Lecture Notes - Classification 1

“Who in the rainbow can draw the line where the violet tint ends and the orange tint begins? Distinctly we see the difference of the colors, but where exactly does the one first blendingly enter into the other? So with sanity and insanity.” Herman Melvile

What is Abnormal? 1. Suffering - person or family 2. Maladaptiveness (not being able to function) 3. Irrationality and incomprehensibility (thought disorders) • M'Naghten Rule – legal rather than psychological • Irresistible impulse is a defense by excuse the defendant argues that they should not be held criminally liable because they could not control those actions. • Policeman at the elbow – 4. Unpredictable and loss of control 5. Observer discomfort 6. Statistical infrequency – if 99% of behaviors are X and 1% of behaviors are Y then Y is abnormal. 7. Violation of moral & ideal standards o Connotative norms – based on society- • Anorexia is really only found in US, England and a few western European Cultures • TKS - Taijin kyofusho – Japanese fear of doing something really embarrassing and breaking social norm.

Lecture Notes - Classification 2

Elements of Optimal Living - Positive Psychology – Martin Seligman 1. positive attitudes of self (like/accept self) 2. growth & development 3. autonomy (independence) 4. accurate perception of reality (see the world as it really is) 5. environmental competence (“When in Rome …”) 6. Positive interpersonal relationships

Adaptation: changing to fit circumstances Adjustment: changing the circumstances

Vulnerability: how likely we Resiliency: the ability to function effectively in are to respond maladaptively the face of adversity. to certain situations.

Coping: how people deal with difficulties and attempt to overcome them. • Born with? – babies temperament • Learned – how do mommy and daddy react to spilled milk

Diathesis *genetic predisposition for a disorder *Environmental stressors trigger it Atypical – catch all Co-morbidity – people can suffer from many disorders

Lecture Notes - Classification 3

Diagnosis: a classification statement that places a disorder within a system of conventional groupings based on important similarities in symptoms.

Goldwater Rule – unethical to diagnose people: • without meeting them • without their permission o usually talking about famous people

Advantages of Classification: 1. What if we don’t have any system? So an imperfect system is better than none 2. useful for statistical purposes – how many people are ill in Maryland 3. Insurance companies will only pay for a diagnosed health condition 4. VALIDITY – more than just a doctor’s opinion based on peer reviewed research • Inter-rater reliability • Intra-rater reliability 5. can contribute to the planning of treatment programs & facilities - public schools conduct disorder and school discipline helicopter parents want their children diagnosed 6. improves communication among caregivers – agreed upon vocabulary

Lecture Notes - Classification 4

Disadvantages of Classification: 1. puts a label on a person (stigma) • self-fulfilling prophesy – once a person hears about their … 2. diagnostic categories are imperfect and the same label may be assigned to behaviors that appear similar but have different causes and require different treatment – “it’s like nailing jelly to a wall” Inter-rater reliability Intra-rater reliability 3. Describing a condition doesn’t explain causality! The Rosenhan experiment was an experiment into the validity of psychiatric diagnosis conducted by psychologist David Rosenhan in 1973 – he and his colleagues fooled experts and their system so easily it pointed out huge flaws in the system of diagnosis

Diagnostic and Statistical Manual of Mental Disorders 1952 – first comprehensive list of disorders - after WWII how should army classify returning soldiers’ mental health 1. their causes 2. their symptoms 3. the possible treatments - notice it does not say cures.

Lecture Notes - Classification 5

There is an illness There is no illness Therapist sees illness Reject Null H0 Type I error or Person gets help False alarm error Therapist doesn’t see Type II error or Accept Null H0 illness Person doesn’t get No treatment needed help 

DSM – 5 "A is a syndrome characterized by clinically significant (p< .05) disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."

