Understanding Psychopathology

MYTHS AND MISCONCEPTIONS ABOUT THE SCIENCE OF PSYCHOPATHOLOGY

ABNORMAL BEHAVIOR • PSYCHOPATHOLOGY
- No Single Definition of Psychological o the scientific study of psychological
Abnormality disorders
- No Single Definition of Psychological Normality • Mental Health Professionals
- Psychology Disorder v. Mental illness o The Ph.D.: Clinical, counseling, and
school psychologists
Many Myths Are Associated With Mental o The Psy.D.: Clinical, counseling, and
Illness school psychologists
– Lazy, crazy, dumb ▪ “Doctors of Psychology”
– Weak in character o M.D.: Psychiatrists (medications)
– Dangerous to self or others
– Mental illness is a hopeless situation THE SCIENTIST-PRACTITIONER MODEL

PSYCHOLOGICAL DISORDER
• Psychological Dysfunction
o Breakdown in cognitive, emotional, or
behavioral functioning
• Personal Distress or Impairment
o Difficulty performing appropriate and
expected roles
o Impairment is set in the context of a
person’s background
• Atypical or Not Culturally Expected
Response
o Reaction is outside cultural norms

PSYCHOLOGICAL DISORDER OR
ABNORMAL BEHAVIOR
- A psychological dysfunction within an individual
associated with distress or impairment in
functioning and a response that is not typical or
culturally expected.

DSM-5 DEFINITION OF ABNORMAL

BEHAVIOR
CLINICAL DESCRIPTION
- A mental disorder is a syndrome characterized
• Presenting problem
by clinically significant disturbance in an
o Presents is a traditional way of
individual’s cognition, emotional regulation or
indicating why the person came to
behavior that reflects a dysfunction in the
the clinic
psychological, biological, or developmental
processes underlying mental functioning. Mental • Clinical Description
disorders are usually associated with significant o represents the unique combination
distress or disability in social, occupational, or of behaviors, thoughts, and feelings
other important activities. An expectable or that make up a specific disorder
culturally appropriate response to a common • Prevalence
stress or loss, such as death of a loved one, is o how many people in the population
not a mental disorder. Socially deviant behavior as a whole have the disorder
(e.g., political, religious, or sexual) and conflicts • Incidence
that are primarily between individuals and o statistics on how many new cases
society are not mental disorders unless the occur during a given period
deviance or conflict results from a dysfunction in • Course
the individual, as described above. o individual pattern
–DSM-5, p. 20. • Prognosis
o anticipated course of a disorder
CLINICAL DESCRIPTION MOON AND STARS
• Begins with the Presenting Problem • Paracelsus (a Swiss physician), suggested
• Description Aims to that the movements of the moon and stars
o Distinguish clinically significant had profound effects on people's
dysfunction from common human psychological functioaning.
experience
• Describe Prevalence and Incidence of The Biological Tradition
Disorders HIPPOCRATES
• Describe Onset of Disorders • father of modern Western medicine
o Acute vs. insidious onset • Hipprocratic Corpus, suggested that
• Describe Course of Disorders psychological disorders could be treated
o Episodic, time-limited, or chronic like any other disease
course • believed that psychological disorders might
• Other features (e.g. age, developmental also caused by brain pathology or head
stage, ethnicity, race) trauma and could be influenced by heredity
• Add: Subtypes and Specifiers – DSM 5 • recognized the importance of psychological
and interpersonal contributions to
CAUSATION, TREATMENT, AND ETIOLOGY psychopathology
OUTCOMES • Four bodily fluids or humors: blood (heart),
• ETIOLOGY black bile (spleen), yellow bile (liver), and
- the study of origins, has to do with why a phlegm (brain)
disorder begins (what causes it) and • coined the term hysteria to describe a
includes biological, psychological, and concept about Egyptians who had
social dimensions identified somatic symptom disorders
• TREATMENT GALEN
- treatment development • adopted ideas of Hippocrates
- includes pharmacologic, psychosocial, • Hippocratic-Galenic approach: humoral
and/or combined treatments theory of disorders
• OUTCOME
- treatment outcome (“Evidence Based Four bodily fluids or humors:
Treatment”) 1. SANGUINE (Blood)
- someone who is ruddy in complexion,
HISTORICAL CONCEPTIONS OF presumably from copious blood flowing
ABNORMAL BEHAVIOR through the body, and cheerful and
optimistic, although insomnia and delirium
• Supernatural Model
weree thought to be caused by excessive
- divinities, demons, spirits or other blood in the brain
phenomena such as magnetic fields or the 2. MELANCHOLIC (Black Bile)
moon or the stars - depressive (depression was thought to be
• Biological Model caused by black bile flooding the brain)
• Psychological Model 3. PHLEGMATIC (Phlegm)
- indicates apathy and sluggishness but
The Supernatural Tradition can also mean being calm under stress
Deviant behavior has been considered a reflection 4. CHOLERIC (Yellow Bile or Choler)
of the battle between good and evil. - Hot tempered
• In the Great Persian Empire from 900 to
600 B.C., all physical and mental disorders THE 19TH CENTURY
are considered the work of evil General Paresis (Syphilis) and the Biological Link
DEMONS and WITCHES With Madness
• The bizarre behavior of people afflicted • Associated with several unusual
with psychological disorders was seen as psychological and behavioral symptoms
the work of the devil and witches • Pasteur discovered the cause – A bacterial
• Treatments exorcism, shaving the pattern microorganism
of a cross in the hair of the victim's head, • Led to penicillin as a successful treatment
securing sufferers to ta wall near the front • Bolstered the view that mental illness = physical
of a church illness and should be treated as such
MASS HYSTERIA
• Large-scale outbreaks of bizarre behavior
also known as Saint Vitus's Dance and
tarantism
JOHN P. GREY o Emphasized how children incorporate
• conditions in hospitals greatly improved (introject) objects
and they becaome more humane, livable o Examples include images, memories,
institutions and values of significant others
(objects)
The Psychological Tradition • The Neo-Freudians: Departures From
MORAL THERAPY Freudian Thought
• Moral referred to more to emotional or o Carl Jung, Alfred Adler, Karen Horney,
psychological factors rather than to a code Erich Fromm, and Erik Erickson
of conduct o De-emphasized the sexual core of
• Tenets: treating institutionalized patients as Freud’s theory
normally as possible in a setting that
encouraged and reinforced normal social PSYCHOANALYTIC PSYCHOTHERAPY:
interaction, by providing them with many THE “TALKING” CURE
opportunities for appropriate social and • free association - patients are instructed
interpersonal contact. to say whatever comes to mind without the
idea program na dapat lahat ng
Proponents: institution is humane ang treatment usual socially required censoring
• Dorothea Dix (Mental Hygiene Movement) • dream analysis - therapist interprets the
• Philippe Pinel and Jean-Baptiste Pussin content of dreams, supposedly reflecting
• William Tuke followed Pinel’s lead in the primary-process thinking of the id, and
England systematically relates the dreams to
symbolic aspects of unconscious conflicts
PSYCHOANALYTIC THEORY • transference - patients comes to relate to
• Freudian Theory of the Structure and the therapist much as they did to important
Function of the Mind figures in their childhood, particularly their
• The Structure of the Mind parents relate so much, close si client kay therapist.
o Id (pleasure principle; illogical, • countertransference - therapist projects
emotional, irrational) some of their own personal issues and
o Ego (reality principle; logical and feelings onto the patient overshare si therapist kay
rational) client.
o Superego (moral principles; keeps Id HUMANISTIC THEORY
and Ego in • Abraham Maslow and Carl Rogers
o balance) • Major Themes
• Defense Mechanisms: When the Ego o That people are basically good
Loses the Battle with the Id and Superego o Humans strive toward self-
o Displacement & denial actualization
o Rationalization & reaction formation • Humanistic Therapy
o Projection, repression, and o Therapist conveys empathy and
sublimation unconditional positive regard
• Psychosexual Stages of Development o Minimal therapist interpretation
o Oral, anal, phallic, latency, and genital
stages THE BEHAVIOR MODEL
• Derived from a Scientific Approach to the
Study of Psychopathology
• Ivan Pavlov, John B. Watson, and Classical
Conditioning
o Classical conditioning is a ubiquitous
form of learning
o Conditioning involves a contingency
between neutral and unconditioned
LATER DEVELOPMENTS IN stimuli
PSYCHOANALYTIC THOUGHT o Conditioning was extended to the
acquisition of fear
• Anna Freud and Self-Psychology
o Emphasized the influence of the ego in Oral - smoke, drinking
defining behavior Anal - burara
• Melanie Klein, Otto Kernberg, and Object Phalic - oedepus complex (son-mother)
Relations Theory electra complex (daughter-father)
Latency - same sex (friends)
Genitals (opposite sex)
THE BEGINNINGS OF BEHAVIOR TIMELINE OF SIGNIFICANT EVENTS
THERAPY
• Reactionary Movement Against
Psychoanalysis and Non-Scientific
Approaches
• Early Pioneers
o Joseph Wolpe – Systematic
desensitization
• Edward Thorndike, B. F. Skinner, and
Operant Conditioning
o Another ubiquitous form of learning
o Most voluntary behavior is controlled
by the consequences that follow
behavior
• Learning Traditions Greatly Influenced the
Development of Behavior Therapy
o Behavior therapy tends to be time-
limited and direct
o Strong evidence supporting the
efficacy of behavior therapies

BEHAVIORAL-COGNITIVE
• Albert Ellis – Rational Emotive Behavior
Therapy – RET/REBT – 1950’s - It is what
we think that causes us to be disturbed
• Albert Bandura – Social Learning Theory –
1960 (vicarious learning) & Social
Modeling
• Aaron (Tim) Beck MD – Cognitive Therapy
(1960 & 70); David Burns, MD – Cognitive
distortions
• Arnold Lazarus – Multimodal Therapy –
1970’s – 7 domains to address in
assessment and treatment
o BASIC- ID; Behavior, Affect,
Sensation, Imagery, Cognitive,
Interpersonal, and Drug (physical)
 Neurodevelopmental Disorders
DSM IV-TR Axis V - Global Assessment of Functioning
• Diagnostic and Statistical Manual of Mental Scale
Disorders. Fourth Edition, Text Revision • A reflection of the evaluating clinician's
• Published by American Psychiatric judgement of a patient's ability to function
Association in daily life. The 100 point scale measures
• Covers all mental disorders of adults and psychological, social and occupational
children. functioning.
• The DSM IV-TR uses a multiaxial or
multidimensional approach to diagnose. DSM-5
Five Axis of Mental Disorders are listed • Published in 2015 by American Psychiatric
below: Association.
o Axis I: Clinical Syndromes • It is intended to assist researchers,
o Axis II: Developmental Disorders and healthcare providers, insurance providers,
Personality Disorders regulatory institutions, and other parties in
o Axis III: Physical Conditions the medical field in guiding treatment of
o Axis IV: Severity of Psychosocial mental health issues.
Stressors
o Axis V: Highest Level of Functioning Changes from DSM IV-TR to DSM-5

