be present 10-20 years before cognitive symptoms
o Measured using special PET scan
Neurofibrillary tangles = twisted protein filaments composed largely of the protein tau in the axons
of neurons
o Measured in cerebrospinal fluid
o Most densely present in hippocampus
Immune response to plaques leads to inflammation, triggers a series of brain changes
Loss of acetylcholinergic (ACh) and gluateminergic neurons, neurons begin to die
Entorhinal cortex and hippocampus shrink, followed by shrinking of frontal, temporal, and parietal
lobes
Ventricles become enlarged
Cerebellum, spinal cord and motor/sensory areas less affected *do not appear to have anything
physically wrong at first
25% eventually experience motor deficits
Heritability estimate of 79%, 21% due to environmental factors
A set of 10 genes explains 20% of the risk for AD among white non-Hispanic samples
Polymorphism of gene on chromosome 19 called apolipoprotein (ApoE-4 allele)
o Having 1 allele increases risk by 20%
o Interferes with clearing excess beta-amyloid from brain
o 2 alleles – overproduction of beta-amyloid plaques, loss of neurons in hippocampus and low
glucose metabolism BEFORE AD
Immune process and high cholesterol can trigger inflammation, related to greater risk of AD (e.g.
type II diabetes)
Brain trauma from accident/injury increases risk
Lifestyle variables: smoking, being single, obesity, depression, low social support = higher risk
o Lower risk: Mediterranean diet, exercise, education, engagement in cognitive activities
Exercise may predict fewer memory problems, less decline in cognitive function
o Low levels of plaques in brain
Frequent cognitive activity related to 46% decrease in risk, protects against cognitive decline
Cognitive reserve = the idea that some people may be able to compensate for the disease by using
alternative brain networks or cognitive strategies such that cognitive symptoms are less pronounced
Depression can be a consequence of dementia, opposite effect occurs as well
Frontotemporal Dementia
= Caused be a loss of neurons in the frontal and temporal regions of the brain (anterior temporal and
prefrontal)
Begins in mid-to-late 50s, progresses rapidly, death occurs in 5-10 years, less than 1% prevalence
Memory is not severely impaired
There are multiple subtypes, most common = behavioural variant FTD
o Deterioration in at least 3 areas at a level that leads to functional impairment:
Empathy, executive function, ability to inhibit behaviour, compulsive/perseverative
behaviour, hyperorality (= tendencies to put nonfood objects in the mouth) and
apathy
Changes in personality and judgment, emotional regulation
Often misdiagnosed as a midlife crisis (begin chain smoking, over eating, drinking alcohol) or
depression/bipolar/schizophrenia
Affects emotion more than AD, damages social relationships, inability to properly express emotions
May violate social conventions
Affects marital satisfaction more than AD
Caused by different molecular processes: Pick’s disease = presence of Pick bodies within neurons
Some have high levels of tau = protein filaments that contribute to neurofibrillary tangles
Strong genetic component
Vascular Dementia
= Caused by cerebrovascular disease
Stroke causes blood clot, impairs circulation, results in death of neurons
7% develop dementia in year after stroke, risk increases with recurrent strokes
Similar risks as for cardiovascular disease: high levels of bad cholesterol (LDL), smoking, elevated
blood pressure
More common in African American than Caucasian
Symptoms vary depending on where stroke occurred
II. Delirium
1) Disturbances in attention and awareness
2) A change in cognition, such as disturbance in orientation, language, memory, perception, or
visuospatial ability, not better accounted for by a dementia
3) Rapid onset (hours/days) and fluctuation during the course of a day
4) Symptoms are caused by a medical condition, substance intoxication or withdrawal, or toxin
“Out of track”, deviating from usual state, clouded state of consciousness
Two most common symptoms: extreme trouble focusing attention, profound disturbances in
sleep/wake cycle
Cannot maintain coherent stream of thought, trouble answering questions
Become drowsy during the day, awake/agitated at night
Vivid dreams and nightmares
Speech is rambling and incoherent
Lose track of what day it is, where they are, who they are
Memory impairment for recent events is common
Perceptual disturbances are frequent, mistake unfamiliar for familiar, visual hallucinations, delusions
in 25% of older adults (poorly worked out, fleeting and changeable)
Mood/activity swings, disordered thoughts, erratic, shift between emotions
Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, incontinence
of urine and feces
Become lethargic/unresponsive
Have lucid intervals – alter and coherent *daily fluctuations help distinguish from AD
Symptoms worsen during sleepless nights
More common among young children and older adults (nursing homes and hospitals)
6-12% nursing home residents developed delirium in 1 year
Often misdiagnosed, especially if lethargy is present or if person has dementia
High mortality rate if left untreated, 1/3 die within a year
Increased risk for further cognitive decline
Etiology
Caused by medical conditions: drug intoxications, withdrawal reactions, metabolic and nutritional
imbalances (diabetes, thyroid dysfunction, kidney/liver failure, congestive heart failure,
malnutrition), dehydration, infections, fevers, neurological disorders, stress of major injury