Lecture Notes - Classification 6

Physiological Based – biological reductionism • Every condition is the result of underlying brain pathology ▪ Good – data driven, empirical ▪ Bad - psych is more complex then

Section I – introduction to DSM, how it is organized and how it is different from previous versions Section II – descriptions of and dysfunctions Section III – “living document” what should be studied, possible new categories Internet addiction? Non-Suicidal Self-Injury (cutting) – not suicide, often an attempt to deal with emotional pain. Catharsis? control? OCD

ICD-11 is the 11th revision of the International Statistical Classification of Diseases and Related Health Problems • No category is discreet • More emphasis on culture (international) Very few “real” difference between the DSM and the ICD

Lecture Notes - Classification 7

Section II: diagnostic criteria and codes 1. Neurodevelopmental disorders Ex. spectrum disorder, ADHD Ex. Intellectual Disability Disorder 2. Schizophrenia spectrum and other psychotic disorders Ex. Hearing voices 3. Bipolar and related disorders 4. Depressive disorders Ex. Dysthymia (Eeoyre) 5. Anxiety Disorders Ex. Phobias, Panic disorders 6. Obsessive-compulsive and related disorders Ex. Hording 7. Trauma- and stressor-related disorders 8. Dissociative disorders Ex. Dissociative Identity Disorder 9. Somatic symptom and related disorders 10. Feeding and eating disorders Ex. anorexia 11. Sleep–wake disorders 12. Sexual dysfunctions 13. Gender dysphoria 14. Disruptive, impulse-control, and conduct disorders 15. Substance use and other addicted disorders Ex. Gambling, internet? 16. Neurocognitive disorders

Lecture Notes - Classification 8

Ex. Alzheimers 17. Paraphilic disorders Ex. fetish 18. Personality disorders Ex. Sociopath

Anxiety Disorders

ELEMENTS OF ANXIETY: 1. Cognitive Elements & expectations of impending harm

2. Somatic Elements Normal Anxiety vs. Pathological Goosebumps, muscle Anxiety: tension, increase heart 1. Anxiety is irrational (it is provoked rate by threats that are exaggerated or 3. Emotional subjective: dread, nonexistent) terror, queasiness, tight 2. response is out of proportion to the stomach actual importance of the situation 4. Behavioral (escape, 3. anxiety is uncontrollable: person avoidance, freezing, decrease cannot shut off alarm reaction appetite) 4. anxiety is disruptive: it interferes with relationships, jobs, academic performance, or everyday activities

1. Generalized Anxiety Disorders : Frequent experience of anxiety, worry, and apprehension more intense and longer lasting than the anxiety experienced by the average person. but still has adequate contact with reality and is rarely incapacitated enough to require institutionalization. Professional help really works here ☺

Lecture Notes - Classification 9

2. Panic Disorder: having reoccurring panic attacks. The frequency and duration can very. • the attacks themselves are quite unpleasant • fear of having an attack can interfere 3. Specfic Phobias: • Mild Phobias: many people are fearful of certain objects or situations, but may not experience incapacitating terror and anxiety Acro - heights • Clinical Phobias: severe and irrational fear due to a Hema - blood Keno -empty specific stimulus rooms o does it cause suffering Cyno – dogs o does it cause interference Aero – flying o Entomo - bugs Very easily treatable ☺ Gamo - marriage • Encountering the feared situation or object can Ophdo – snakes provoke a full-fledged panic attack. Xeno – strangers Garbage disposal spiders drains folding knives mice Melissa - bees • (flexible definition) fear of having a panic attack in a public place from which it might be difficult to escape or get help. - Types of situations avoided include crowds, standing in line, stores or elevators, public transportation - Result: many become prisoners in their own homes, unable to beyond their front door. • Social phobia • Selective mutism • Separation anxiety