Axis I - Clinical Syndromes MODIFICATION OF ARTIFICIAL

• This is the top-level diagnosis that usually CATEGORIZATION
represents the acute symptoms that need • No longer.
treatment. • With the release of the DSM-5, this
o e.g., major depressive episode, categorization has been simplified to clarify
schizophrenic episode, panic attack. relationships between different disorders.
Axis II - Developmental Disorders and THE AUTISM SPECTRUM
Personality Disorders • In the DSM-5, four separately classified
• Axis II is the assessment of personality issues— that are unfortunately very
disorders and intellectual disabilities. common—have been unified under the
• These disorders are usually life-long header of autism spectrum disorder.
problems that first arise in childhood • The previous categories of autism,
• Axis II disorders are accompanied by Asperger’s, childhood disintegrative
considerable social stigma because they disorder, and pervasive developmental
are suffered by people who often fail to disorder are no longer in use.
adapt well to society. ELIMINATION OF CHILDHOOD BIPOLAR
Axis III - General Medical Conditions DISORDER
• Axis III describes physical problems that • In response to an observed trend of
may be relevant to diagnosing and treating harmful over- diagnosis and over-
mental disorders. treatment of childhood bipolar disorder, the
• For example, a patient with an Axis I DSM-5 removes childhood bipolar disorder
diagnosis of mood disorder who also had and replaces it with Disruptive Mood
glaucoma, would have the glaucoma Dysregulation Disorder (DMDD).
recorded on Axis IV; the pain and REVISIONS TO ADHD DIAGNOSIS
increasing blindness of glaucoma could be • The new DSM-5 broadens the ADHD
a relevant factor influencing depression. diagnosis, allowing for adult-onset and
Axis IV Psychosocial and Environmental relaxing the strictness of the criteria to
Problems more accurately reflect new research on
• Axis IV is fairly easy to understand: this disorder.
essentially, it is for recording life events - • Given that adults have more developed
e.g. marriage, new job, death of a loved brains and generally greater impulse
one - that may affect a patient's mental control, adults can now be diagnosed with
health diagnosis and treatment. ADHD if they have fewer signs and
• For example, someone with an Axis I symptoms than children do.
diagnosis of depression who had recently INCREASING DETAIL ON PTSD SYMPTOMS
lost their job would have "job loss" or • Partly due to the wars in Iraq and
"unemployment" recorded on Axis IV. Afghanistan, medical researchers have
gained a great deal more insight into PTSD
in the last 15 years.
 • The DSM-5 reflects this increased
understanding, adds nuance for children • characterized by significant, below average
with PTSD, and describes four main types intelligence and impairment in adap tive
of symptoms: functioning
o Arousal • In DSM-5, ID is classified as mild,
o Avoidance moderate, severe, or profound based on
o Flashbacks overall functioning; in DSM-IV, it was
o Negative impacts on thought patterns classified according to intelligence quotient
and mood (IQ) as mild (50-55 to 70), moderate (35-40
RECLASSIFICATION OF DEMENTIA to 50-55), severe (20-25 to 35--40), or
• In the DSM-5, both dementia and the profound (below 20-25)
category of memory/learning difficulties • global developmental delay - children
called amnestic disorders have been younger than 5 years with severe defects
subsumed into a new category, exceeding those above
Neurocognitive Disorder. • borderline intellectual functioning -
INTELLECTUAL DISABILITY categorized as a condition that may be the
• To reflect common language, the issues focus of clinical attention, but no criteria are
previously referred to as “mental given
retardation” are now classified as DSM-5 CRITERIA
“intellectual disability.” • Intellectual deficits (e.g., in solving
• The diagnostic criteria for this disorder problems, reasoning, abstract thinking)
have also been updated to more strongly determined by intelligence testing and
focus on adaptive functioning, rather than broader clinical assessment
IQ score. • Significant deficits in adaptive functioning
relative to the person’s age and cultural
group in one or more of the following areas:
Classification of Neurodevelopmental communication, social participation, work
Disorders or school, independence at home or in the
- THESE DISORDERS ARE USUALLY FIRST community, requiring the need for support
DIAGNOSED IN INFANCY, CHILD HOOD, OR at school, work, or independent life
ADOLESCENCE • Onset before age 18
DSM-5 CHANGES
EXTERNALIZING DISORDERS • There is explicit recognition that an IQ
• Characterized by outward-directed score must be considered within the
behaviors cultural context of a person
• Noncompliance, aggressiveness, • Adaptive functioning must also be
overactivity, impulsiveness assessed and considered within the
• Includes attention-deficit/hyperactivity person’s age and cultural group
disorder, conduct disorder, and • No longer distinguish among mild,
oppositional defiant disorder moderate, and severe ID based on IQ
• More common in boys scores alone
INTERNALIZING DISORDERS
• Characterized by inward-focused
behaviors Etiology: Neurological Factors
• Depression, anxiety, social withdrawal
DOWN SYNDROME
Includes childhood anxiety and mood
disorders • Chromosomal trisomy 21: an extra copy of
chromosome 21
• More common in girls
Intellectual Disability or Intellectual • 47 instead of 46 chromosomes
Developmental Disorder (previously called FRAGILE-X SYNDROME
mental retardation in DSM-IV) • Mutation in the fMRI gene on the X
• Formerly called mental retardation in DSM- chromosome
IV-TR RECESSIVE-GENE DISEASE
o Not preferred due to stigma • Phenylketonuria (PKU)
o Followed the guidelines of the MATERNAL INFECTIOUS DISEASE,
American Association on Intellectual ESPECIALLY DURING FIRST TRIMESTER
and Developmental Disabilities • Cytomegalovirus, toxoplasmosis, rubella,
(AAIDD) herpes simplex, HIV, and syphilis
• LEAD OR MERCURY POISONING
Treatment Childhood-Onset Fluency Disorder
(Stuttering)
RESIDENTIAL TREATMENT
• Small to medium-sized community
residences
BEHAVIORAL TREATMENTS
• Language, social, and motor skills training
• Method of successive approximation to \\\
teach basic self-care skills in severely
retarded
o e.g., holding a spoon, toileting
• Applied behavioral analysis
COGNITIVE TREATMENTS
• Problem-solving strategies
COMPUTER- ASSISTED INSTRUCTION

Communication Disorders
Four types of communication disorders that are
diagnosed when problems in communication Social (Pragmatic) Communication
cause significant impairment in function‐ ing: Disorder
• language disorder - characterized by a
developmental impairment in vocabulary
resulting in difficulty producing age-
appropriate sentences
• speech sound disorder - difficulty in
articulation
• childhood-onset fluency disorder or
stuttering - characterized by difficulty in
fluency, rate, and rhythm of speech
• social or pragmatic communication
disorder - difficulty in social interaction and
communication with peers.

Language Disorder
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Autism Spectrum Disorder

• a range of behaviors characterized by
severe difficulties in multiple
developmental areas, including social
relatedness; communication; and range of
activity and repetitive and stereotypical
patterns of behavior, including speech
• Divided into 3 levels:
o Level l - characterized by the ability to
speak with reduced social interaction
(this level resembles Asperger's
Speech Sound Disorder disorder, which is no longer part of
DSM-5)
o Level 2 - characterized by minimal
speech and minimal social interaction
(diagnosed as Rett's disorder in DSM-
IV but not part of DSM-5)
o Level 3 - marked by a total lack of
speech and no social interaction
DSM-5 COMBINES MULTIPLE DIAGNOSES
INTO ONE: AUTISM SPECTRUM
DISORDER
 • Autistic disorder, Asperger’s disorder, • Engage in obsessional play
pervasive developmental disorder not • Engage in ritualistic body movements
otherwise specified, and childhood • Become attached to inanimate objects
disintegrative disorder (e.g., keys, rocks)
• Research did not support distinctive
categories COMORBIDITY
• Share similar clinical features; vary only in • IQ < 70 is common
severity o Children with intellectual
• Specifiers include with or without developmental disorder score
accompanying intellectual impairment, poorly on all parts of an IQ test;
language impairment, or catatonia children with ASD score poorly on
those subtests related to language,
such as tasks requiring abstract
thought, symbolism, or sequential
logic
PREVALENCE
• 1 out of 110 children
• Found in all SES, ethnic, and racial groups
• Diagnosis of ASD is remarkably stable
PROGNOSIS
• Children with higher IQs who learn to speak
before age six have the best outcomes

Etiology

GENETIC FACTORS
PROFOUND PROBLEMS WITH THE • heritability estimates of around .80 Twin studies
SOCIAL WORLD o 47 to 90% concordance rates for MZ twins;
• Rarely approach others, may look through 0-20% for DZ twins
people • Genetic flaw
• Problems in joint attention o Deletion on chromosome 16
• Pay attention to different parts of faces than NEUROBIOLOGICAL FACTORS
do people without autism; focus on mouth, • Brain size
neglect eye region o Although normal size at birth, brains of
• This neglect likely contributes to difficulties autistic adults and children are larger
in perceiving emotion in other people than normal
THEORY OF MIND o Pruning of neurons may not be
• Understanding that other people have occurring
different desires, beliefs, intentions, and • “Overgrown” areas include the frontal,
emotions temporal, and cerebellar, which have been
• Crucial for understanding and successfully linked with language, social, and emotional
engaging in social interactions functions
• Typically develops between 2½ and 5 • Abnormally sized amygdalae predicted
years of age more difficulties in social behavior and
• Children with ASD seem not to achieve this communication
developmental milestone
Treatment
• Psychological treatments more promising
COMMUNICATION DEFICITS than drugs
• Children with ASD evidence early language • Earlier treatment associate with better
disturbances outcomes
• Echolalia: immediate or delayed repeating • Intensive operant conditioning (Lovaas,
of what was heard 1987)
• Pronoun reversal: refer to themselves as o Dramatic and encouraging results
“he” or “she” • Parent training and education
• Literal use of words • Pivotal response treatment (Koegel et al.,
REPETITIVE AND RITUALISTIC ACTS 2003)
• Become extremely upset when routine is
altered
 o Focus on increasing child’s motivation GIRLS WITH ATTENTION-
and responsiveness rather than on DEFICIT/HYPERACTIVITY DISORDER
discrete behaviors • Hinshaw et al. (2006) large, ethnically
• Joint attention intervention and symbolic diverse study of girls
play used to improve attention and o Combined type had:
expressive skills ▪ More disruptive behaviors than
• Medication used to treat problem behaviors inattentive type
o Haloperidol (Haldol) ▪ More comorbid diagnoses of
▪ Antipsychotic conduct disorder or oppositional
▪ Reduces aggression and defiant disorder than girls without
stereotyped motor behavior ADHD
▪ Does not improve language and ▪ Viewed more negatively by peers
interpersonal relationships than inattentive type or girls
without ADHD

