Clinical Psychology Summary JOHO

Ch1: What are the underlying concepts, procedures and

practices in psychopathology

What is the historical perspective on

psychopathology?
The view of what causes mental health problems has changed over time. We will
examine the historical perspective on psychopathology, such as the demonic
possession perspective, and the contemporary models of explanation such as the
medical or disease model.

What is the Demonic Possession Perspective?

Since many forms of psychopathology seem to appear together with what looks like
a personality change in the individual and which is noticed as one of the first
symptoms, the historical explanation described these individuals as being
'possessed'. The change in their behavior was attributed to someone/something
having taken over their personality. This has led the sufferers to be persecuted and
physically abused instead of being cared for. Demonology is a term which describes
the belief that someone with symptoms of psychopathology is under the possession
of bad spirits.

What is the Medical or Disease Model?

In the 19th century it became clear that many mental or psychological illnesses
could be explained in terms of biological or medical accounts. The somatogenic
hypothesis describes explanations of psychological problems in terms of physical or
biological impairments. It was found that syphilis had a biological cause and that
later stages of the disease, such as dementia, gradual blindness, and paralysis,
caused dramatic changes in one's personality. This finding was used to explain the
mental disorder known as general paresis. Contemporarily, psychiatry is a scientific
approach based on medicine to primarily find the biological causes of
psychopathology and treating them with medication or surgery.

The medical or disease model supplies important implications for how we view
mental health, but there are some important points to keep in mind:

 Often, it is a person's dysfunctional experiences and not biological

dysfunctions that account for their experienced psychopathology
 The medical model tries to reduce the complex psychological and
emotional aspects of psychopathology to simple biology
  The view that something is broken and needs to be fixed in the
individuals is problematic, as psychopathology may just be normal
behavior, but then in an extreme form. Labeling psychopathology as a
normal process gone wrong or broken can lead to stigmatization of these
individuals and lead to perceiving them as second-class citizens
 It is a widespread belief that people with mental health problems are
dangerous, hard to talk to and that (some of) their mental health
problems are self-inflicted
 Psychopathology should be viewed as dimensional, and not as a discrete
phenomenon that is set apart from normal experience. Medical models of
mental health can often make a sufferer feel like a victim and powerless
regarding their condition and their future life. They can feel socially
excluded and often experience low self-esteem and depression after a
psychiatric diagnosis.

What is the history of treatment for those with a

mental illness?
Not too long ago, prior to the 18th century, mental illnesses were seen as
'madness', and were treated in hospitals like other, non-mental diseases were. With
the increase of mental diseases, many hospices were transformed to asylums for the
confinement of sufferers of mental health problems. Treatments were unnecessarily
cruel and painful, and these asylums not only accepted those with mental issues, but
also other people who fell below the societal desirable standards, like poor people
and young, pregnant women. These approaches towards the mentally ill are
probably part of the roots of the nowadays still running negative stigma towards
sufferers of mental illnesses. In the 19th century, people were advocating for more
humane treatments. For instance, Philippe Pinel began removing the chains and
restraints of patients, and treated the patients as sick people, instead of as animals.
The Quaker Movement (UK) developed the moral treatment approach, which
abandoned medical approaches and instead implemented understanding, hope,
occupational therapy, and moral responsibility during treatments.

Because most of the care started to rely on the (undereducated) nurses and
caretakers, many patients were restrained. This often led to patients developing
social breakdown syndrome, making the patients aggressive, exerting challenging
behavior for the caretakers, and a lack of interest in personal welfare and hygiene.
Therapeutic refinements of the hospital environment were the token economy, which
consisted of a reward system in which patients could earn 'tokens' for various
desired items or privileges, and milieu therapies, which were implemented to
develop productivity, feelings of self -respect, independence, and responsibility. This
was achieved by mutual respect between staff and patients, and the opportunity for
the patients to express themselves with the use of vocational and recreational
activities.

Because of modern therapy and medical treatments, many people do not have to a
life in a mental health facility. Many individuals, after being treated, return to a state
where they can live a normal life. For people who still need some sort of after-care,
there are assertive outreach programs available which help people who are
recovering from psychosis to live a normal life as independent as possible.

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How can psychopathology be defined?
Abnormal Psychology is a term that is often used to refer to psychopathology. This
definition has a negative connotation, suggesting that an individual is
malfunctioning, and this term therefore attaches a stigma to an individual who
experiences psychopathology. Service user groups therefore advocate to change
these labels. Two examples are the Rethink and Time to Change programs, which
aim to educate people about mental health, and fight against discrimination and
negative stigmas.

What are statistical norms used for?

In clinical psychology, the statistical norm, which often refers the average, is used to
decide whether symptoms meet diagnostic criteria. For example, mental retardation
is often diagnosed by an IQ score significantly below the norm of 100. This is
problematic, as individuals with exceptionally high IQ scores, which are also
statistically rare, would not be considered as exhibiting psychopathology.

What kind of political or societal norms are there?

Often, there is a tendency within societies for the members of that society to label a
behaviour or activity as indicative of psychopathology if it is far removed from what
we consider to be the social norms for that culture. It is quite difficult to use
deviations from social norms as evidence for psychopathology, as distinct cultures
have very different views on what is socially normal. For example, in the Soviet
Union, during the 1970 and 1980s, political dissidents who were active against the
communist regime were regularly diagnosed with schizophrenia and incarcerated in
psychiatric hospitals. Also, cultural factors are a major influence on how
psychopathology manifests itself in the individual. This includes the degree of
vulnerability of an individual to causal factors, and the 'culture-bound' symptoms of
psychopathology. Two examples of 'culture-bound' effects are Ataque de Nervios, a
form of panic disorder found in Latinos from the Caribbean and Seiziman, a state of
psychological paralysis found in the Haitian community.

What is maladaptive behaviour?

Maladaptive behaviour might involve behaving in a way that is a threat to the health
and well-being of the individual and to others. We cannot define psychopathology
solely in terms of maladaptive behaviour, as it is not the only criterion by which
psychopathological conditions are defined. The problem by defining psychopathology
solely in terms of maladaptive behaviour is that not all maladaptive behaviours can
be labelled as psychopathology. For example, murders or terrorists show
maladaptive behaviours, but they do not all have mental health problems. Moreover,
some psychopathological disorders such as height phobia, water phobia, or snake
phobia might have an adaptive function, as they could protect individuals from
potentially life-threatening situations.

What about distress and impairment?