One of most common triggers is hip surgery
Usually has more than one cause
Physical declines of late life, increased susceptibility to chronic diseases, many medication
prescribed, greater sensitivity to drugs = increased vulnerability for elderly
Treatment
Recovery if underlying cause is treated promptly
Atypical antipsychotic medication
Treatment takes 1-4 weeks for condition to clear, longer in older people
Preventative strategies:
o Clocks of hospital patients in field of vision, helps stay oriented
o Shades open during the day, lights turned off at night
o Minimal sleep disruptions
o Stress-free, hydration
Risk factors: sleep deprivation, immobility, dehydration, visual/hearing impairment
High risk of delirium among those with dementia
Very common in clinical settings, very hard to treat, associated with recurrent periods of suicidality
Core features: impulsivity and instability in relationships and mood, emotional reactivity
Emotions are intense, erratic, shift abruptly *passionate idealization to contemptuous anger
Overly sensitive to small signs of emotions in others
No clear/coherent sense of self
Cannot bear to be alone (fear of abandonment), chronic depression and emptiness
Psychotic and dissociative symptoms when stressed
2/3 engage in self-mutilation
Likely to have comorbid PTSD, mood disorders, substance related disorders, eating disorders = more
likely to last longer
Etiology
Neurobiological Factors:
o Highly heritable (60%)
o Lower serotonin function – general dysregulation
o Increased activation of amygdala to emotional pictures – emotion dysregulation
o Deficits in prefrontal cortex – impulsivity
o Disrupted connectivity between prefrontal cortex and amygdala
Social Factors: Childhood Abuse in the Context of Genetic Vulnerability:
o Parental separation, verbal & emotional abuse during childhood
o Tied to high rates of childhood abuse/neglect and high heritability
o Childhood abuse doesn’t predict BPD after genetic risk is controlled
o Childhood trauma accounts for less than 1% in variance
o Genetically driven impulsivity, emotionality and risk-seeking in parents could increase risk of
abusing children
Linehan’s Diathesis-Stress Theory:
o BPD develops when people who have difficulty controlling their emotions because of a
biological diathesis are raised in a family environment that is invalidating
o Emotional regulation diathesis interactions with experiences of invalidation = BPD
development
Biological diathesis: Emotional dysregulation in the child great demands on the
family invalidation by parents through punishing/ignoring emotional outbursts
by child to which parents attend emotional dysregulation of child
VI. Histrionic Personality Disorder (HPD)
Presence of 5+ of the following signs of excessive emotionality and attention seeking from early
adulthood across many contexts:
o 1) Strong need to be the centre of attention
o 2) Inappropriate sexually seductive behaviour
o 3) Rapidly shifting and shallow expression of emotions
o 4) Use of physical appearance to draw attention to self
o 5) Speech that is excessively impressionistic and lacking in detail
o 6) Exaggerated, theatrical emotional expression
o 7) Overly suggestible
o 8) Misreads relationships are more intimate than they are
Key feature: overly dramatic and attention-seeking behaviour
Use physical appearance to draw attention to themselves
Emotionally shallow, overly concerned with physical attractiveness, uncomfortable when not the
centre of attention
Many enter treatment for condition other than PD (e.g. substance abuse, anxiety, depression)
General Approaches to the Treatment of PDs
Psychotherapy is the treatment of choice – small but positive effects, often supplemented with
medication
Weekly sessions, or day-treatment programs (several hours/day), occupational therapy provided
Psychodynamic theory – childhood problems are at the root of PDs, help patient reconsider those
early experiences, become more aware of how they drive current behaviour and reconsider
beliefs/responses to early events
Cognitive theory – negative cognitive beliefs are at the heart of PDs, help person become aware of
those beliefs and challenge maladaptive cognitions
o Explore biases in thinking
o Look for dysfunctional schemas/assumptions the underline person’s thoughts/feelings
Cannot change underlying traits of PD, but can change disorder into a style or more adaptive way of
approaching life
Treatment of Schizotypal Disorder and Avoidant Personality Disorder
Antipsychotic drugs (risperidone) for schizotypal, reduces unusual thinking
Avoidant PD responds to same treatments as social anxiety disorder – antidepressant medications
and cognitive behavioural treatment
o Help person challenge negative beliefs about social interactions, teach behavioural strategies
for dealing with social situations, exposure treatment
Psychopathy – psychotherapy, either CBT or psychodynamic
Treatment of Borderline Personality Disorder
***Difficult to treat
Show interpersonal problems in therapeutic relationship
Client finds it difficult to trust others, idealize and vilify the therapist
Difficult to tell if call at 2:00 from patient is call for help or a manipulative gesture to test the
therapist
Medications – anti-depressants, mood stabilizers
Hospitalization is often necessary to protect against suicide
Many therapist consult with others due to high stress of treatment
Metallization based therapy – fail to think about their own and other’s feelings