Attention-Deficit/Hyperactivity Disorder • Inattentive type

(ADHD) o Viewed more negatively by peers than
• one of the most frequently discussed girls without ADHD
psychiatric disorders in the lay media • Girls with ADHD more likely to:
because of the sometimes-unclear line o Be anxious and depressed
between age- appropriate normal and o Exhibit neurological deficits (e.g., poor
disordered behavior and because of the planning, problem-solving)
concern that children without the disorder o Have symptoms of eating disorder and
are being misdiagnosed and treated with substance abuse by adolescence
medication
• The central features of the disorder are Etiology
persistent inattention, hyperactivity and GENETIC FACTORS
impulsivity, or both that cause clinically • Adoption and twin studies
significant impairment in functioning o Heritability estimates as high as 70 to
80%
• Two dopamine genes implicated
o DRD4
▪ Dopamine receptor gene
o DAT1
▪ Dopamine transporter gene Mixed
support for this gene
• Either gene associated with increased risk
only when prenatal maternal nicotine or
alcohol use is present
NEUROBIOLOGICAL FACTORS
• Dopaminergic areas smaller in children
THREE SPECIFIERS IN DSM-5 TO with ADHD
INDICATE WHICH SYMPTOMS o Frontal lobes, caudate nucleus, globus
PREDOMINATE pallidus
• Predominantly inattentive type • Poor performance on tests of frontal lobe
• Predominantly hyperactive-impulsive type function
• Combined type
• ADHD often comorbid with anxiety and
depression
• Prevalence estimates 8 to 11% worldwide
• Public policy can affect diagnosis rates
• More common in boys than girls
• May be because boys’ behavior more likely
to be aggressive
• Symptoms persist beyond childhood
• Numerous longitudinal studies show 65 to
80% still exhibit symptoms
• 60% of adults continue to meet criteria for
ADHD in remission
PERINATAL AND PRENATAL FACTORS • DSM-5 Criteria for Specific Learning
• Low birth weight Disorder:
o Can be mitigated by later maternal • Difficulties in learning basic academic skills
warmth (reading, mathematics, or writing)
• Maternal tobacco and alcohol use inconsistent with person’s age, schooling,
ENVIRONMENTAL TOXINS and intelligence
• Limited evidence that food additives or food • Significant interference with academic
coloring can have a small impact on achievement or activities of daily living
hyperactive behavior • Dyscalculia and dyslexia no longer distinct
• No evidence that refined sugar causes diagnoses
ADHD • Specifiers include impairments in reading,
• Nicotine from maternal smoking written expression, and mathematics
o Exposure to tobacco in utero
associated with ADHD symptoms Learning, Communication, and Motor
o May damage dopaminergic system, Disorders: DSM-5
resulting in behavioral disinhibition
PARENT-CHILD RELATIONSHIP
• Parents give more commands and have
more negative interactions
• Family factors
o Interact with genetic and
neurobiological factors
o Contribute to or maintain ADHD
behaviors but do not cause them

Treatment
PSYCHOLOGICAL TREATMENT
• Parental training
• Change in classroom management
• Behavior monitoring and reinforcement of Etiology: Impairment in Reading (Formerly
appropriate behavior Dyslexia)
SUPPORTIVE CLASSROOM STRUCTURE
• Brief assignments GENETIC FACTORS
• Immediate feedback • Evidence from family and twin studies
• Task-focused style • Genes are those associated with typical
• Breaks for exercise reading abilities (generalist genes)
PROBLEMS IN LANGUAGE PROCESSING
• Speech perception
Learning Disability • Analysis of sounds and their relationship to
• Evidence of inadequate development in a printed words
specific area of academic, language, • Difficulty recognizing rhyme and alliteration
speech or motor skills • Problems naming familiar objects rapidly
o e.g., arithmetic or reading • Delays learning syntactic rules
• Not due to mental retardation, autism, • Deficient phonological awareness
physical disorder, or lack of educational o Inadequate left temporal, parietal,
opportunity occipital activation
• Individual usually of average or above
average intelligence
• Often identified and treated in school Etiology: Impairment in Mathematics
• Reading disorders more common in boys (Formerly Dyscalculia)
Specific Learning Disorders GENETIC AND BIOLOGICAL FACTORS
- These are maturational deficits in development • Evidence from twin studies suggest
that are associated with difficulty in acquiring common genetic factors underlie both
specific skills in reading (also known as dyslexia), reading and math deficits
in written expression, or in mathematics (also • Intraparietal sulcus implicated
known as dyscalculia) • Has different cognitive deficits from
dyslexia
 • Children with only dyscalculia do not have Stereotypic Movement Disorder
deficits in phonological awareness

Cortex of intraparietal sulcus is highly involved in

sensorimotor functions

Treatment
READING AND WRITING SPECIFIERS
• Multisensory instruction in listening,
speaking, and writing skills
• Readiness skills in younger children as
preparation for learning to read Phonics
instruction
COMMUNICATION DISORDERS
• Fast ForWord
o a computer-based reading program Tic Disorders
intended to help students develop and
strengthen the cognitive skills
necessary for successful reading and
learning by Scientific Learning
Corporation
o Involves computer games and
audiotapes that slow speech sounds

Motor Disorders
- diagnosed when motor coordination is
substantially below expectations based on age and
intelligence and when coordination problems
significantly interfere with functioning

Three major types of motor disorders:

• developmental coordination disorder -
an impairment in the development of motor
coordination (e.g., delays in crawl ing or
walking, dropping things, or poor sports
performance)
• stereotypic movement disorder -
consists of repetitive motion activity (e.g.,
head banging and body rocking)
• tic disorder - characterized by sudden
involuntary, recurrent, and stereotyped
movement or vocal sounds
Two types of tic disorders:
• Tourette's disorder - characterized by
motor and vocal tics, including coprolalia
• persistent chronic motor or vocal tic
disorders - a single motor or vocal tic

Developmental Coordination Disorder

 APPROACH TO PSYCHOPATHOLOGY
MULTIDIMENSIONAL INTEGRATIVE APPROACH o Less than 50%
• Biological dimensions o Epigenetic- the environment influences
- include causal factors from the fields of gene development
genetics and neuroscience THE INTERACTION OF GENETIC AND
• Psychological dimensions
ENVIRONMENTAL EFFECTS
- causal factors from behavioral and cognitive
• Eric Kandel and Gene-Environment
processes, including learned helplessness,
Interactions
social learning, prepared learning, and even
o suggested that the very genetic structure
unconscious processes
of cells may change as a result of learning if
• Emotional dimensions
genes that were inactive or dormant
- contributes in a variety of ways to
interact with the environment in such a
psychopathology, as do social and
way that they become active
interpersonal influences
• The Diathesis-Stress Model
• Developmental dimensions
o individuals inherit tendencies to express
- any discussion of causes of psychological
certain traits or bahaviors, which may then
disorders
be activated under conditions of stress
o Examples: Blood-injury-injection phobia,
One Dimensional vs Multidimensional Models alcoholism
One Dimensional Models
• Could mean a paradigm, school, or conceptual
approach
• Could mean an emphasis on a specific cause
of abnormal behavior
• Most paradigms are complex in considering
causation
• Problems occur when information from other • Reciprocal Gene-Environment Model
areas is ignored o or gene-environment correlation model
Multidimensional Models o hypothesis that people with a genetic
• Interdisciplinary, eclectic, and integrative predispostion for a disorder may also
• “System” of influences that cause and have a genetic tendency to create
maintain suffering environmental risk factors that promote
• Draws upon information from several sources the disorder
• View abnormal behavior as multiply o Examples: Depression, impulsivity
determined • Non-Genomic Inheritance of Behavior
MULTIDIMENSIONAL MODELS OF ABNORMAL o Genes are not the whole story
BEHAVIOR
• BIOLOGICAL INFLUENCES NEUROSCIENCE CONTRIBUTIONS TO
• BEHAVIORAL INFLUENCES PSYCHOPATHOLOGY
• EMOTIONAL INFLUENCES • THE FIELD OF NEUROSCIENCE
• SOCIAL INFLUENCES - The role of the nervous system in disease
• DEVELOPMENTAL INFLUENCES and behavior.
• THE CENTRAL NERVOUS SYSTEM (CNS)
GENETIC CONTRIBUTIONS TO - Brain and spinal cord
• THE PERIPHERAL NERVOUS SYSTEM (PNS)
PSYCHOPATHOLOGY
- Somatic and autonomic branches
• Phenotype (observable) vs. Genotype (genetic
makeup)
NEUROSCIENCE AND THE CENTRAL NERVOUS
• Nature of Genes
o Deoxyribonucleic acid (DNA) – The double SYSTEM
helix The Neuron
o 23 pairs of chromosomes • Soma – Cell body
o Dominant vs. recessive genes • Dendrites – Branches that receive messages
o Development and behavior is often from other neurons
polygenetic • Axon – Trunk of neuron that sends messages
• Genetic Contribution to Psychopathology to other neurons
 • Axon terminals – Buds at end of axon from • Hypothalamus – Controls eating, drinking,
which chemical messages are sent aggression, sexual activity
• Synaptic cleft – Small gaps that separate
neurons NEUROSCIENCE: PERIPHERAL NERVOUS AND
ENDOCRINE SYSTEMS
NEURONS FUNCTION ELECTRICALLY, BUT
• SOMATIC BRANCH OF PNS: CONTROLS VOLUNTARY
COMMUNICATE CHEMICALLY
MUSCLES AND MOVEMENT
NEUROTRANSMITTERS ARE THE CHEMICAL • AUTONOMIC BRANCH OF THE PNS
MESSENGERS o Sympathetic and parasympathetic branches
o Regulates cardiovascular system & body
NEUROSCIENCE AND MAJOR temperature
NEUROTRANSMITTERS IN PSYCHOPATHOLOGY o Also regulates the endocrine system and aids
• NOREPINEPHRINE (OR NORADRENALINE) in digestion
• THE ENDOCRINE SYSTEM: HORMONES
• SEROTONIN
• THE HYPOTHALAMIC-PITUITARY
• DOPAMINE ADRENALCORTICAL AXIS (HYPAC AXIS)
• GAMMA AMINOBUTYRIC ACID (GABA o Integration of endocrine and nervous system
NOTE: FOCUS OF MANY MEDICATIONS – function
“CHEMICAL IMBALANCE” HYPOTHESIS
NEUROSCIENCE: FUNCTIONS OF MAIN TYPES OF
NEUROSCIENCE AND BRAIN STRUCTURE NEUROTRANSMITTERS
TWO MAIN PARTS FUNCTIONS OF NEUROTRANSMITTERS
• Brainstem and forebrain o Agonists, antagonists, and inverse agonists
THREE MAIN DIVISIONS o Most drugs are either agnostic or antagonistic
MAIN TYPES OF NEUROTRANSMITTERS
• Hindbrain
• Serotonin(5HT)
• Midbrain • Gamma aminobutyric acid (GABA)
• Forebrain • Norepinephrine
• Dopamine
NEUROSCIENCE AND THE DIVISIONS OF THE BRAIN
HINDBRAIN IMPLICATIONS OF NEUROSCIENCE FOR
• Medulla – Heart rate, blood pressure, PSYCHOPATHOLOGY
respiration • Relations Between Brain and Abnormal
• Pons – Regulates sleep stages Behavior
• Cerebellum – Involved in physical Example: Obsessive Compulsive Disorder
coordination (OCD)
MIDBRAIN • Experience can change Brain Structure and
• Coordinates movement with sensory input Function
• Contains parts of the reticular activating • Therapy can change Brain Structure and
system (RAS) Function
FOREBRAIN (CEREBRAL CORTEX) Medications and psychotherapy
• Location of most sensory, emotional, and
cognitive processing PSYCHOLOGICAL CONTRIBUTIONS TO
• Two specialized hemispheres (left and right) PSYCHOPATHOLOGY
joined by the corpus callosum Conditioning and Cognitive Processes
• Respondent and operant learning
NEUROSCIENCE AND BRAIN STRUCTURE
• Learned helplessness
LOBES OF CEREBRAL CORTEX
• Modeling and observational learning
• Frontal – Thinking and reasoning abilities,
• Prepared learning
memory
Cognitive Science and the Unconscious
• Parietal – Touch recognition
Implicit memory, blindsight, Stroop paradigm
• Occipital – Integrates visual input Cognitive - Behavior Therapy
• Temporal – Recognition of sights and sounds,
long-term memory storage
LIMBIC SYSTEM
• Thalamus – Receives and integrates sensory
information
THE ROLE OF EMOTION IN PSYCHOPATHOLOGY
The Nature of e-Motion
• To elicit or evoke motion
• Action tendency different from affect and mood
• Intimately tied with several forms of
psychopathology
Components of Emotion
• behavior, physiology, and cognition
• example of fear
Harmful side of emotional dysregulation
• anger, hostility, emotional suppression, illness, and
psychopathology