Neurodevelopmental Disorders: Tourettes Syndrome

Lecture Notes - Classification 10

Autism Spectrum Disorder What does spectrum mean? Asperger’s – no longer in the DSM “Aspies” Usually males – why? 75% Male intelligence? Hyper intra-wiring but hypo inter-wiring Symptoms – each person is different Savant – less than 10% of people with ASD Social cues Emotional regulation “Obsessions” with details and specific interests Sensory sensitivity Repetitive or self-soothing Intellectual Disability (Intellectual Developmental Disorder) Used to be called mental retardation Remember Ratio IQ

Attention-Deficit Hyperactivity Disorder Specific Learning Disorder No longer separating from discalcula

Obsessive Disorders: Obsessive Compulsion Disorder Obsession thoughts that revolve around potential harm - disease, crime, accidents

Lecture Notes - Classification 11

Compulsion a behavior that is believed to prevent the thing that is obsessed over rituals Hand washing arranging things perfectly routines

▪ Hoarding fear ______will not throw anything away ▪ Hair Pulling - usually present in children o more common in women o “” ▪ Excoriation ▪ – excessive concern with a perceived flaw in one’s body. BDD often co-occurs with depression, anxiety, social withdrawal, and social isolation. Neurocognitive Disorders Dementia Alzheimer’s

Disorders related to Trauma P.T.S.D. Can manifest differently for everyone flashbacks Can occur immediately or even a year later General Adaptive Syndrome 1. Alarm stage 2. Resistance stage 3. Exhaustion stage Symptoms – could be anything • Impulsive behavior • Addiction / self-medicating • Avoidance as a coping mechanism • Cognitive difficulties – Not responding to a bad life even properly Low mood, worry, insomnia, poor self-esteem, feeling trapped

Lecture Notes - Classification 12

Eating Disorders ▪ Anorexia – less than 85% ideal weight o Motivation - food & life or body image ▪ Bulimia binge - purge ▪ Binge Eating ▪ PICA – eating strange things

Impulse Control Disorders – limbic system Men more than women why? ▪ Similar symptoms of Autism, ADD, OCD, addiction o Phineas Gage ▪ conduct disorder – pervasive inability to follow rules irritable mood, argumentative/defiant behavior that lasts for 6 months or more antisocial if over age 18 ▪ ODD – pattern of angry mood, argumentative, defiance o Could look like attention deficit hyperactivity disorder ▪ Intermittent Explosive Disorder - Recurrent behavioral outbursts representing a failure to control aggressive impulses manifested through verbal or physical aggression. ▪ substance-related disorders, ▪ pyromania ▪ kleptomania

Lecture Notes - Classification 13

▪ internet addiction ??? section 3 of DSM-5 ▪ compulsive shopping

Affective Disorders Depression isn’t just about feeling sad. It is as if the person doesn’t want anything

Major Depressive Disorder (uni-polar) “common cold of mental illness” • Continuum or spectrum • Symptoms – loneliness, physical pain, lethargy, lack of concentration, lack of joy, loss of interest in food, family, friends, sex, • 5-htt gene responsible for reuptake of serotonin • There is less depression in collectivist societies more in individualistic societies • Usually worse in the morning – sleep cycles, blood sugar? • diagnostic criteria = 2 weeks

• Post-partum Depression o depression after giving birth o extreme examples have new mom’s harming their babies.  Andrea Yates • Dysthymia – JV depression - less intense, but longer lasting • Seasonal Affective Disorder – winter months, related to UV light • Bereavement

Lecture Notes - Classification 14

Bipolar Disorders (manic/depressive) alternate between extremes of depression & mania in between and schizophrenia ✓ or what if we called them motivation disorders? ❖ Depression = don’t want anything ❖ Mania = want everything now Rapid cycle – can change in a few minutes Type I 1. More severe symptoms Mania can be psychotic 2. Sometimes requiring hospitalizations Type II 1. Less severe symptoms 2. Treated easier Easily confused with 3. Hypomanic ADHD, borderline 4. Cyclothymic personality disorder Manic Symptoms: 1. hyperactivity 2. decreased need for sleep 3. talkativeness 4. inflated self-esteem 5. excessive involvement in activities without regard to painful consequences 6. flight of ideas: rapid shifts in conversation 7. Lithium reduce the extremes in either pole