A useful way of describing psychopathology is the degree of clinically significant
distress or impairment in social, academic, or occupational functioning. With the use
of this criterion, the individual can judge his or her own 'normality', which enables
self judgment of their needs instead of society-enforced judgment. Yet, this
approach does not define the single standard by which behavior should be judged.
Often, a person exhibiting psychopathology does not report experiences of personal
distress, for example because they do not want to admit that they are behaving
unusual, when they don't experience any personal distress (for example during
antisocial personality disorder sufferers) or when they don't experience any distress
(for example when abusing substances).

What are explanatory approaches to

psychopathology?
To understand many mental health problems, different paradigms are used to gather
information about the brain and mind. Symptoms can be explained at various levels,
some of which are genetics, behaviour, biology or cognition. These different
paradigms are categorized under biological and psychological models.

What are the biological models of psychopathology?

Genetics is the study of heredity and the inheriting of characteristics and is therefore
often used to look at the role that heredity plays in psychopathology. Included
methods are concordance studies, which look at different family members and the
relation between a psychological disorder and the amount of shared genetic
material, and twin studies, where monozygotic twins (identical genes) and dizygotic
twins (50% shared genes) are used to examine if there is a genetic explanation for
psychopathology. Many psychopathologies don't occur spontaneously due to a
person's genes. Rather, they are a result of the combination of a genetic
predisposition and some environmental influence. This is also known as the diathesis
stress model, which suggests that problems develop from an interaction between
the expression of our genes and the environment we experience. This model also
supports the measure of heritability, which measures the degree to which some
quality is explained by our genes, ranging from 0 to 1.

The field of molecular genetics is also involved in finding which individual genes are
involved in the transmission of symptoms seen in psychopathology. A common
method used is genetic linkage analysis, which examines the role of genes by linking
some gene responsible for a specific characteristic (e.g., eye colour) with
psychopathology symptoms. So, if some eye color is strongly co-occurring with a
psychopathology symptom in a family, it is quite likely that the genes important for
this symptom is found on the same chromosome as the one for eye colour. A
downside to this method is that some symptom is often not relatable to a single
gene, but instead to a greater number of genes interacting. Another subfield of
genetics is the field of epigenetics, which does not focus on the altering of the
genetic code, but on the expression of current existing genes. There can be many
reasons why some genes are or aren't expressed at a certain point in an organism’s
life, the field of epigenetics is concerned with finding out what can alter the
expression of a gene and what implications these differences in expression might
have on the individual.

Neuroscience seeks to understand psychopathology by looking at an individual's

biology to help explain symptoms, where the bigger focus is on the brain structure,
its function, and also the neuroendocrine system, since hormones contribute a lot to
behavior. The two brain hemispheres are connected by the corpus callosum, which is
a bundle of nerve fibres. The cerebral cortex, the outer layer of tissue, consists of
four lobes. The occipital lobe, found at the back of the brain, is associated with
visual perception. The temporal lobe can be found behind the temples to the side of
the head, and it's involved with functions such as hearing, memory, emotion,
language, illusions, and processing tastes and smells, and the parietal lobe is
associated with visuomotor coordination. Located at the front of the head is the
frontal lobe, which is known to be important for higher cognitions like problem
solving, controlling voluntary movements, willpower, and planning.

Especially the frontal lobes are often implicated in many psychopathologies, since
they have such a major executive function over behaviour. Below these lobes many
other structures can be found, and some of them are collectively known as the
limbic system, which is thought to be involved in emotion and learning. The limbic
system consists of the mammillary body, thalamus, fornix, hypothalamus,
amygdala, and the hippocampus. The hippocampus is known for being involved in
spatial learning, and the amygdala is crucial for processing emotions and learning
from them. Especially the frontal lobes are often implicated in many
psychopathologies since they have such a major executive function over behaviour.
Below these lobes many other structures can be found, and some of them are
collectively known as the limbic system, which is thought to be involved in emotion
and learning.

The main method of communication between brain structures and thus neurons, is
with neurotransmitters. These are chemicals that are the main part of regulating
brain functioning. For example, dopamine is often associated with schizophrenia and
psychotic symptoms. Serotonin is linked to depression and mood disorders, and
norepinephrine and Gamma-aminobutyric acid (GABA) are thought to play a role in
anxiety symptoms.

What are the psychological models of psychopathology?

Psychological models try to provide psychological explanations of psychopathology.
These models view mental health problems as normal reactions to adaptations to
stressful life conditions.

Sigmund Freud (1856-1939), neurologist and psychiatrist tried together with Joseph
Breuer to explain symptoms such as hysteria and paralysis that could not be
explained by medical causes. Using hypnosis, the symptoms of Freud's clients eased
just talking about repressed experiences and emotions. On these cases, Freud built
his theory of psychoanalysis. This theory tries to explain normal and abnormal
psychological functioning regarding defence mechanisms being used against anxiety
and depression. He coined the concept of three psychological forces:

1. ID: describes innate instinctual, especially sexual, needs

2. EGO: rational; tries to control the id's impulses with ego defense
mechanisms that also reduce the anxiety that the id impulses may
generate.
3. SUPEREGO: develops out of the other two psychological forces, and is
responsible for integrating 'values', such as those learned from society or
our parents.

Freud said that psychological health can only be reached if all three forces are in
balance and that we develop defence mechanisms to avoid conflicts between the
three forces or conflicts arising from external factors.

Freud believed that by the way children go through stages of development they
could develop psychopathology. Failing to adjust to a particular stage of
development could lead to the individual becoming fixed on this stage. The stages
are:

 Oral stage: refers to the first 18 months of life where the child is
dependent on the food from the mother. Failing to receive food could lead
to 'oral stage characteristics', such as extreme dependence on others.
 Anal stage: (18 months to 3 years)
 Phallic stage: (3 to 5 years)
 Latency stage: (5-12 years)
 Genital stage: (12 years to adulthood)

The concepts of the psychoanalytic approach are difficult to observe, measure, and
objectively define, which is why this theory is not applied by many psychologists
today.

The behavioral model explains psychopathology in terms of learned reactions to life

experiences. The learning theory, based on principles of classical conditioning (e.g.,
dog salivating) and operant conditioning (e.g., Skinner's box), explain how
dysfunctional behavior can be acquired just like adaptive behaviour. For example,
many emotional disorders are explained by classical conditioning such as specific
phobias or even post-traumatic stress disorder (PTSD).

Behavior therapy is based on the principles of classical conditioning and operant

conditioning, the goal of which is to unlearn behaviors or emotions that are
maladaptive. Behavior modification therapy focuses on the principles of operant
conditioning.

The cognitive model describes how psychopathology develops through the

acquisition of irrational beliefs, the development of dysfunctional ways of thinking
and information processing biases. According to Albert Ellis (1962), people judge
their own behavior according to the irrational beliefs they developed, which cause
emotional distress (e.g., anxiety). Aaron Beck developed a successful cognitive
therapy against depression, which rests on the idea that people develop unrealistic
expectations that guide their view of themselves, the world and their future.