CULTURAL, SOCIAL, AND INTERPERSONAL

FACTORS IN PSYCHOPATHOLOGY
Cultural Factors
• influence the form and expression of normal
and abnormal behavior
Gender Effects
• exerts a strong and puzzling effect on
psychopathology

Social Relationships
• frequency and quality related to mortality,
disease, and psychopathology
• interpersonal psychotherapy
The stigma of Psychopathology is Culturally, Socially,
and Interpersonally Situated
 CLINICAL ASSESSMENT & DIAGNOSIS
The Basic Elements in Assessment Three Concepts Determine the Value of
Assessment
Identification of presenting problem • Reliability
• Situational or pervasive? o Consistency in measurement
• Duration? o Examples include test-retest, inter-
• Prior attempts to help or treat? rater reliability
• Self-defeating or resourceful? • Validity
• How does problem impact social roles? o What the test measures and how well
• Does problem match any DSM-5 disorder it does so
criteria? o Examples include content, concurrent,
discriminant, construct, and face
The Relationship Between Assessment validity
and Diagnosis • Standardization and Norms
o Foster consistent use of techniques
Classification of presenting problem o Provide population benchmarks for
• Treatment planning comparison
• Knowledge of range of diagnostic problems o Examples include administration
• Insurance payment procedures, scoring, and evaluation of
data
Assessing Psychological Disorders
• Purposes of Clinical Assessment Three Concepts Determine the Value of
o To understand the individual Assessment
o To predict behavior
o To plan treatment
o To evaluate treatment outcome Figure 3.1 Concepts that determine the value of
• Analogous to a Funnel clinical assessments.
o Starts broad
o Multidimensional in approach
o Narrow to specific problem areas

Taking a Social or Behavioral History

\\\

Ensuring Culturally Sensitive Assessment Domains of Assessment:

Procedures The Clinical Interview and Physical Exam
• Clinical Interview
• Awareness of increasing population o Most common clinical assessment
diversity method
• APA ethical code related to cultural o Structured or semi-structured
competence • Mental Status Exam
• Cultural variables inclusion o Appearance and behavior
o Thought processes
Influence of Professional Orientation o Mood and affect
o Intellectual functioning
Professional Orientation o Sensorium
• May determine assessment techniques • Physical Exam
• Does not limit clinician to one type of
assessment
Trust and Rapport Between the Clinician and the Psychosocial Assessment
Client
What role does psychosocial assessment attempt
to provide?

Assessment of physical organism

incorporates:
• General physical examination Domains of Assessment: Psychological
• Neurological examination Testing and Projective Tests
• Neuropsychological examination • Psychological Testing
o Must be reliable and valid
General Physical Examination • Projective Tests
o Project aspects of personality onto
ambiguous stimuli
o Roots in psychoanalytic tradition
o High degree of inference in scoring
and interpretation
o Examples include the Rorschach
Inkblot Test, Thematic Apperception
Test
o Reliability and validity data tend to be
mixed
Domains of Assessment: Behavioral Rorschach Test
Assessment and Observation
• Behavioral Assessment
o Focus on here and now
o Tends to be direct and minimally
inferential
o Target behaviors are identified and
observed Thematic Apperception Test
o Focus on antecedents, behaviors, and
consequences
• Behavioral Observation and Behavioral
Assessment
o Can be either formal or informal
o Self-monitoring vs. others observing
o Problem of reactivity using direct
observation
Domains of Assessment: Psychological
Domains of Assessment: Testing and Objective Tests
Behavioral Assessment and Observation • Objective Tests
o Test stimuli are minimally ambiguous
o Roots in empirical tradition
o Require minimal inference in scoring
and interpretation
• Objective Personality Tests
o Minnesota Multiphasic Personality
Inventory (MMPI, MMPI-2, MMPI-A)
o Over 549 true or false items
o Extensive reliability, validity, and
normative database
 • Objective Intelligence Tests • Imaging Brain Structure
o Nature of intellectual functioning and o Computerized axial tomography (CAT
IQ or CT scan)
o The deviation IQ o CAT utilizes X-rays of brain; pictures in
o Verbal and performance domains slices
o Magnetic resonance imaging (MRI)
Domains of Assessment: Psychological o MRI has better resolution than CAT
Testing and Neuropsychology scan
o MRI operates via strong magnetic field
• Neuropsychological Test around head
o Assess broad range of skills and
abilities Domains of Assessment: Neuroimaging and
o Goal is to understand brain-behavior Brain Function (cont.)
relations • Imaging Brain Function
o Used to evaluate a person’s assets o Positron emission tomography (PET)
and deficits o Single photon emission computed
o Examples include the Luria-Nebraska tomography (SPECT)
and Halstead- Reitan Batteries o Both involve injection of radioactive
o Overlap with intelligence tests isotopes
• Problems with Neuropsychological Tests o Radioactive isotopes react with
o False Positives – Saying “you have a oxygen, blood, and glucose in the brain
brain problem, but you do not” o Functional MRI (fMRI) – Brief changes
o False Negatives – Saying “you do not in brain activity
have a brain problem, but you do” • Advantages and Limitations
o Provide detailed information regarding
Neurological Examination brain function
o Procedures are expensive, lack
Neurological tests aid in determination of adequate norms
• site of organic brain disorder o Procedures have limited clinical utility
• extent of organic brain disorder
Domains of Assessment: Psychophysiological
Neuropsychological Examination may Assessment
include: • Psychophysiological Assessment
1. EEG o Methods used to assess brain
2. CAT scan structure, function, and activity of the
3. MRI nervous system
4. PET scan • Psychophysiological Assessment Domains
5. fMRI o Electroencephalogram (EEG) – Brain
wave activity
Neuropsychological examination o Heart rate and respiration –
1. Involves use of expanding array of testing Cardiorespiratory activity
devices o Electrodermal response and levels –
2. Measures cognitive, perceptual, and motor Sweat gland activity
performance o Electromyography (EMG) – Muscle
3. Provides clues to extent and location of brain tension
damage • Uses of Routine Psychophysiological
Assessment
Halstead-Reitan Battery o Disorders involving a strong emotional
• Halstead Category Test component
• Tactual Performance Test o Examples include PTSD, sexual
• Rhythm Test dysfunctions, sleep disorders,
• Speech Sounds Perception Test headache, and hypertension
• Finger Oscillation Task
Diagnosing Psychological Disorders:
Domains of Assessment: Neuroimaging and Foundations in Classification
Brain Structure • Clinical Assessment vs. Psychiatric
• Neuroimaging: Pictures of the Brain Diagnosis
o Allows examination of brain structure o Assessment – Idiographic approach
and function o Diagnosis – Nomothetic approach
 o Both are important in treatment Projective personality tests
planning and intervention • Unstructured stimuli are presented
• Diagnostic Classification • Meaning or structure projected onto stimuli
o Classification is central to all sciences • Projections reveal hidden motives
o Develop categories based on shared
attributes Projective personality tests include:
• Terminology of Classification Systems • Rorschach Inkblot Test
o Taxonomy – Classification in a • Thematic Apperception Test
scientific context • Sentence Completion Test
o Nosology – Taxonomy in psychological
/ medical contexts
o Nomenclature – Nosological labels
MMPI (now MMPI-2 and MMPI-A)
(e.g., panic disorder)
• The MMPI includes ten clinical scales
Diagnosing and Classifying Psychological measuring psychopathology and a few
Disorders validity scales measuring
straightforwardness
• The Nature and Forms of Classification
Systems • Objective personality tests have the
o Classical (or pure) categorical benefits of being cost-effective and highly
approach – Categories reliable
o Dimensional approach – Classification • They have been criticized for being too
along dimensions mechanistic and requiring too much
o Prototypical approach – Both classical reading ability (literacy) and cooperation
and dimensional • Actuarial procedures are used for MMPI
• Two Widely Used Classification Systems and other scientifically constructed
o International Classification of Diseases objective tests
and Health Related Problems (ICD-
10); published by the World Health Integration of Assessment Data
Organization
o Diagnostic and Statistical Manual of
Mental Disorders (DSM); published by
the American Psychiatric Association;
currently the DSM-IV and DSM-IV-TRa

Assessment Interviews
1. Face-to-face interaction
2. Structured interviews
3. Unstructured interviews
Ethical Issues in Assessment
Clinical Observation of Behavior • Potential cultural bias
1. Clinical observation in natural
• Theoretical orientation of clinician
environments
• Under-emphasis on external
2. Clinical observations in therapeutic or
situation
medical settings
3. Use and purpose of rating scales • Insufficient validation
• Inaccurate data or premature
evaluation
Psychological Tests
Classifying Abnormal Behavior
Two general categories of psychological tests for
Complete the sentence below.
use in clinical practice are:
1. Intelligence tests
Classification involves attempts to delineate
2. Personality tests
meaningful sub-varieties of MALADAPTIVE
BEHAVIOR
Most commonly used intelligence tests include:

1. WISC-IV and Stanford-Binet (for

children)
2. WAIS-IV (for adults)
Classifying Abnormal Behavior • Provides structured interview regarding
cultural influences
Benefits of classification include:
• Introduction of order
• Communication establishment
• Statistical research data use
• Clarification of insurance issues

Differing Models of Classification

Formal Diagnostic Classification of Mental

Disorders

TRUE OR FALSE
The DSM is a categorical system.
TRUE

Purposes and Evolution of the DSM

• Purposes of the DSM System
o Aid communication
o Evaluate prognosis and need for
treatment
o Treatment planning
• DSM-I (1952) and DSM-II (1968)
o Both relied on unproven theories and
were unreliable
• DSM-III (1980) and DSM-III-R
o Were atheoretical, emphasizing
clinical description
o Multiaxial system with detailed criterion
sets for disorders
o Problems included low reliability, and
reliance on committee consensus

Formal Diagnostic Classification of Mental

Disorders
The DSM-5
• More comprehensive and more subtypes of
disorders
• Allows for gender related differences in
diagnosis
 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
WHAT IS PSYCHOSIS? People with schizophrenia do not all show the same
• Generic term kinds of symptoms. Symptoms vary from person to
• “Break with Reality” person and may be clinical. Common symptoms
• Symptom, not an illness include:
• Caused by a variety of conditions that affect • Delusions
the functioning of the brain. o Unrealistic and bizarre beliefs not shared by
• Includes hallucinations, delusions and others in the culture.
thought disorder o May be delusions of grandeur (that you are
really Mother Teresa or Napoleon) or
NATURE OF SCHIZOPHRENIA AND
delusions of persecution (the cyclist who
PSYCHOSIS: AN OVERVIEW believed her competitors were sabotaging
• Schizophrenia vs. Psychosis her by putting pebbles in the road).
o Psychotic behavior – Cluster of • Hallucinations
disorders characterized by hallucinations o Censor events that aren’t based on any
and/or loss of contact with reality external event (hearing voices, seeing
o Schizophrenia – A type of psychosis with people who have died).
disturbed thought, perception, language, o Many have auditory hallucinations (David
emotion, and behavior hears his dead uncle talking to him).
• Historical Background • Disorganized speech
o Emil Kraeplin – Used the term dementia o Jumping from topic to topic.
praecox, focused on onset and outcomes o Talking Illogically (not answering direct
o Eugen Bleuler – Introduced the term questions, going off on tangents).
“schizophrenia” or “splitting of the mind” o Speaking on an unintelligible words and
• Impact of Early Ideas on Current Thinking sentences.
About Schizophrenia • Behavioral problems
o Many of Kraeplin and Bleuler’s ideas are o Pacing excitably, wild agitation.
still with us o Catatonic immobility.
o Understanding onset and course are still o Waxy flexibility (keeping body parts in the
considered important same position when they are moved by
EARLY FIGURES IN THE HISTORY OF someone else)
o Inappropriate Dress (coats in the summer,
SCHIZOPHRENIA
shorts in the winter).
o Inappropriate effect
o Ignoring personal hygiene

SCHIZOPHRENIA: THE “POSITIVE”

SYMPTOM CLUSTER
• The Positive Symptoms
o Active manifestations of abnormal behavior,
distortions of normal behavior
o Examples include delusions, hallucinations,
and disorganized speech
• Delusions: “The Basic Characteristics of
Patient-Specific Health Factors in Schizophrenia Madness”
Prevalence in Prevalence in o Gross misrepresentations of reality
Factor o Examples include delusions of grandeur
Schizophrenia General Population
Smoking 75% 25% or persecution
Obesity 50% 33% • Hallucinations
Diabetes 14% 7% o Experience of sensory events without
Mellitus (DM) environmental input
HIV 3% 0.3% o Can involve all senses, but auditory
Hepatitis C 20% 1.8% hallucinations are the most common
Other Inactivity o Findings from SPECT studies
Poor Nutrition
Substance Use
SOME MAJOR LANGUAGE AREAS OF THE TYPES OF SCHIZOPHRENIA
CEREBRAL CORTEX
• Paranoid
o Delusions of grandeur or persecution
o hallucinations (especially auditory)
o Higher level of functioning between
episodes
o May have stronger familiar link than other
types.
• Disorganized
o Disorganized speech and/or behavior
o Immature emotionality (inappropriate affect)
o Chronic and lacking in remissions,
• Catatonic
o alternating immobility and excited agitation
o Unusual motor responses (waxy flexibility,
rigidity)
o Odd facial or body mannerisms (often
mimicking others)
SCHIZOPHRENIA: THE “NEGATIVE” o Rare.
SYMPTOM CLUSTER • Residual
o Person. Has had at least one schizophrenic
• The Negative Symptoms episode, but no longer shows major
o Absence or insufficiency of normal behavior symptoms
o Examples are emotional/social withdrawal, o Still shows “leftover” symptoms (social
apathy, and poverty of thought/speech withdrawal, bizarre thoughts, inactivity, flat
• Spectrum of Negative Symptoms affect)
o Avolition (or apathy) – Inability to initiate • Undifferentiated
and persist in activities o Symptoms of several types that taken
o Alogia – A relative absence of speech together do not neatly fall into one specific
o Anhedonia – Inability to experience pleasure category.
or engage in pleasurable activities
o Flat affect – Show little expressed emotion,
but may still feel emotion SUBTYPES OF SCHIZOPHRENIA
• Paranoid Type – 295.30
SCHIZOPHRENIA: THE “DISORGANIZED” o Intact cognitive skills and affect, and do not
SYMPTOMS show disorganized behavior
o Hallucinations and delusions center around
• The Disorganized Symptoms a theme (grandeur or persecution)
o Include severe and excess disruptions in • Disorganized Type – 295.10
speech, behavior, and emotion o Marked disruptions in speech and behavior,
• Nature of Disorganized Speech flat or inappropriate affect
o Cognitive slippage – Illogical and o Hallucinations and delusions have a theme,
incoherent speech but tend to be fragmented
o Tangentiality – “Going off on a tangent” and o This type develops early, tends to be
not answering a question directly chronic, lacks periods of remissions
o Loose associations or derailment – Taking • Catatonic Type – 295.20
conversation in unrelated directions o Show unusual motor responses and odd
• Nature of Disorganized Affect mannerisms (e.g., echolalia, echopraxia)
o Inappropriate emotional behavior (e.g., o This subtype tends to be severe and quite
crying when one should be laughing) rare
• Nature of Disorganized Behavior • Undifferentiated Type – 295.90
o Includes a variety of unusual behaviors o Major symptoms of schizophrenia, but fail to
o Catatonia – Spectrum from wild agitation, meet criteria for another type
waxy flexibility, to complete immobility
• Residual Type – 295.60
o One past episode of schizophrenia
o Continue to display less extreme residual
symptoms (e.g., odd beliefs)
OTHER PSYCHOTIC DISORDERS o Type II – Negative symptoms, poor
• Schizophreniform Disorder – 295.40 response to medication, pessimistic
o Schizophrenic symptoms for less than 6 prognosis, and intellectual impairments
months
SCHIZOPHRENIA: SOME FACTS AND
o Associated with good premorbid functioning;
STATISTICS
most resume normal lives
• Onset and Prevalence of Schizophrenia
• Schizoaffective Disorder – 295.70
worldwide
o Symptoms of schizophrenia and a mood
o About 0.2% to 1.5% (or about 1%
disorder (e.g., bipolar disorder)
population)
o Prognosis is similar for people with
o Usually develops in early adulthood, but can
schizophrenia
emerge at any time
o Such persons do not tend to get better on
• Schizophrenia Is Generally Chronic
their own
o Most suffer with moderate-to-severe
• Delusional Disorder – 297.1
impairment throughout their lives
o Delusions that are contrary to reality without
o Life expectancy in persons with
other major schizophrenia symptoms
schizophrenia is slightly less than average
o Many show other negative symptoms of
• Schizophrenia Affects Males and Females About
schizophrenia
Equally
o Type of delusions include erotomanic,
o Females tend to have a better long-term
grandiose, jealous, persecutory, and
prognosis
somatic
o Onset of schizophrenia differs between
o This condition is extremely rare
males and females
• Schizophrenia Appears to Have a Strong
ADDITIONAL DISORDERS WITH PSYCHOTIC Genetic Component
FEATURES
• Brief Psychotic Disorder – 298.8
SCHIZOPHRENIA: GENETIC INFLUENCES
o Experience one or more positive symptoms
of schizophrenia • Family Studies
o Usually precipitated by extreme stress or o Inherit a tendency for schizophrenia, not a
trauma specific form of schizophrenia
o Lasts less than one month o Schizophrenia in the family increases risk
for schizophrenia in other family members
• Shared Psychotic Disorder – 297.3
o Delusions from one person manifest in • Twin Studies
another person o Risk of schizophrenia in monozygotic twins
o Little is known about this condition is 48%
o Risk of schizophrenia drops to 17% for
• Schizotypal Personality Disorder -
fraternal (dizygotic) twins
o May reflect a less severe form of
schizophrenia • Adoption Studies
o Risk of schizophrenia remains high in
adopted children with a biological parent
CLASSIFICATION SYSTEMS AND THEIR suffering from schizophrenia
RELATION TO SCHIZOPHRENIA • Summary of Genetic Research
• Process vs. Reactive Distinction o Risk of schizophrenia increases as a
o Process – Insidious onset, biologically function of genetic relatedness
based, negative symptoms, poor prognosis o One need not show symptoms of
o Reactive – Acute onset (extreme stress), schizophrenia to pass on relevant genes
notable behavioral activity, best prognosis o Schizophrenia has a strong genetic
• Good vs. Poor Premorbid Functioning in component, but genes alone are not
Schizophrenia enough
o Focus on person’s level of function prior
to developing schizophrenia SEARCH FOR BEHAVIORAL AND
o No longer widely used
GENETIC MARKERS OF SCHIZOPHRENIA
• Type I vs. Type II Distinction and
Schizophrenia • The Search for Behavioral Markers:
o Type I – Positive symptoms, good Smooth-Pursuit Eye Movement
response to medication, optimistic o Tracking a moving object visually with
prognosis, and absence of intellectual the head kept still
impairment o Tracking is deficit in persons with
schizophrenia, including their relatives
• The Search for Genetic Markers: Linkage SCHIZOPHRENIA: PSYCHOLOGICAL AND
and Association Studies SOCIAL INFLUENCES
o Search for genetic markers is still
inconclusive • The Role of Stress
o Schizophrenia is likely involves multiple o May activate underlying vulnerability
genes and/or increase risk of relapse
• Family Interactions
o Families of people with schizophrenia
SCHIZOPHRENIA: NEUROBIOLOGICAL show ineffective communication patterns
INFLUENCES o High expressed emotion in the family is
• Neurobiology and Neurochemistry: The associated with relapse
Dopamine Hypothesis • The Role of Psychological Factors
o Drugs that increase dopamine (agonists), o Psychological factors likely exert only a
result in schizophrenic-like behavior minimal effect in producing
o Drugs that decrease dopamine schizophrenia
(antagonists), reduce schizophrenic-like
behavior
o Examples include neuroleptics and L- TREATMENT OF SCHIZOPHRENIA
Dopa for Parkinson’s disease
o The dopamine hypothesis proved Individual, Group, and Family Therapy
problematic and overly simplistic • Can help patient and family understand the
o Current theories emphasize several disease and symptom triggers
neurotransmitters and their interaction • Teaches families communication skills
• Structural and Functional Abnormalities • Provides resources for dealing with emotional
in the Brain and practical challenges
o Enlarged ventricles and reduced tissue
volume Social Skills Training
o Hypofrontality – Less active frontal
lobes (a major dopamine pathway) • Can occur in hospital or community settings
• Viral Infections During Early Prenatal • Teaches the person with schizophrenia
Development social, self-care, and vocational skills
o The relation between early viral exposure
and schizophrenia is inconclusive Medication
• Conclusions About Neurobiology and
Schizophrenia • Taking neuroleptic medications may help
o Schizophrenia is associated with diffuse people with schizophrenia to:
neurobiological dysregulation - clarify thinking and perception of reality
o Structural and functional abnormalities in - reduce hallucinations and delusions
the brain are not unique to schizophrenia • Drug treatment must be consistent to be
effective. Inconsistent dosage may aggravate
existing symptoms or create new ones.
LOCATION OF THE CEREBROSPINAL
FLUID IN THE HUMAN BRAIN
MEDICAL TREATMENT OF
SCHIZOPHRENIA
• Historical Precursors
• Antipsychotic (Neuroleptic) Medications
o Medication is often the first line of
treatment for schizophrenia
o Began in the 1950s
o Most medications reduce or eliminate the
positive symptoms of schizophrenia
o Acute and permanent extrapyramidal
and Parkinson-like side effects are
common
o Poor compliance with medication is
common
• Transcranial Magnetic Stimulation
o Relatively untested procedure for
treatment of hallucinations
PSYCHOSOCIAL TREATMENT OF
SCHIZOPHRENIA
• Historical Precursors
• Psychosocial Approaches: Overview and
Goals
o Behavioral (i.e., token economies) on
inpatient units
o Community care programs
o Social and living skills training
o Behavioral family therapy
o Vocational rehabilitation
• Psychosocial Approaches Are Usually a
Necessary Part of Treatment