Personality Disorders enduring behavioral, emotional and cognitive traits that often conflict with society and others. Warrior gene? MAOA-L gene variant seems to be a mix of the gene and childhood. Abusive childhood seems to turn on the gene. ***Bradley Waldroup was not convicted of first degree murder(even though it clearly was) because his attorney argued that having a certain gene “made” him do it***

Lecture Notes - Classification 15

3 common characteristics of all personality disorders are: • Reduced sense of empathy • Reduced sense of insight into oneself • Reduced sense of consequences Cluster A - odd disorders Paranoid Personality Disorder: a person is irrationally suspicious & mistrustful of others • expects, without sufficient basis, to be harmed by others • questions the loyalty peers • reads hidden meanings into benign remarks or events Schizoid personality disorder: • detachment from social relationships, • flat affect, secretiveness, • not schizophrenia o doesn’t have neurological components (we haven’t found it yet) o Does have rationality Schizotypal personality disorder: • extreme discomfort interacting socially • distorted cognitions and perceptions • not schizophrenia o doesn’t have neurological components o Does have rationality Cluster B - dramatic, emotional or erratic disorders

• Antisocial Personality Syndrome: pervasive pattern of disregard for and violation of the rights of others, lack of empathy o sociopathy /psychopathy a debate is ongoing about the difference o average or superior intelligence – psychopathy o can appear sane and normal o charming

Lecture Notes - Classification 16

o Some sense of empathy – might know others or hurting but might not be able to feel it or care o To be able to manipulate people, must know what they need. o lower intelligence impulse issues - sociopathy o absence of irrationality o reduced regard for truth o reduced sense shame or guilt o little fear even of anticipated punishment • Borderline personality disorder: pervasive pattern of instability in relationships, self-image, identity, behavior and affects often leading to self-harm and impulsivity o “I hate you! Don’t ever leave me!” o Can be mistaken for Bi-Polar o Used to be considered borderline schizphrenia o intense fear of abandonment o recurrent suicidal thoughts and threats of suicide to manipulate others, o chronic feelings of emptiness, o used to be considered borderline schizophrenia

• Histrionic Personality Disorder: is very similar to borderline but people are more “positive and outgoing” they use the social skills to get attention o Flirtatious, sex seeking behavior o rapidly shifting expressions of emotions o overly concerned with

Lecture Notes - Classification 17

physical attractiveness o inappropriately sexually seductive in appearance o uncomfortable when not the center of attention

• Narcissistic Disorder: characterized by extreme self- love & neglect of others o requires excessive admiration & attention o sense of entitlement o lacks empathy for other people’s needs and feelings o often envious of others or believes others are envious of them o arrogant, haughty behavior or attitudes

Somatic Symptom Disorders (Psychosomatic Disorders) (Somatization Disorders) Definition: physical disorders which have psychological causes • relationship between certain personality traits and incidence of these disorders Type A Personality Conversion Disorder: “converting negative mental energy to physical problems” Positive symptoms – adding something bad Negative symptoms – subtracting something good Lack of affect alogia Illness (hypochondriasis) a person has a persistent belief that he has a serious illness, despite medical reassurance, a lack of physical findings, and failure to develop the disease. Often go from doctor to doctor to find one who will agree with them

Lecture Notes - Classification 18

• Munchausen Syndrome: simulation of disease for the sole purpose of obtaining medical attention. • Munchausen by proxy: mother hurting child –