When the dysfunctional beliefs which maintain the symptoms of psychopathology

are identified, they can be changed and replaced by functional cognitions. Cognitive
behavior therapy aims at changing behaviors and cognitions. Even though this
approach has been widely adopted and successful, there is not much known about
the origin of the dysfunctional thoughts. The dysfunctional thoughts could merely be
a symptom of psychopathology rather than a cause of it.

The humanistic-existential approach works with the view that individuals can acquire
insight into their lives from a wide spectrum of perspectives, and only by gaining
this insight can they achieve insights into their emotional and behavioral problems.
Then, psychopathology and conflicts can be resolved.

Client-centered therapy is an approach in which the therapist makes use of empathy

and unconditional positive regard to help the client achieve a sense of positive self-
worth.This approach places little emphasis on the acquisition of psychopathology but
tries to place the client from a phenomenological perspective, such as one consisting
of fears and conflicts, into one that is functional (e.g., where the client feels self-
worthy). This form of therapy is used only by some clinical psychologists, as the
humanistic and existentialist approach is hard to evaluate.

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What are perspectives on mental health and
stigma?
Many still hold negative views of those with mental illnesses. This might be
explained due to a lack of knowledge, which is why it is important that people are
educated about mental health, so that sufferers will feel less stigmatized and be
treated the same as anyone else.

What are the types of mental health stigma?

There are two types of mental health stigma: social stigma which is directed at
others who are suffering from some sort of mental health problem, and perceived
stigma (or self-stigma) which are the internalized feelings of discrimination a
sufferer experiences due to their condition. The latter can be quite discouraging and
result in a negative impact on possible treatment outcomes. Some of the biggest
stigmas are that 1) patients are often dangerous, 2) that some disorders are self-
inflicted, and 3) that sufferers are often hard to talk to.

Who hold stigmatising beliefs?

Stigmatising beliefs about individuals with mental health problems are held by a
broad range of individuals within society. This happens regardless of whether they
know someone with a mental health problem, have a family member with a mental
health problem, or have good knowledge and experience of mental health problems.

What causes stigmas?

Misguided views that the mentally ill are dangerous or shouldn't be part of the
society might be the basis why some still think that these people should be excluded
and treated differently. Current views on mental health can still be stigmatizing,
such as the medical model which implies that sufferers are different from others, or
the fact that a label is put on those suffering from a mental issue does not help to
alleviate any negative stigma. Another source of misguided views on mental health
are the media.

Why are stigmas a problem?

Stigma can be discriminating, which results in social exclusion, low self-esteem, poor
social support, and poor subjective quality of life. All of these factors have a huge
impact on the treatment of mental disorders, like slowing down the recovery or even
worse demotivating the sufferer from undergoing any treatment.

How can stigmas be eliminated?

Much is done to eliminate stigma, like the Time to Change campaign (UK), which
attempts to educate people about mental health with the use of blogs, videos, TV
ads and events. Campaigns like these that are made to make contact between
individuals with and without mental illnesses, have been shown to improve the
attitudes towards people with mental health problems, promote people's behavior
for anti-stigma engagement, and lastly increase the willingness of people to be open
about any mental health problem they might experience in the future.
Ch2: How is psychopathology assessed and classified?

The type of technique employed by clinicians for clinical classification and

assessment often depends on their theoretical orientation to psychopathology. These
techniques help in diagnosing, finding the best intervention, and evaluating whether
the treatment effectively targeted the symptoms of the client.

How can psychopathology be classified?

We need to use categorization and classification in order to gain knowledge about
the aetiology and causes of mental health problems. Different approaches are
required for the various mental health problems, so classifying them helps in
providing good and specialized support and service for sufferers. We can only define
success of interventions if there is an objective way of defining what makes out the
symptoms of psychopathology.

How were classification systems developed?

Emil Kraepelin (1883-1923) defined a distinct set of symptoms as a syndrome. The
World Health Organization followed Kraepelin's scheme and extended the
International List of Causes of Death (ICD) with psychological disorders in 1939.

What are the DSM and the DSM-5?

The American Psychiatric Association (APA) improved classification by developing the
first Diagnostic and Statistical Manual (DSM) in 1952. The most recent classification
system is the DSM-5, which is the most widely adopted psychopathology
classification system.

The Four basic objectives of the DSM-5 are:

1. Sufficient criteria must be provided to achieve a correct differential

diagnosis
2. It should discriminate between 'true' psychopathology from normal
'problems in living
3. Diagnostic criteria should allow the application by different clinicians in
different settings
4. It should be theoretically neutral, therefore not favoring one theoretical
approach over another one

It also provides the following information:

 Essential features of the disorder

 Associated features
 Diagnostic criteria
 Information on differential diagnosis
Diagnosis should be made almost fully on the basis of observable behavioral
symptoms, it therefore ignores the nature of the disorder (unless it is certain), and
solely focuses on symptoms.

What are problems with the DSM-5?

The DSM-5 classifies psychopathology according to symptoms and not causes. Due
to this classification by symptoms, it gives the impression of explaining symptoms,
when it is just a different description of the symptoms. Labeling people according to
criteria using the DSM-5 can attach stigma or be harmful. It can also lead to the
view of disorders being discrete entities, while it has also been suggested that
psychopathology may be viewed as rather dimensional. In practice, two or more
distinct disorders co-occur, which is called comorbidity. This suggests that most
disorders consist of symptoms of hybrid disorders (e.g., mixed anxiety-depressive
disorder), rather than independent discrete disorders. Since comorbidity is so
common, new terms have been introduced, such as a disorder spectrum. These are
presented in a hierarchical structure, with individual discrete disorders as defined in
the DSM-5 making up the bottom level of an overarching spectrum. Anxiety and
depression are, in this new structure, part of the group of emotional disorders.

The DSM-5 is no longer categorized in a multi-axis system, but now consists of 20

chapters describing disorder families. Users of the DSM-5 are now encouraged to
rate the disorders' severity of symptoms on a continuum. Some other changes are:

 Some disorders are now represented by their own chapter, like Obsessive
Compulsive Disorder (OCD) and Stress-related disorders.
 Many previously separate autism labels are now incorporated under
Autism Spectrum Disorder.
 The new disorder Mood Dysregulation Disorder diagnoses children
suffering from persistent irritability.
 Binge eating disorder, skin picking disorder, and hoarding disorder are
now independent disorder categories.
 Personality disorders' categorical model stays but has an added
dimensional scale.
 Bereavement is no longer excluded as a symptom in major depression.
 PTSD is now included in a new chapter on stress.
 Substance use disorder now combines both substance abuse and
substance dependence.