Schema-focused cognitive therapy – identify maladaptive assumptions that underlie cognitions
Dialectical behaviour therapy – combines client-centered empathy and acceptance with cognitive
behavioural problem solving, emotion-regulation techniques and social skills training
o Constant tension between any phenomenon and its opposite is resolved by creating a new
phenomenon (the synthesis) *term dialectical used on 2 main ways:
1) Seemingly opposite strategies that the therapist must use when treating BPD –
accepting them as they are and yet helping them change
2) The patient’s realization that splitting the world into good and bad is not necessary;
instead one can achieve a synthesis of these apparent opposites
o 4 stages:
1) Dangerously impulsive behaviours are addressed with the goal of promoting
greater control
2) Learning to modulate the extreme emotionality – learn to tolerate emotional
distress
3) Improving relationships and self-esteem
4) Designed to promote connectedness and happiness
Learn more effective and socially acceptable ways to handle day-to-day problems
1) A person is not responsible for criminal conduct if at the time of such conduct as a
result of mental disease or defect he lacks substantial capacity either to appreciate
the criminality of his conduct or conform his conduct to the requirements of law
2) The terms “mental disease/defect” do not include an abnormality manifested only
by repeated criminal or otherwise antisocial conduct
o First guideline combines M’Naghten rule and irresistible impulse
Insanity Defense Reform Act:
o John Hinckley Jr. found not guilty by reason of insanity (NGRI) for assassination attempt
against President Ronald Reagan
o Many committed to mental hospital stay there longer than would have stayed in prison
o As a consequence of political pressures to get tough on criminal, congress enacted the
Insanity Defense Reform Act
Addressed insanity defense at federal level for the first time
1) Eliminates irresistible-impulse component of the ALI rules
2) Changes the ALI’s “lacks substantial capacity…to appreciate” to “unable to
appreciate” *tightens the grounds for an insanity defense, making criteria for
impairment judgment more stringent
3) Stipulates that mental disease/defect must be severe
No longer can use defense “diminished capacity” or “diminished
responsibility” based on mitigating circumstances as extreme passion or
temporary insanity
4) Shifts the burden of proof from prosecution to defense *defense must prove the
defendant insane, with clear and convincing evidence
5) Person may remain committed longer than the ordinary sentence, released only
when deemed by professionals to be no longer dangerous and no longer mentally ill
Current Insanity Pleas:
o Not guilty by reason of insanity (NGRI) = there is no dispute over whether the person
actually committed the crime – both sides agree that the person committed the crime
Due to the person’s insanity at the time, the defense argues that the person should
not be held responsible for and thus should be acquitted of the crime
Successful: person not held responsible due to psychological disorder
Committed indefinitely to forensic hospital, released only when deemed no longer
dangerous and no longer mentally ill
Forensic hospital perimeter is secure with gates, barbed wires, or electric fences,
doors to different units may be locked, bars may be placed on windows, security
doesn’t carry weapons or wear uniforms
Someone found NGRI could not remain committed if no longer mentally ill, even if still
considered dangerous
o Guilty but mentally ill (GBMI) = allows an accused person to be found legally guilty of a crime
– thus maximizing the chances of incarceration – but also allows for psychiatric judgment on
how to deal with the convicted person if he/she is considered to have been mentally ill at
time of crime
Usually put in general prison population, may or may not receive treatment
May be committed to mental hospital if still considered dangerous/mentally ill after
sentence is over
E.g. Jeffery Dahmer – accused of and admitted to butchering, cannibalizing and having
sex with the corpses of 15 boys and young men, entered plea of guilty, attorneys
argued disorder should be considered during sentencing
Critics argue that it doesn’t benefit criminals with psychological disorders, and doesn’t
result in appropriate treatment
Some believe GMBI is not as tough as a guilty verdict, but people receiving GBMI
verdict often spend more time incarcerated
Standards of Proof (table 16.2)
o Beyond a reasonable doubt – 95% certainty needed to convict
o Clear and convincing evidence – 75%
o Beyond a preponderance of the evidence – 51%
Competency to Stand Trial
Insanity defense concerns accused’s mental state at the time of the crime
Competency to stand trial = whether the defendant has sufficient present ability to consult with his
lawyer with a reasonable degree of rational understanding, and whether he has a rational as well as
a factual understanding of the proceedings against him
Must be decided before it can be determined whether a person is responsible for the crime which
he/she is accused
Pate v. Robinson – the defense attorney, prosecutor, or judge may raise the question of the
psychological disorder whenever there is reason to believe that the accused person’s mental
condition might interfere with his/her upcoming trial
In absentia “not present” = a centuries old principle of English common law that refers to the