SUMMARY OF SCHIZOPHRENIA AND

PSYCHOTIC DISORDERS
• Schizophrenia Includes a Spectrum on
Cognitive, Emotional, and Behavioral
Dysfunctions
o Positive, negative, and disorganized
symptom clusters
• DSM-IV and DSM-IV-TR Divides
Schizophrenia Into Five Subtypes
• Other DSM-IV and DSM-IV-TR Disorders
Include Psychotic Features
• Several Causative Factors Have Been
Implicated for Schizophrenia
• Successful Treatment Rarely Includes
Complete Recovery
 MOOD DISORDERS AND SUICIDE
MOOD DISORDERS common sa babae DSM IV-TR
• Mood is a pervasive and sustained
MOOD DISORDER
emotional tone that influences behaviors
• Major Depression
and thoughts.
o a person experienced profound
• Disorders of mood, also called affective
sadness as well as related
disorders, are common among the general
problems such as sleep and
population. They include depressive
appetite disturbances and loss of
disorder, bipolar disorder, and other
energy and self-esteem.
disorders.
• Bipolar Disorder
• Patients with only major depressive
o characterized by periods of
episodes are said to have major depressive
elevated mood and periods of
disorder or unipolar depression.
(may depression) depression
DSM 5 Elevated mood = Hyper/Extreme emotions
MOOD DISORDERS: HISTORY • Bipolar I Disorder
• Bipolar II Disorder
• The story of King Saul as depicted by The
• Cyclothymic Disorder
Old Testament describes a depressive
syndrome: Saul was at times possessed by • Substance/ Medication-Induced Bipolar
an “evil spirit” which “tormented him”. He and Related Disorder
had several symptoms such as insomnia, • Bipolar and Related Disorders due to
feelings of worthlessness, indecisiveness another Medical Condition
and even paranoia and irritability. He may • Other Specified Bipolar and Related
have committed suicide during a battle. Disorders
• About 400 BC, Hippocrates used the terms • Unspecified Bipolar and Related Disorders
mania and melancholia to describe mental
disturbances. The DSM-5 Classification of Mood Disorders
• Around 30 AD, Celsus described • Section II, Chapter 3 (pages 123-154):
melancholia (from Greek melan [“black”] Bipolar and Related Disorders.
and chole [“bile”]) as a depression caused • Section II, Chapter 4 (pages 155-188):
by black bile. Depressive Disorders.
• In 1854, Jules Falret described a condition
called folie circulaire, in which patients
experience alternating moods of BIPOLAR I DISORDER
depression and mania. - characterized by the occurrence of at least one
• In 1882, the German psychiatrist Karl manic or mixed episode.
Kahlbaum, using the term cyclothymia,
described mania and depression as stages MANIC EPISODE
of the same illness. A. A distinct period of abnormally and
• In 1899, Emil Kraepelin described manic- persistently elevated, expansive, or irritable
depressive psychosis using most of the mood and abnormally and persistently
criteria that psychiatrists now use to increased goal-directed activity or energy,
establish a diagnosis of bipolar I disorder. lasting at least 1 week and present most of
• According to Kraepelin, the absence of a the day, nearly every day.
dementing and deteriorating course in B. During the period of mood disturbance and
manic-depressive psychosis differentiated increased energy or activity, three or more
it from dementia precox (as schizophrenia of the following symptoms are present to a
was then called) significant degree and represent a
noticeable change from usual behavior.
SYMPTOMS
BIPOLAR DISORDER
1. Inflated self-esteem or grandiosity.
- also known as manic-depressive illness, is a brain
2. Decreased need for sleep (e.g., feels
disorder that causes unusual shifts in mood,
rested after only 3 hours of sleep).
energy, activity levels, and the ability to carry out
3. More talkative than usual or pressure to
day-to-day tasks.
keep talking.
4. Flight of ideas or subjective experience that
thoughts are racing.
 5. Distractibility (i.e., attention too easily C. The episode is associated with an
drawn to unimportant or irrelevant external unequivocal change in functioning that is
stimuli), as reported or observed. uncharacteristic of the individual when not
6. Increase in goal-directed activity (either symptomatic.
socially, at work or school, or sexually) or D. The disturbance in mood and the change in
psychomotor agitation (i.e., purposeless functioning are observable by others.
non-goal-directed activity). E. The episode is not severe enough to cause
7. Excessive involvement in activities that marked impairment in social or
have a high potential for painful occupational functioning or to necessitate
consequences (e.g., engaging in hospitalization. If there are psychotic
unrestrained buying sprees, sexual features, the episode is, by definition,
indiscretions, or foolish business manic. No need to take sa hospital/rehab
investments). F. The episode is not attributable to the
Need i-rehab/hospitalized mga may Bipolar I physiological effects of a substance (e.g., a
C. The mood disturbance is sufficiently severe drug of abuse, a medication, other
to cause marked impairment in social or treatment).
occupational functioning or to necessitate
hospitalization to prevent harm to self or MAJOR DEPRESSIVE EPISODE
others.
D. The episodes is not attributable to the A. Five (or more) of the following symptoms
physiological effects of a substance or to have been present during the same 2-week
another medical condition. period and represent a change from
previous functioning; at least one of the
HYPOMANIC EPISODE symptoms is either (1) depressed mood or
A. A distinct period of abnormally and (2) loss of interest or pleasure.
persistently elevated, expansive, or irritable SYMPTOMS
mood and abnormally and persistently 1. Depressed mood most of the day, nearly
increased activity or energy, lasting at least every day, as indicated by either subjective
4 consecutive days and present most of the report (e.g., feels sad, empty, or hopeless)
day, nearly every day. or observation made by others (e.g.,
B. During the period of mood disturbance and appears tearful). Self-report
increased energy and activity, three (or 2. Markedly diminished interest or pleasure in
more) of the following symptoms (four if the all, or almost all, activities most of the day,
mood is only irritable) have persisted, nearly every day (as indicated by either
represent a noticeable change from usual subjective account or observation).
behavior, and have been present to a 3. Significant weight loss when not dieting or
significant degree weight gain (e.g., a change of more than
Insomnia - gusto matulog
SYMPTOMS pero inde makatulog 5% of body weight in a month), or decrease
1. Inflated self-esteem or grandiosity. Hypersomnia - madali makatulog
(kahit saan)
or increase in appetite nearly every day.
2. Decreased need for sleep (e.g., feels (Note: In children, consider failure to make
rested after only 3 hours of sleep). expected weight gain.)
3. More talkative than usual or pressure to 4. Insomnia or hypersomnia nearly every day.
keep talking. 5. Psychomotor agitation or retardation nearly
4. Flight of ideas or subjective experience that every day (observable by others; not
thoughts are racing. merely subjective feelings of restlessness
5. Distractibility (i.e., attention too easily or being slowed down).
drawn to unimportant or irrelevant external 6. Fatigue or loss of energy nearly every day.
stimuli), as reported or observed. 7. Feelings of worthlessness or excessive or
6. Increase in goal-directed activity (either inappropriate guilt (which may be
socially, at work or school, or sexually) or delusional) nearly every day (not merely
psychomotor agitation (i.e., purposeless self-reproach or guilt about being sick).
non-goal-directed activity). 8. Diminished ability to think or concentrate,
7. Excessive involvement in activities that or indecisiveness, nearly every day (either
have a high potential for painful by subjective account or as observed by
consequences (e.g., engaging in others).
unrestrained buying sprees, sexual 9. Recurrent thoughts of death (not just fear
indiscretions, or foolish business of dying), recurrent suicidal ideation without
investments). a specific plan, or a suicide attempt or a
specific plan for committing suicide
Attempt suicide is parasuicide
 B. The symptoms cause clinically significant D. The disturbance in mood and the change in
distress or impairment in social, functioning are observable by others.
occupational, or other important areas of E. The episode is not severe enough to cause
functioning. marked impairment in social or
C. The episode is not attributable to the occupational functioning or to necessitate
physiological effects of a substance or hospitalization. If there are psychotic
another medical condition. features, the episode is, by definition,
manic.
BIPOLAR II DISORDER F. The episode is not attributable to the
• Like Bipolar I Disorder, with moods cycling physiological effects of a substance (e.g., a
between high and low over time. A person drug of abuse, a medication or other
experiences the same depression as in treatment).
major depressive disorder, but they
experience hypomania (literally lesser MAJOR DEPRESSIVE EPISODE
manias) A. Five (or more) of the following symptoms
• At least one hypomanic episode and at have been present during the same 2-week
least one major depressive episode. period and represent a change from
• There has never been a manic episode. previous functioning; at least one of the
symptoms is either (1 ) depressed mood or
HYPOMANIC EPISODE (2) loss of interest or pleasure.
A. A distinct period of abnormally and SYMPTOMS
persistently elevated, expansive, or irritable 1. Depressed mood most of the day, nearly
mood and abnormally and persistently every day, as indicated by either subjective
increased activity or energy, lasting at least report (e.g., feels sad, empty, or hopeless)
4 consecutive days and present most of the or observation made by others (e.g.,
day, nearly every day. appears tearful).
B. During the period of mood disturbance and 2. Markedly diminished interest or pleasure in
increased energy and activity, three (or all, or almost all, activities most of the day,
more) of the following symptoms have nearly every day (as indicated by either
persisted (four if the mood is only irritable), subjective account or observation).
represent a noticeable change from usual 3. Significant weight loss when not dieting or
behavior, and have been present to a weight gain (e.g., a change of more than
significant degree 5% of body weight in a month), or decrease
SYMPTOMS or increase in appetite nearly every day.
1. Inflated self-esteem or grandiosity. (Note: In children, consider failure to make
2. Decreased need for sleep (e.g., feels expected weight gain.)
rested after only 3 hours of sleep). 4. Insomnia or hypersomnia nearly every day.
3. More talkative than usual or pressure to 5. Psychomotor agitation or retardation nearly
keep talking. every day (observable by others; not
4. Flight of ideas or subjective experience that merely subjective feelings of restlessness
thoughts are racing. or being slowed down).
5. Distractibility (i.e., attention too easily 6. Fatigue or loss of energy nearly every day.
drawn to unimportant or irrelevant external 7. Feelings of worthlessness or excessive or
stimuli), as reported or observed. inappropriate guilt (which may be
6. Increase in goal-directed activity (either delusional) nearly every day (not merely
socially, at work or school, or sexually) or self-reproach or guilt about being sick).
psychomotor agitation (i.e., purposeless 8. Diminished ability to think or concentrate,
non-goal-directed activity). or indecisiveness, nearly every day (either
7. Excessive involvement in activities that by subjective account or as observed by
have a high potential for painful others).
consequences (e.g., engaging in 9. Recurrent thoughts of death (not just fear
unrestrained buying sprees, sexual of dying), recurrent suicidal ideation without
indiscretions, or foolish business a specific plan, or a suicide attempt or a
investments). specific plan for committing suicide.