Some criticisms of the DSM-5 are:

 The many changes now require less criteria to be met for a diagnosis.
This can turn out good or bad, but it will likely 'medicalise' many normal
human emotions and thoughts.
 The new disorder categories (e.g., attenuated psychosis syndrome, seen
as a potential precursor to psychotic episodes) that are made to identify
people showing early signs of disorders might also again medicalise
perfectly fine and healthy people, just because they are showing normal
adaptations to life that might seem abnormal at first.
 The new diagnostic criteria can result in lowered rates of diagnosis for
some particularly vulnerable populations (e.g., children diagnosed with
autism), and there are concerns that the changes to specific learning
disabilities (relating to conditions such as dyslexia or other
communication disabilities) could disadvantage people with learning
disabilities.
  The usage of neuroscience in the diagnostic criteria is called because
neuroscience has not been able to help defining mental health problems a
lot lately.
 Since disorders are now generally seen as dimensional, any criteria
defining a cut-off score is quite arbitrary.

What are alternatives to the DSM?

Over the past decade, alternatives to the DSM have been developed. For instance, in
the Research domains criteria (RDoC) approach, classifying psychopathologies in
terms of their causes is done by researching causes and then relating them to
observable symptoms. Moreover, the Hierarchical Taxonomy of Psychopathology
(HiTOP) approach is a recently developed hierarchical classification of
psychopathology symptoms that help to predict comorbidity and also higher-order
dimensions that reflect associations between lower-order dimensions. Another
alternative is network analyses, which assumes that there is some kind of underlying
cause or latent variable that connects symptoms together. For example, a lung
tumour can explain why an individual experiences chest pains, and a chronic cough.
In clinical practice, depression is the name given to the dynamic causal interactions
between symptoms, and it is not called the underlying cause. Lastly, the Power
Threat Meaning (PTM) Framework represents an attempt to move away from
primarily biological and medical models of mental health problems that are based on
psychiatric diagnosis and the assumption that mental health problems are disorders
of biology and are pathological. Instead, the framework takes a broad view of the
causes of psychopathology and views people as social beings whose experiences of
distress and troubling behaviour depend on their material, social, environmental,
socio-economic, and cultural contexts.

Which assessment methods can be used for

psychopathology?
What is the clinical interview?
During the clinical interview, a first form of contact is made, and the clinical
psychologist will try to get a general overview of the client as a person and their
problems. This can be difficult, as a lot of clients do not give out all information to
the therapist, possibly because it is something they are embarrassed about,
involving a painful memory or illegal incident. Additionally, they do not have enough
insight about themselves to answer questions correctly.

To get hold of standardized information, the therapist can engage in the structured
interview to make a diagnosis or form a case formulation. One of those structured
interviews which allow clinicians to make decisions about functioning and diagnosis
is called Structured Clinical Interview for DSM-IV-TR (SCID). This interview uses a
branching method whereby one response the client makes decides which question
will be asked next. It is highly reliable for most AXIS I disorder diagnoses.
Structured interviews also serve the assessment of overall intellectual and
psychological functioning levels. One such example is the Mini Mental State
Examination (MMSE), which is reliable and only takes 10 minutes.

Limitations are:

 Low reliability for unstructured interview

  Race and sex might influence responses of client
 Poor self-awareness of client
 Interviewer might also be biased
 Client wants to mislead interviewer

What are psychological tests?

Psychological tests are more structured than clinical interviews. Advantages are:

 Assessment of one trait or specific characteristics.

 A pre-conceived scoring system can be used because the test's response
requirements are very rigid (e.g., STAI, State-Trait Anxiety Inventory).
 Statistical norms, by process of standardization, can be used to
determine how client's score compare to normal distribution.
 Psychological tests are both reliable and valid.
 Most of the psychological tests go by the psychometric approach, which
holds that people have stable underlying traits that are active at different
levels in everyone. Psychological tests can be used for example to assess
psychopathology symptoms, cognitive or neurological deficits, and
intelligence.

Personality Inventories
The Minnesota Multiphasic Personality Inventory (MMPI) is one of the most well-
known inventories used by clinical psychologists and psychiatrists. The most recent
update, MMPI-2, includes 567 self-statements which the client answers by choosing
the best of the three points: 'true', 'false' or 'cannot say'. The inventory only
includes questions which were previously responded to differently by a large sample
of non-psychiatric patients and psychiatric patients. The test consists of 4 validity
scales and 10 clinical scales.

Results from the MMPI are displayed in a graph, presenting a profile that indicates
general personality features of the client, potential psychopathology, and emotional
needs. The provided validity scales are important because clients might provide false
information. The MMPI has good internal reliability and scores on it seem to have
very good clinical validity, due to accurate correspondence of clinical diagnoses and
symptoms rated by own family members and the clinician. One limitation of the
MMPI is that it takes very long. The MMPI-2 is a shorter version with good validity
and reliability.

Specific Trait Inventories

The Specific Trait Inventories measures one specific psychopathology, or a
functioning that is relevant to psychopathology. The Obsessive Belief Questionnaire
(OBQ) is an example to measure cognitive functioning relevant to obsessive
compulsive disorder (OCD). These specific tests not only measure characteristics
found in observable behaviour but can also measure hypothetical constructs.
Nevertheless, most of the specific trait inventories are not subject of validation and
reliability tests and are also not standardized.

Projective Tests
Clients taking a projective test are confronted with a fixed set of stimuli that leave
room for interpretation because the stimuli are ambiguous. The Rorschach Inkblot
Test, the Thematic Apperception Test (TAT) and the Sentence Completion Test are
the projective tests that are used most widely. Yet, all of them are less reliable and
valid in a considerable amount than more structured tests.

Hermann Rorschach created Rorschach Inkblot Test test by dropping ink onto paper
and then folding it in half, creating a symmetrical image, called an inkblot. The test
consists of 10 official ink blots. There is a highly structured scoring system which
clinicians can use to compare the client's score with a set of standardized personality
norms that might indicate psychopathology. Nevertheless, the test is often subject
to the clinician's interpretation of the client's responses. It can be a valid and reliable
test though to detect thought disorders possibly indicating schizophrenia or the risk
of developing it.

The Thematic Apperception Test (TAT) is an example of a projective test, and it

requires clients to create a dramatic story around a picture which displays people in
vague and ambiguous situations. The whole test consists of 30 of these pictures,
which are all in black and white. The 'hero' is the character of the picture with whom
the client identifies, and in that way the client describes what he feels, as if he was
part of the scene. The TAT may in that way express expectations the client holds
about relationships with various people in his life (e.g., parents, romantic partner).
This test can be used well after a client was matched with an appropriate form of
therapy or to evaluate individuals accused of violent crimes.