person’s mental state, not his/her physical presence
o Trial can be delayed, accused person placed in hospital with hopes of restoring adequate
mental function
Being deemed mentally ill doesn’t necessarily mean cannot stand trial
Being judged incompetent to stand trial has consequences for individual:
o Bail is automatically denied, person usually kept in hospital for pretrial examination
(supposed to receive treatment to become competent to stand trial), person may lose
employment, undergo trauma from being separated from family/friends/familiar
surroundings
Jackson v. Yates – deaf and mute man with intellectual disability, deemed unlikely to ever be
competent to stand trial
o If deemed not ever competent, state must either institute civil commitment or release the
defendant
o Cannot be committed to process of determining competency that exceeds longest possible
sentence
o Most people deemed competent in about 6 months
Can proceed in trial with “synthetic sanity” due to medication
Cannot forced defendant to take medication, until 2003***new ruling, can be used only if
alternative treatments had failed
Medications are often the most effective means of restoring competency
Insanity, Intellectual Disability, and Capital Punishment
Should someone who is sentenced to death have to be legally sane at the time of the execution?
Daryl Atkins – intellectual disability and capital punishment – lacked understanding of consequences
of actions, not morally culpable for acts as a person of normal intelligence *capital punishment
would be unconstitutional
o Ruled that capital punishment of those with intellectual disability constitutes cruel and
unusual punishment (8th amendment prohibits)
o State of Virginia defined intellectual disability as IQ of 70 or less along with difficulties in self-
care and social interaction ***varies from state-to-state
Supreme Court 2014 – intellectual disability cannot be determined solely on the basis of IQ score,
must also include assessments of adaptive functioning over the lifetime
2. Civil Commitment
Governments have a duty to protect their citizens from harm
Right and obligation to protect us both from ourselves, parens patriae, “power of the state” & from
others, the police power of the state
A person can be committed to a hospital against his/her will if judgment is made that he/she is:
o 1) Mentally ill and, 2) A danger to self (suicidal or unable to provide for basic physical needs)
or to others
o Dangerousness to others is more often the principle criterion in court rulings
Civil commitment is supposed to last only as long as the person remains dangerous
Formal and informal commitment procedures:
o Formal (judicial) commitment is by order of a court, can be requested by any responsible
citizen
Judge will order mental health examination if believes there is a good reason to
Person has the right to object the these attempts, court hearing scheduled to allow
person to present evidence against commitment
o Informal (emergency) commitment can be accomplished without involving the courts initially
If hospital board believes a person requesting discharge is too mentally ill and
dangerous, can detain the person with a temporary, informal commitment order
Police can take any person acting out-of-control or in a dangerous manner to a
psychiatric hospital
Most common is the Physician’s Certificate (PC) – physician can sign a certificate that
allows a person to be hospitalized for some period between 24 hours to 20 days
Affects more people than criminal commitment
Preventative Detention and Problems in the Prediction of Dangerousness
Not the case that people with psychological disorders account for a significant proportion of the
violence that besets society
3% of US violence is linked to psychological disorders
Over 90% diagnosed with psychotic disorders (mostly schizophrenia) are not violent
MacArthur Violence Risk Assessment Study – large prospective study of violent behaviour in persons
recently discharged from psychiatric hospitals
o People with psyc disorders who did not also abuse substances were no more likely to engage
in violence that are people without psyc disorders and substance abuse
o When people with psyc disorders do act aggressively, usually against family/friends, and at
home
o People with psyc disorders report more violent thoughts in hospital
o People with psyc disorder more likely to be aggressive if have positive or disorganization
symptoms of schizophrenia or also abusing drugs
o Issues of substance abuse rather than psychotic disorders are the main contributory factors
to violence
The Prediction of Dangerousness:
o Mental health professionals are poor at making a judgment of whether or not a person will
commit a dangerous act
o Only he or she may release the other person to disclose confidential information in a legal
proceeding
There are limits:
o If person has accused the therapist of malpractice – can divulge info about therapy in self-
defense
o If the person is less than 16 years old and therapist has reason to believe that the child has
been a victim of a crime (e.g. child abuse) *psychologist is required to report to police to
child welfare within 36 hours any suspicion
o If the person initiated therapy in hopes of evading the law for having committed a crime or
for planning on doing so
o If the therapist judges that the person is a danger to self or others and disclosure of info is
necessary to ward off danger