C. The episode is associated with an B. The symptoms cause clinically significant

unequivocal change in functioning that is distress or impairment in social,
uncharacteristic of the individual when not occupational, or other important areas of
symptomatic. functioning.
 C. The episode is not attributable to the depressed mood, or markedly diminished
physiological effects of a substance or interest or pleasure in all, or almost all,
another medical condition. activities.
- Kapag kulang sa required symptoms
- Duration is 2 years w/ hypomanic and depressive B. There is evidence from the history, physical
CYCLOTHYMIC DISORDER - Short-duration Cyclothymic disorder kapag inde
umabot ng 2 years examination, or laboratory findings of both
- Is a chronic fluctuating mood disturbance (1) and (2):
involving numerous periods of hypomanic 1. The symptoms in Criterion A
symptoms and periods of depressive symptoms developed during or soon after
that are distinct from each other. substance intoxication or
withdrawal or after exposure to a
A. For at least 2 years (at least 1 year in medication.
children and adolescents) there have been 2. The involved substance/medication
numerous periods with hypomanic is capable of producing the
symptoms that do not meet criteria for a symptoms in Criterion A.
hypomanic episode and numerous periods C. The disturbance is not better explained by
with depressive symptoms that do not meet a bipolar or related disorder that is not
criteria for a major depressive episode. substance/medication-induced.
B. During the above 2-year period (1 year in D. The disturbance does not occur exclusively
children and adolescents), the hypomanic during the course of a delirium.
and depressive periods have been present E. The disturbance causes clinically
for at least half the time and the individual significant distress or impairment in social,
has not been without the symptoms for occupational, or other important areas of
more than 2 months at a time. Hypomanic symptoms (1-2 symptoms)
Depressive symptoms (3 symptoms)
functioning. Drugs dahilan sa pagkakaroon ng inbalance sa hormones
C. Criteria for a major depressive, manic, or
hypomanic episode have never been met. Bipolar and Related Disorder Due to
D. The symptoms in Criterion A are not better Another Medical Condition
explained by schizoaffective disorder, A. A prominent and persistent period of
schizophrenia, schizophreniform disorder, abnormally elevated, expansive, or irritable
delusional disorder, or other specified or mood and abnormally increased activity or
unspecified schizophrenia spectrum and energy that predominates in the clinical
other psychotic disorder. picture.
E. The symptoms are not attributable to the B. There is evidence from the history, physical
physiological effects of a substance (e.g., a examination, or laboratory findings that the
drug of abuse, a medication) or another disturbance is the direct pathophysiological
medical condition. consequence of another medical condition.
F. The symptoms cause clinically significant C. The disturbance is not better explained by
distress or impairment in social, another mental disorder.
occupational, or other important areas of D. The disturbance does not occur exclusively
functioning. during the course of a delirium.
E. The disturbance causes clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning, or necessitates hospitalization
to prevent harm to self or others, or there
are psychotic features.

Other Specified Bipolar and Related Disorder

1. Short-duration hypomanic episodes (2-3
days) and major depressive episodes.
2. Hypomanic episodes with insufficient
symptoms and major depressive episodes
3. Hypomanic episode without prior major
depressive episode.
4. Short-duration cyclothymia (less than 24
Substance/Medication-Induced Bipolar months)
and Related Disorder
A. A prominent and persistent disturbance in Unspecified Bipolar and Related Disorder
mood that predominates in the clinical • This category applies to presentations in
picture and is characterized by elevated, which symptoms characteristic of a bipolar
expansive, or irritable mood, with or without and related disorder that cause clinically
 significant distress or impairment in social, E. Criteria A–D have been present for 12 or
occupational, or other important areas of more months. Throughout that time, the
functioning predominate but do not meet individual has not had a period lasting 3 or
the full criteria for any of the disorders in the more consecutive months without all of the
bipolar and related disorders diagnostic symptoms in Criteria A–D.
class. The unspecified bipolar and related F. Criteria A and D are present in at least two
disorder category is used in situations in of three settings (i.e., at home, at school,
which the clinician chooses not to specify with peers) and are severe in at least one
the reason that the criteria are not met for of these.
a specific bipolar and related disorder and G. The diagnosis should not be made for the
includes presentations in which there is first time before age 6 years or after age 18
insufficient information to make a more years.
specific diagnosis (e.g., in emergency room H. By history or observation, the age at onset
settings). of Criteria A–E is before 10 years.
I. There has never been a distinct period
The DSM-5 Classification of DEPRESSIVE lasting more than 1 day during which the
Disorders full symptom criteria, except duration, for a
• Disruptive Mood Dysregulation Disorder manic or hypomanic episode have been
• Major Depressive Disorder met. Note: Developmentally appropriate
• Persistent Depressive Disorder mood elevation, such as occurs in the
• Premenstrual Dysphoric Disorder context of a highly positive event or its
anticipation, should not be considered as a
• Substance/Medication-Induced
symptom of mania or hypomania.
Depressive Disorder
J. The behaviors do not occur exclusively
• Depressive Disorder Due to Another
during an episode of major depressive
Medical Condition
disorder and are not better explained by
• Other Specified Depressive Disorder another mental disorder (e.g., autism
• Unspecified Depressive Disorder spectrum disorder, posttraumatic stress
disorder, separation anxiety disorder,
Disruptive Mood Dysregulation Disorder persistent depressive disorder). Note: This
(DMDD) diagnosis cannot coexist with oppositional
• A new addition to the DSM. defiant disorder, intermittent explosive
• Characterized by severe, developmentally disorder, or bipolar disorder, though it can
inappropriate, and recurrent temper coexist with others, including major
outbursts at least three times per week, depressive disorder, attention-
along with a persistently irritable or angry deficit/hyperactivity disorder, conduct
mood between temper outbursts. K. The symptoms are not attributable to the
• Symptoms must be present for at least a physiological effects of a substance or
year, and the onset must be by age 10. another medical or neurological condition.
• Studies suggest that youth with chronic
irritability and severe mood dysregulation Disruptive Mood Dysregulation Disorder
are at higher risk for future unipolar (DMDD): Prevalence
depressive disorders and anxiety • DMDD is common among children
disorders. presenting to mental health clinics.
• Prevalence estimates in the community are
A. Severe recurrent temper outbursts unclear. Overall 1-year prevalence in
manifested verbally (e.g., verbal rages) children and adolescents is probably 2%-
and/or behaviorally (e.g., physical 5%.
aggression toward people or property) that • Rates are expected to be higher in males
are grossly out of proportion in intensity or than in females, and in children compared
duration to the situation or provocation. to adolescents.
B. The temper outbursts are inconsistent with
developmental level. Disruptive Mood Dysregulation Disorder
C. The temper outbursts occur, on average, (DMDD): development & course
three or more times per week. • Rates of conversion to bipolar disorder are
D. The mood between temper outbursts is very low.
persistently irritable or angry most of the
• Children with chronic irritability are at risk to
day, nearly every day, and is observable by
develop unipolar depression and / or
others (e.g., parents, teachers, peers).
anxiety disorders in adulthood.
Disruptive Mood Dysregulation Disorder C. During the 2-year period (1 year for
(DMDD): functional consequences children or adolescents) of the disturbance,
• Marked disruption in a child’s family and the individual has never been without the
peer relationships, as well as in school symptoms in Criteria A and B for more than
performance. 2 months at a time.
• Because of their low frustration tolerance, D. Criteria for a major depressive disorder
such children have difficulty succeeding in may be continuously present for 2 years.
school and sustaining friendships. E. There has never been a manic episode or
• Levels of dysfunction in children with a hypomanic episode.
bipolar disorder and DMDD are generally F. The disturbance is not better explained by
comparable. Also, dangerous behaviors a persistent schizoaffective disorder,
and psychiatric hospitalizations are schizophrenia, delusional disorder, or other
common. specified or unspecified schizophrenia
spectrum and other psychotic disorder.
Disruptive Mood Dysregulation Disorder G. The symptoms are not attributable to the
physiological effects of a substance (e.g., a
(DMDD): Comorbidity
drug of abuse, a medication) or another
• Rates of comorbidity in DMDD are very medical condition (e.g., hypothyroidism).
high. H. The symptoms cause clinically significant
• The strongest overlap occurs with distress or impairment in social,
oppositional defiant disorder (ODD). occupational, or other important areas of
• Attention Deficit Hyperactivity Disorder functioning.
(ADHD) is also very frequently comorbid
with DMDD. PERSISTENT DEPRESSIVE DISORDER
• Children with DMDD present to clinical (DYSTHYMIA): PREVALENCE
attention with a wide range of disruptive
• The 12-month prevalence in the US is
behavior, mood, anxiety, and even autism
approximately 0.5% for PDD and 1.5% for
spectrum diagnoses.
chronic MDD.
PERSISTENT DEPRESSIVE DISORDER PERSISTENT DEPRESSIVE DISORDER
(DYSTHYMIA) (DYSTHYMIA): DEVELOPMENT & COURSE
• Its essential feature is a depressed mood
• PDD often has an early and insidious onset
that occurs for most of the day, for more
and, by definition, a chronic course.
days than not, for at least 2 years (or at
• Early onset (i.e., before age 21 years) is
least 1 year for children and adolescents).
associated with a higher likelihood of
• Individuals whose symptoms meet major
comorbid personality disorders and
depressive disorder criteria for 2 years
substance use disorders.
should be given a diagnosis of persistent
depressive disorder (PDD) as well as major
depressive disorder (MDD).
PERSISTENT DEPRESSIVE DISORDER
• Because these symptoms have become (DYSTHYMIA): COMORBIDITY
part of the individual’s day-to-day • Compared to patients with MDD,
experience, they may not be reported individuals with PDD are at a higher risk for
unless the individual is directly prompted. psychiatric comorbidity in general, and for
anxiety disorders and substance use
A. Depressed mood for most of the day, for disorders in particular.
more days than not, as indicated by either • Early-onset PDD is strongly associated
subjective account or observation by with Cluster B and C personality disorders.
others, for at least 2 years. Note: In children
and adolescents, mood can be irritable and PERSISTENT DEPRESSIVE DISORDER
duration must be at least 1 year. (DYSTHYMIA): TREATMENT
B. Presence, while depressed, of two (or • Recent data offer the most objective
more) of the following: support for cognitive therapy, behavior
1. Poor appetite or overeating. therapy and pharmacotherapy.
2. Insomnia or hypersomnia. • The combination of pharmacotherapy and
3. Low energy or fatigue. some form of psychotherapy may be the
4. Low self-esteem. most effective treatment for the disorder.
5. Poor concentration or difficulty
making decisions.
6. Feelings of hopelessness.
PERSISTENT DEPRESSIVE DISORDER 1. Decreased interest in usual activities (e.g.,
(DYSTHYMIA): DOUBLE DEPRESSION work, school, friends, hobbies).
• An estimated 40% of patients with major 2. Subjective difficulty in concentration.
depressive disorder also meet the criteria 3. Lethargy, easy fatigability, or marked lack
for dysthymia, a combination often referred of energy.
to as double depression. 4. Marked change in appetite; overeating; or
• Double depression has a poorer prognosis specific food cravings.
than only major depressive disorder. 5. Hypersomnia or insomnia.
• The treatment of patients with double 6. A sense of being overwhelmed or out of
depression should target both disorders control.
because the resolution of the symptoms of 7. Physical symptoms such as breast
major depressive episode still leaves these tenderness or swelling, joint or muscle
patients with significant psychiatric pain, a sensation of “bloating,” or weight
impairment. gain.