The Sentence Completion Test gives clients sentences that are uncompleted and
which they need to fill in with their own words. This can indicate how a client might
be biased in thinking or processing information from his or her psychopathology. The
test was applied for example to combat veterans with post-traumatic stress
disorder. The clinician will find from the sentence completion which ways of thinking
should be targeted.

 Projective tests are becoming less and less popular over the years.
Reasons are:
 They often reveal information just relevant to the psychodynamic
approach, an approach which is experiencing decline in popularity itself.
 They have low reliability.
 They infer psychopathology when there is otherwise little evidence for it
(such as the Rorschach Test), with exception of indications for
schizophrenia.
 They contain intrinsic cultural biases.
 They are labour-intensive and in return give little objective information.
 Computerised Adaptive Testing (CAT)
 Contemporarily, psychological tests can be administered and completed
via computer, scored by the computer, and interpreted by the computer.
This is known as computerised adaptive testing (CAT). CAT uses existing
data to streamline and individualise the measurement process optimally
selecting questions from a large bank of questions and responses.

Intelligence Tests
Intelligence tests aim to measure intellectual ability. The first intelligence test was
created in 1905 by the French psychologist Alfred Binet. Most are standardized,
having a score of 100 as the mean and 15 or 16 as score for standard deviation.
Advantages of intelligence tests include high internal consistency, high test-retest
reliability, and good validity.

Intelligence tests are used in variety of situations by clinicians:

  They are used together with other measures of ability for the diagnosis of
learning and intellectual disabilities.
 They are used for the assessment of individuals with disabilities, so they
can be provided with support for specific needs. Best used for this is the
Wechsler Adult Intelligence Scale (WAIS), which covers a range of
different ability scales.
 They are used in neurological evaluations as part of an assessment
battery.

There are also limitations of using intelligence tests:

 Intelligence is a hypothetical and inferred construct.

 There is a cultural bias, many IQ tests being based on middle class
majority ethnic background views, making the intelligence dependent on
the reliability and validity of the individual IQ test.
 They are 'static' tests that capture intellectual ability at one point in time.
They do not measure the potential of acquisition of new cognitive
abilities.
 Many other skills are not contained in measures and conceptions of
intelligence (e.g., music ability), making our current conceptions too
narrow.

What are biologically based assessments?

Neurological impairment tests deal with identifying if cognitive deficits in an
individual can be attributed to brain damage, and if so, which brain areas have been
affected. This is done by using EEG, PET scans and fMRI scans, blood tests, and
chemical analysis of cerebrospinal fluid. Neurological tests are also very important in
an assessment, and help measure perceptual, cognitive, and motor performance. By
finding a specific cognitive deficit it can become easier to identify the area of brain
damage. The Adult Memory and Information Processing Battery (AMIPB), the
Halstead-Reitan Neuropsychological Test Battery and the Mini Mental State
Examination (MMSE) are the tests commonly used by clinical neuropsychologists.

Psychophysiological tests
To gather information about emotionally based psychological problems,
psychophysiological tests can be very helpful. The electrodermal responding, also
known as the galvanic skin response (GSR) or skin conductance response (SCR),
measures changes in sweat gland activity by electrodes attached to the fingers. A
polygraph records the changes in skin conductance caused by emotional responses
(e.g., fear, anxiety).

Neuroimaging techniques
The electromyogram (EMG), measuring the electrical activity in muscles, and the
electrocardiogram (ECG), measuring heart rate. The lie detector is not used as often
anymore, especially less in cases of finding evidence of criminal guilt, as arousal not
attributed to lying can be detected and interpreted falsely as lying. The
electroencephalogram (EEG) is an assessment measure that records underlying
electrical activity, by attaching electrodes to the scalp. Unusual brain patterns in
different brain areas can be localized.

One technique to provide images of the brain is the computerized axial tomography
(CAT). For that the patient needs to lie in a large tube and 3D versions are formed
of the brain. With these images abnormal growths or enlargements of the ventricles
can be detected. The positron emission tomography or PET scans use radiation to
develop images. Participants emit gamma radiation, which comes from small given
amount of a radioactive drug. Areas colored brightly in the image indicate high
metabolism of glucose in the brain. Furthermore, the magnetic resonance imaging
(MRI) is a scanning technique which creates visual pictures of the brain by placing a
participant inside a circular magnet that makes the hydrogen atoms in the body
move.

What is meant by reliability and validity of

assessment methods?
To be sure that assessment methods provide objective information about clients, it
is important to be sure about two things, namely reliability and validity. Reliability
means that the method will still provide the same result when used by different
clinicians on different occasions. Second, we need to be sure that the assessment
has validity. This means that it actually measures what it claims to measure. For
instance, if a test assesses anxiety, then scores on the test should correlate well
with other ways of measuring anxiety.

What is the concept of clinical observation?

Direct observation allows the assessment of frequency of a specific behaviour, what
precedes the behaviour, and what follows it. An ABC chart can be used for this
assessment, including A) what occurs before the target behavior takes place B) what
the individual had done C) what consequences follow the behaviour.

Advantages of clinical observation are:

 An important objective measure of the behavior frequency is provided, as

well as for what precedes and follows behaviour.
 Greater external or ecological validity than for other testing ways (e.g.,
self-reports) is provided.
 The context in which behavior takes place might provide hints to
workable answers.

Drawbacks of clinical observation:

 Time consuming assessment.

 Behavior in one context of observation might not be typical to behavior in
another context.
 The observed individual might act differently because the observer is
present. Analogue observation takes place in a controlled environment
where the client can be observed secretly.
 Poor inter-observer reliability.
 Expectations of observer can influence data.

In self-observation or self-monitoring, the client keeps track of his own behavior,

and notes down when and in what contexts certain behaviors take place. Ecological
momentary assessment (EMA) is a method in which the client makes use of
electronic diaries to capture self-observation. It helps lower the frequency of
undesirable behaviors.

What is cultural bias in assessment?

Many tests can be culturally biased and in return do not yield a correct picture of an
individual's mental health. Not all ethnic groups score the same on assessment
tests, consequently they are often given different diagnoses and popular ethnic
stereotypes influence the medical and psychiatric practice. Also, clinicians often
make judgments in unstructured interviews that are influenced by socioeconomic
stereotypes.

What are examples of cultural bias in assessment?

Cultural anomalies can be identified in a number of different ways. For example,
some ethnic groups score differently on assessment tests than others. For example,
American Asians often score higher on most scales of the MMPI compared to White
Americans. Moreover, Black Americans have a higher rate of diagnosis of disorders
such as alcoholism or schizophrenia, whereas White Americans are more likely to be
given the diagnosis of major depression.