Dissociative Disorders very Freudian Definition: The mind divides itself to deal with… • Organic vs. psychogenic disease • Controversial because it is not empirical or organic • Hollywood sensationalizes it o It is subtle and hard to spot o Lost time, forgetfulness, doing thing for “no” reason, déjà vu • Dissociative Amnesia: repression - • extensive, but selective, memory loss in the absence of indications or organic change (head injuries). It is usually precipitated by a physical accident or emotionally traumatic event. Although they cannot remember personal details of their life, they do remember how to function in the world. Implicit vs. explicit memory

Dissociative Identity Disorder: an individual assumes alternate personalities. Each personality has its own set of memories and typical behaviors and may not have any awareness of the others. It usually develops as a result of childhood abuse as a way of protecting one’s sanity. Is separate from personality disorders

Lecture Notes - Classification 19

• Psychogenic Fugue: unexpected travel away from home and customary workplace, the assumption of a new identity, and the inability to recall previous identity. In 2006, Jeffrey Alan Ingram had to go on the local news to ask viewers if anyone knew who he was because part of his mind did not want to deal with the stress and grief. – no physiological reason for amnesia • Depersonalization Disorder: a change in self- perception and the person’s sense of reality is temporarily lost or changed. The person feels they are not in complete control of his actions, including speech. They may feel their extremities change size or see themselves from a distance.

Lecture Notes - Classification 20

Schizophrenia Spectrum Disorders

Delusional Disorders – at least one month of delusions but no other psychotic symptoms

Schizophrenia(s) • Schizophrenia is translated as “split mind’ but is NOT multiple personality disorder or dissociative identity disorder • if depression is the common cold, then schizophrenia is cancer o but like most cancers it can be treated with success • 1:100 people 1% • Many genes are involved - polygenic • usually strikes during late adolescence/early adulthood o men get it earlier and more suddenly then women • very heavily researched – but still is a mystery • linked with genetics and brain abnormalities • THOUGHT QUESTION: would you want to know if you had one of the high risk factors?

Symptoms: can be confused or overlap with other diseases, and drugs ❖ Symptoms are not 24/7 ❖ People can be symptom free for long, long time + POSITIVE SYMPTOMS adding something you shouldn’t – like positive punishment • disorganized thinking

Lecture Notes - Classification 21

o no logical order, setting, characters, time, place o Delusion: a schema of false beliefs 1. Paranoia/persecution: someone or Delusion usually some group is out to get you: the involves government, CIA, FBI, aliens, anything that wrong beliefs is hard to disprove. That makes treating Hallucination people difficult, because the doctor might be involves wrong one of them. perceptions 2. Grandeur: thinking you are someone you are not, usually a famous figure. No one thinks they are a nameless, uneducated peasant from the 4th century, Often: Jesus, Napoleon, any president • The Three Christs of Ypsilanti • Disturbed perceptions: focusing on minutia instead of the whole. The texture of the bricks in a room might mean more to the person than the conversation hallucination: perceptions and brain activity without sensation o most common are auditory voices o visual and smell are less common HOWEVER: Hallucinations are actually pretty common and can happen to ‘Normal’ people Charles Bonnet syndrome - • 99% of people with schizophrenia hear voices • But most people who hear voices are not schizophrenic

Lecture Notes - Classification 22

-NEGATIVE SYMPTOMS not having something you should • Apathetic – pathos disease or feeling • Alogia – no logic • Avolition – no motivation • Flat Affect, lack of emotional display empathy, understanding of consequence

Types of schizophrenia 1. a blend of both a mood disorder and a thought disorder a. Depression and delusions b. Mania and hallucinations c. Might be more treatable than straight schizophrenia 2. disorganized type confused behavior, incoherent speech, hallucinations inappropriate affective response – word salad – flight of ideas 3. Catatonic type – bizarre movements, postures or grimaces, often motionless for hours, - say they hear conversations around them. waxy inflexibility body position can be molded by others that the person will then hold for hours, even uncomfortable. 4. paranoid type – a common type – Beautiful Mind 5. undifferentiated type = atypical- BS diagnosis Tardive dyskinesia – kinetic Dopamine hypothesis