PREMENSTRUAL DYSPHORIC DISORDER D. The symptoms cause clinically significant

distress or interference with work, school,
• Triggered by changing levels of sex
usual social activities, or relationships with
hormones that accompany the menstrual
others (e.g., avoidance of social activities;
cycle.
decreased productivity and efficiency at
• Occurs about 1 week before the onset of work, school, or home).
menses and is characterized by irritability, E. The disturbance is not merely an
emotional lability, headache, anxiety, and exacerbation of the symptoms of another
depression. disorder, such as major depressive
• Somatic symptoms include edema, weight disorder, panic disorder, persistent
gain, breast tenderness, syncope, and depressive disorder, or a personality
parasthesias. disorder (although it may co-occur with any
• Approximately 5% of women are affected. of these disorders).
• Treatment is symptomatic and includes F. Criterion A should be confirmed by
analgesics and sedatives. Some patients prospective daily ratings during at least two
respond to short courses of SSRIs. Fluid symptomatic cycles. (Note: The diagnosis
retention is relieved with diuretics. may be made provisionally prior to this
confirmation.)
A. In the majority of menstrual cycles, at least G. The symptoms are not attributable to the
five symptoms must be present in the final physiological effects of a substance (e.g., a
week before the onset of menses, start to drug of abuse, a medication, other
improve within a few days after the onset of treatment) or another medical condition
menses, and become minimal or absent in (e.g., hyperthyroidism).
the week postmenses.
B. One (or more) of the following symptoms • The generally recognized syndrome
must be present: involves
o mood symptoms (e.g., lability,
1. Marked affective lability (e.g., mood irritability)
swings; feeling suddenly sad or tearful, or o behavior symptoms (e.g., changes in
increased sensitivity to rejection). eating patterns, insomnia)
2. Marked irritability or anger or increased o and physical symptoms (e.g., breast
interpersonal conflicts. tenderness, edema, and headaches).
3. Marked depressed mood, feelings of • These symptoms occur at a specific time
hopelessness, or self-deprecating during the menstrual cycle, and resolve
thoughts. between menstrual cycles.
4. Marked anxiety, tension, and/or feelings of • The hormonal changes that occur during
being keyed up or on edge. the menstrual cycle are thought to cause
the symptoms, although the exact etiology
C. One (or more) of the following symptoms is unknown.
must additionally be present, to reach a
total of five symptoms when combined with
PREMENSTRUAL DYSPHORIC DISORDER:
symptoms from Criterion B above.
EPIDEMIOLOGY
• The prevalence is unclear.
• Up to 80% of all women experience some
alteration in mood or sleep and some
 somatic symptoms during the premenstrual • There are clear associations with stroke,
period, and about 40% of them have Huntington’s disease, Parkinson’s disease,
premenstrual symptoms that prompt them and traumatic brain injury.
to seek medical advice. • Several other conditions are associated
• Only 3 to 7% of women have symptoms with depression, including Cushing’s
that meet the full diagnostic criteria for disease, hypothyroidism and multiple
PMDD. sclerosis.

PREMENSTRUAL DYSPHORIC DISORDER: OTHER SPECIFIED DEPRESSIVE

COURSE & PROGNOSIS DISORDER
• Treatment includes support and • This category applies when symptoms of
recognition of the symptoms. depression predominate but do not meet
• SSRIs (e.g., fluoxetine) and the full criteria for any of the disorders in the
benzodiazepine (e.g., alprazolam) have depressive disorders diagnostic class.
been reported to be effective. 1. Recurrent brief depression:
• If symptoms are present throughout the Concurrent presence of
menstrual cycle, clinicians should consider depressed mood and at least 4
one of the non-menstrual cycle- related other symptoms of depression for
mood and anxiety disorders. 2-13 days at least once per month
• The presence of especially severe for at least 12 consecutive
symptoms should prompt clinicians to months.
consider other mood and anxiety disorders. 2. Short-duration depressive
A thorough medical workup is necessary to episode (4-13 days)
rule out medical or surgical conditions that 3. Depressive episode with
may account for symptoms (e.g., insufficient symptoms: Depressed
endometriosis). affect and at least one of the other
symptoms of depression that
SUBSTANCE/MEDICATION-INDUCED persist for at least 2 weeks
DEPRESSIVE DISORDER
• Depressed mood or markedly diminished UNSPECIFIED DEPRESSIVE DISORDER
interest or pleasure in all, or almost all, • This category applies to presentations in
activities which symptoms of depression
• There is evidence that predominate but do not meet criteria for
• The symptoms developed during or soon any of the disorders in the depressive
after substance intoxication or withdrawal disorders diagnostic class.
or after exposure to a medication • The unspecified category is used in
o The involved substance/medication is situations in which the clinician chooses not
capable of producing the symptoms. to specify the reason that the criteria are
• The symptoms are not better explained by not met for a specific depressive disorder,
a depression that is not substance- and includes presentations for which there
induced. is insufficient information to make a more
specific diagnosis (e.g., in emergency room
• Lifetime-prevalence in the US: 0.26%
settings).
o Examples of culprit-agents: efavirenz,
clonidine, isotretinoin, corticosteroids,
oral contraceptives, interferon. Suicidality
Key Terms in the Study of Suicidality
DEPRESSIVE DISORDER DUE TO • Suicide ideation: thoughts of killing oneself
ANOTHER MEDICAL CONDITION • Suicide attempt: behavior intended to kill
• Depressed mood or markedly diminished oneself
interest or pleasure in all, or almost all, • Suicide: death from deliberate self-injury
activities. • Non-suicidal self-injury: behaviors intended
• There is evidence that the disturbance is to injure oneself without intent to kill oneself
the direct pathopysiological consequence Cuts sa wrist.
of another medical condition. Epidemiology of Suicide and Suicide
• The disturbance is not better explained by Attempts
another mental disorder (e.g., adjustment • Suicide rate in US is 1 per 10,000 in a given
disorder in which the stressor is a serious year; worldwide, 9% report suicidal ideation
medical condition). at least once in their lives, and 2.5% have
made at least one suicide attempt
 • Men are four times more likely than women Preventing Suicide
to kill themselves; women are more likely • Talk about suicide openly and matter-of-
than men are to make suicide attempts that factly
do not result in death • Most people are ambivalent about their
• Guns are by far the most common means suicidal intentions
of suicide in the United States (60%); men • Treat the associated mental disorder
usually shoot or hang themselves; women • Treat suicidality directly
more likely to use pills • Suicide prevention centers
• The suicide rate increases in old age. The
highest rates of suicide in the United States
are for white males over age 50
• The rates of suicide for adolescents and
children in the United States are increasing
dramatically
• Being divorced or widowed elevates
suicide risk four- or fivefold

Annual Deaths Due to Suicides per 100,000

People

Risk Factors for Suicide

• Psychological Disorders
o Half of suicide attempts are depressed
at the time of the act
• Neurobiological Models
o Heritability of 48% for suicide attempts
o Low levels of serotonin
o Overly reactive HPA system
• Social Factors
o Economic recessions
o Media reports of suicide
o Social isolation and a lack of social
belonging
• Psychological Models
o Problem-solving deficit
o Hopelessness
o Life satisfaction
o Impulsivity

Myths About Suicide