What are causes of cultural bias in assessment?

There are a number of causes of cultural anomalies in assessment and diagnosis.
First, there are different manifestations of mental health symptoms in different
cultures. Secondly, there might be a language barrier between client and clinician.
Thirdly, perception of psychopathology is influenced by religion and spiritual beliefs.
Fourthly, culture differences affect client-clinician relationships. Lastly, there are
different perceptions on what is considered 'normal' and 'abnormal'. The judgment
of clinicians is often also influenced by the confirmatory bias, which means that
clinicians only pay attention to information that supports their initial hypotheses and
ignore information that does not support it.

What is case formulation?

In case formulation, an approach is used which tries to formulate a psychological
explanation from clinical information and from there on develop a plan for therapy.
This approach works from an established theoretical account to explain problems the
client is experiencing. This collaborative way of therapy consists of six components:

1. Creation of a list of the client's problems

2. Identification and description of the underlying psychological mechanism
of the problem
3. How these mechanisms generate the problem
4. Events that led up to the problem
5. How these events may have caused the problem regarding the
psychological mechanism
 6. Development of a treatment scheme and prediction of possible obstacles

The theoretical approach of the therapist determines the construction of the case
formulation. The ABC approach aims at explaining the client's problems by the
cognitive-behavioral model by explaining (A) antecedents (B) beliefs and (C)
consequences of an event. In the psychodynamic approach the problems of a client
can be viewed as interactions between various 'actors' (family members). Clinicians
like to use diagrams to represent their formulations.

Advantages of the case formulation approach include:

 Flexibility in understanding the client's problems, regardless of any

previous diagnoses they have received.
 A collaborative form of treatment.
 A basis of theoretical understanding of psychopathology.
 The past history of the client is considered.
 Appropriate treatment can be administered to target specific needs, even
in complex cases that do not easily fit standard diagnostic categories.
Ch3: What are the research methods in clinical
psychology?

What is research and what is meant with the

scientific method?
Results of research should be replicable, meaning that other researchers can
produce the exact same findings because collection of results has taken place under
controlled conditions. If a scientific explanation gives suggestions of ways by which
it can be tested or potentially falsified, it is testable. The scientific method relies on
theories, which describe the cause-effect relationship in terms of sets of
propositions. From there on a hypothesis can be created, which then explains the
phenomenon and furthers investigation. Disconfirmed hypotheses are wrong or need
to be changed.

What are the pros and cons of the scientific method?

The National Institute for Health and Clinical Excellence (NICE) is a UK organization
that uses scientific evidence to see which treatments can be labeled as evidence-
based, treatments that have proven to be efficient. These treatments are then
recommended. In contrast to the scientific method, the alternative approach of
social constructionism proposes that there are no basic 'truths' because reality is
only a social construct. Because many disorders involve individuals developing their
own realities, this approach is relevant in clinical psychology, seeing only language
itself as means of understanding psychopathology.

What do we want to find out in clinical psychology

research?
Goals of clinical psychology research entails description, prediction, control, and
explanation (understanding). Description refers to definition and categorization of
events that are of relevance in psychopathology. Prediction attempts to explain
future behavior under specific conditions. Risk factors indicate which factors might
contribute to a greater risk of developing psychopathology at some point in life. We
control events and behavior in a way to learn more about the causal relationships
that are involved and to find better treatment methods. Finally, we try to arrive at
the stage of understanding. By using models of a phenomenon, we describe the
interaction of all factors, in terms of a mechanism.

What questions can be answered with research?

Aetiology is a term used for the description of the origins and causes of symptoms of
psychopathology. When research is done on a healthy population to gain knowledge
about the aetiology of psychopathology, this is known as analogue research.
Evaluative research or clinical audit aims at investigating whether a treatment has
been effective. This supports the effective use of current knowledge.

⇧
Which research designs are used in clinical
psychology?
What are correlational designs?
This type of research design allows a researcher to see if there is a relationship
between two or more variables. Yet, this methodology does not provide a causal
explanation of a relationship. The researcher needs to collect pairs of scores to
perform a correlational analysis. Analysis can be done in computer programs such as
The Statistical Package for the Social Sciences (SPSS). When computing correlation,
the program will give the correlation coefficient r, which goes from +1.00 to -1.00,
the former meaning a perfect positive correlation and the latter giving a perfect
negative correlation. In a scatterplot the relationship between two variables can be
displayed. Because of the differing nature of the relationships of the variables, the
line of best fit differs with it. If the outcome of a study has a low probability of
occurring by chance,

What are longitudinal studies and prospective designs?

The longitudinal studies, also known as prospective designs, do not obtain measures
only at one point in time, but at several points to find out more about the time-
relationship between variables. In the cross-sectional design only one sample from
one point of time is taken.

What are epidemiological studies?

Epidemiological studies try to yield details about the prevalence of psychological
disorders within a specific population over a set period of time. The frequency and
distribution have been studied, giving an epidemiological study the form of a large-
scale and descriptive survey. Prevalence rates can be described by lifetime
prevalence, one-moth prevalence, and point-prevalence. Prevalence is represented
by incidence x duration. It is important that the epidemiological study uses a sample
that is a true representative of the population. This is hard to achieve as many
people do not want to participate in studies.

What are types of experimental designs?

In an experiment, which can determine a causal relationship, a researcher starts
with an experimental hypothesis or experimental prediction, which predicts how the
experimental manipulation might affect the outcome response. The manipulated
variable is called the independent variable and the variable of the outcome is called
the dependent variable. Control conditions control for confounding effects, which are
effects not produced by the independent variable but by something else. The
independent variable is experienced in the experimental group, but not in the control
group. Still, there has to be an objective way to measure the dependent variable, so
statistical analysis can be applied. Random assignment is used to assign participants
to the different experimental conditions. A participant might exhibit demand
characteristics, which means that the participant thinks about certain behaviors that
might be expected of him or her in the experiment and behaves according to that.
The experimenter might also be prone to giving certain cues to a participant because
of knowing to which experimental condition he or she was assigned. To prevent this,
a double-blind experimental procedure can be used.
To avoid ethical difficulties, such as experimenting with humans who already
experience difficulties or suffer from mental health disorders, experimenters often
use analogue experiments. In analogue experiments, analogue populations are often
used. Analogue populations are usually participants without any mental health
problems and often consist of a normal sample of healthy, student participants.
When using analogue populations, it needs to be considered what makes these
populations valid analogues of psychopathology processes. There are three ways in
which it can be argued that analogue studies are valid. First, it is often argued that
psychopathology is dimensional rather than discrete. This means that
psychopathology is often an extreme form of normal behaviours. Then, what one
finds out about these behaviours in nonclinical populations will tell us something
about the processes that cause the more severe reactions found in clinical
populations. Second, one can use experimental manipulations to simulate mild
psychopathology symptoms in nonclinical participants, and then study how this
psychopathology may be alleviated. Third, nonclinical participants might be selected
for an experimental study because they are similar to individuals with
psychopathology.

In addition to analogue populations, researchers often use animal studies. Animal

models allow researchers to experimentally investigate factors such as the genetics
of psychopathology, changes in brain biochemistry associated with specific
psychopathologies, and the effects of drugs on psychopathology. The advantage of
this is that experimenters have complete control over the organism’s developmental
history and permit the use of more intrusive experimental methods.

Another important experimental design is the use of clinical trials. In clinical trials, it
can be examined whether a treatment is more effective than no treatment, whether
treatment A is more effective than treatment B, or whether a newly developed
treatment is more effective than existing treatments. In clinical trials, a placebo
effect can arise, where a participant may improve simply because the procedure,
they are undergoing leads them to believe they should or might get better. To
control for this, researchers often use a placebo control condition.

What are mixed designs?

A mixed design is a type of research that works with participants that are not
randomly assigned to groups, but rather assigned consciously to groups. This design
can be especially helpful in psychopathology research because researchers can see
how a group of participants with one specific psychopathology reacts to a variable in
comparison to a group of participants with another psychopathology. Even though
this technique is very useful, it does not provide information about the causal
relationship.

What are natural experiments?

Observing the effects of naturally occurring events on behavior is another form of
research, coined by the term natural experiments. These events can be a natural
disaster, accidents, terrorist attacks or poverty and social deprivation.

What are single-case studies?

An individual's psychopathology can be studied by means of a case study, and case
formulation can be a form of that used in therapy. Besides using case formulations,
clinical practitioners can make use of the single-case experiment, which assesses an
individual's behavior at two points, before the experimental manipulation and
afterwards.
Case studies were one of the first research designs used, such as by Sigmund Freud
with his psychoanalysis approach. Case studies are also a good source to disprove
existing theories. Drawbacks of using case studies include little objectivity and
control, low external validity, and the difficulty of providing evidence which supports
the theory.

In a single-case experiment, the participant acts as both the experimental and

control participant. For psychopathologies that are rare this is a good option, as
often there are not enough participants for the experimental and control groups.
Baseline measures of the behavior are taken before the experimental manipulation,
which are then compared with the behavior after the manipulation. The ABA design
is often used, which measures changes in behavior directly after the experimental
manipulation, and hence controls for confounding factors that could occur within
time after the manipulation. The ABAB design adds a second manipulation after the
second stage of no intervention. Problematic is the alternation between periods of
treatment with non-treatment if treatment provides important benefits for the
participant. To solve this problem, the multiple-baseline design can be introduced.
Two or more behaviors are measured in this design, while one behaviour is
manipulated, and the other behaviors serve as the control condition. Another option
is to use multiple participants, where in stage A the baseline measures are taken
and then in stage B the manipulation is installed successively for all participants. A
limitation of single-case studies is that results are not easily generalizable to other
individuals, but this problem can be overcome by having more than one participant
in the study.

What are mediators and moderators?

In statistical analyses, mediators are a third variable between the relationship of the
independent and dependent variable. For instance, in a correlational study, a
mediator can be examined to find out whether this variable is mediating the
relationship between two variables. For instance, males weigh more than females,
but this is mediated by length. So, a mediator explains the relationship between two
variables.

What are meta-analyses and systematic reviews?

A meta-analysis attempts to provide an objective review of existing studies by using
statistical methods. A particular finding across a number of studies is assessed in its
strength, detecting possible trends by comparing effect size of the different studies.
Effect size measures the magnitude of the effect in an objective and standardized
way, whereby the problem of different numbers of participants, forms of
measurement, and procedures of the studies is overcome. Meta-analyses therefore
allow a comparison between different studies that deal with similar research topics.
But meta-analysis has its limitations too, such as that published studies usually
provide significant results, thereby overestimating mean effect-size. Also, meta-
analysis does not control the quality of the studies they include, with effect size
being influenced by the quality that the research was conducted with. A second
method of assessing multiple studies is with the use of a systematic review. A
systematic review is a literature review where a clearly formulated question is
attempted to be answered, which is done with systematic and explicit methods for
identifying, selecting and appraising relevant research.
⇧

What are qualitative methods?

Next to the quantitative methods that draw conclusions from studies using statistical
inference, qualitative methods represent a growing body of methods used in clinical
psychology research. They place emphasis on the raw material for research, with
analysis being verbal and not statistical. Because the raw data are descriptions the
participants make of their feelings, experiences and thoughts, the researcher can
gain insight into the daily life of individuals with a certain psychopathology. The
qualitative methods are usually open-ended and can also be a good precursor to
studies using quantitative methods. Also, qualitative methods allow in-depth study
of individuals and interesting things can be discovered which were not initially
looked for.

In qualitative studies participants are usually deliberately assigned to groups, such

as those with the same psychopathology. In the first phase participants are
undertaken a semi-structured and open-ended interview. Participants can respond to
specific but also general questions. The researcher then makes sense of the data,
noting down and relating a participant's re-occurring issues in the responses back to
the original research question. The grounded theory presents an approach to
organize the gathered information into units. Abstract theoretical insights are formed
from identified consistent themes within the data, which then help in forming a
refined research question. Qualitative and quantitative methods can be combined
very well. Often, research in a new area will start with qualitative data and then go
over to or develop quantitative methods from there.

What are ethical issues in clinical psychology?

Ethical committees’ control for basic ethical standards in research to protect the
participant. The three main ethical issues fall under these categories: informed
consent, causing distress or withholding benefits, and privacy and confidentiality.

What is informed consent?

The informed consent is requested from participants prior to the study by means of
an informed consent form which includes information about the purpose, procedure,
duration, confidentiality, whether the participant is paid or participates voluntarily,
and that they can leave the study any time without prejudice. The participant should
also be given the opportunity to ask questions. Deception is sometimes used in the
informed consent to prevent the results from being influenced due to revelation of
all details of the study to the participant. This means for example that not all
information is revealed of what the study will be about. At the end of the study, they
will then receive a debriefing, an explanation of any deception or withheld
information. At the end it comes down to ensuring that the participation in the study
is truly voluntary. A problem with informed consent is that some participants might
not be able to make rational decisions about their consent, like children or
individuals suffering from mental problems. The consent of children is often obtained
by a parent or guardian.

What about causing distress or withholding benefits?

The researcher needs to be attentive to any indications of stress that might come
from the participant, and if this is the case, the study should be terminated or
otherwise continued at a point when the participant feels well. A participant should
never feel worse after having done a study. If the participant feels distressed after
participation, the experimenter should provide a way for the participant to deal with
these feelings (e.g., relaxation tape). Also, the ethical question stands whether one
should withhold effective treatment in the no treatment control condition from a
participant who would be in need for it (such as a new psychotherapy). A good way
how to avoid this ethical conflict is to use participants who are on a waiting list for
this treatment anyway, who would serve as the no treatment condition called
waiting-controls.

Confidentiality and privacy

Privacy and confidentiality are rights that every participant in psychological research
has. Confidentiality ensures participants that their data will be treated confidentially,
and privacy enables participants to withhold some information that they do not want
to provide, such as age or sexual orientation. The informed consent should always
indicate who will access the data of the study if it collects personal information from
the participant. Confidentiality is not absolute, like in case of illegal or immoral
activities being revealed in data collection. For individuals who are in danger of
harming themselves, the individual can be provided with reference to appropriate
support after the study.

What can be concluded about research methods in

clinical psychology?
Research methods in clinical psychology for understanding psychopathology allow
the description of symptoms, the understanding of causes and the assessment of
efficacy of interventions and treatment services. Many research methods are based
on the scientific approach, which is often criticized for not fitting the investigation of
important aspects of psychopathology, such as the phenomenology.
Ch4: How can psychopathology be treated?

What is the nature and function of

psychopathology treatments?
Treatments for psychopathology usually entail providing clients with relief from the
distress, insight to their problems and self-awareness, acquisition of coping and
problem-solving skills and identification and resolving of the causes of
psychopathology. The palliative effect occurs when a form of treatment does not
provide the client with insight into their problems and only reduces the severity of
symptoms. The theoretical orientation and a therapist's training together with the
nature of the psychopathology determine the treatment approach. Therapists take
part in continuing professional development (CPD) to update their knowledge of
recent developments in treatment techniques.

Which theoretical approaches to treatment are

there?
What are psychodynamic approaches?
The psychodynamic approach works with the assumption that an individual develops
unconscious conflicts early in life. This approach tries to uncover these events. The
therapist will work out strategies with the client for change by bringing these
conflicts into conscious awareness through acknowledgment. Sigmund Freud (1856-
1939) introduced the form of psychodynamic therapy called psychoanalysis, in which
the therapist works with free association, dream interpretation and transference
analysis to uncover the client's unconscious conflicts. For the client to call conflicts
into awareness, to understand the source of the conflicts and to help the individual
gain control over behavior, feelings and attitudes, psychoanalysts make use of these
techniques:

 Free association: Any thoughts, feelings, or images that the client has in
mind are verbalized
 Transference: The therapist becomes a representative for an important
person in the client's life, and thus any emotional responses or behaviors
targeted towards that person are acted out on the therapist. This helps
the client understand his feelings towards that person
 Dream analysis: Dreams represent unconscious conflicts in a symbolic
form
 Interpretation: The information from all three sources is interpreted and
ways of conflict solving are developed

Psychoanalysis treatment takes long (3-7 years) to yield benefits and is based on
the acquisition of self-knowledge.

What is behavior therapy?

Behavior therapy uses objective knowledge to create a therapy approach. The
approach is built on the principles of classical and operant conditioning. Earlier it was
thought that psychological disorders came from faulty learning, in which pathological
responses are learned. If psychological problems can be learned, then it should be
possible to 'unlearn' them. From this idea the behavior analysis or behavior
modification approach evolved, which uses the principles of operant conditioning,
and the behavior therapy approach, which is based on principles of classical
conditioning.

Wolpe (1958) postulated that through the classical conditioning principle of

extinction emotional disorders could be cured. Associations between the situation
and the threat are in that way 'unlearned'. Popular techniques used for extinction
are flooding, counterconditioning and systematic desensitization, which are all
termed exposure therapies. Another principle of Wolpe is reciprocal inhibition, in
which an anxiety-incompatible response is attached to the cue that induces the
emotion. These techniques are utilized for a wide range of disorders. Aversion
therapy tries to condition an individual to feel aversion towards a stimulus that they
are wrongly attracted to (e.g., addictive behaviour, distressing sexual activities).

Influencing the frequency of a behavior is the target of operant conditioning.

Rewards or reinforcing consequences following a behavior increase the frequency
and punishment or negative consequences following a behavior decrease the
frequency. Three principles are used in therapy: 1) functional analysis 2)
establishment of appropriate behaviors by using reinforcers or rewards 3)
eliminating problematic behavior by using punishment and negative consequences.
Functional analysis looks at consistencies between problematic behaviors and their
consequences, such as a reward that follows a problematic behavior thereby
maintaining it. Another intervention is the token approach, in which tokens are
distributed for the desired behavior and can later be exchanged for a fancied item or
activity (e.g., cinema visit). With the response shaping procedure, the frequency of
new and desired behaviors is increased, thereby developing new behaviours. A
behavior that occurs already frequently serves as an approximation to the frequency
in which the new behavior should ultimately occur, and reinforcement is given to
approximations that come closer to this model. With behavioral self-control, an
individual can make personal use of the operant conditioning principles to bring
about change in his or her own behaviour. A good example of this is the program
developed by Stuart (1967) to prevent overeating. and reinforcement is given to
approximations that come closer to this model. With behavioral self-control, an
individual can make personal use of the operant conditioning principles to bring
about change in his or her own behaviour

What are cognitive therapies?

Dysfunctional ways of thinking or processing and interpreting incoming information
can cause psychopathology. Cognitive therapy tries to identify and change these
faulty ways of thinking about the world. Beck's cognitive therapy and rational
emotive therapy (RET) represent two early approaches to cognitive therapy. Rational
emotive therapy, by Albert Ellis (1962) focuses on how people construct themselves,
their life and the world, and how this creates their feelings. This approach tries to
free individuals from irrational and unrealistic beliefs, by which they judge
themselves and others, and set more attainable life goals. The aim is to replace
these implicit assumptions that the individual carries around with more rational
beliefs. Beck's cognitive therapy for depression requires the individual to provide
evidence for the biased views held of the world, helping him or her to come to the
conclusion that the existing schemas are irrational. From these approaches, the
approach of cognitive behavior therapy (CBT) was born, which aims to change both
thought and behaviour.

The following points are usually part of this therapy:

 The client writes a diary, writing down important events and associated
feelings.
 The therapist helps the client identify and challenge dysfunctional beliefs.
 Clients do homework, which allows them to see that their assumptions
are irrational.
 For situations eliciting their psychopathology, clients practice new ways of
thinking, behaving and reacting.

New forms of cognitive behavior therapy are developed over time, and these
different forms of CBT are described as waves. The first wave of CBT was
represented mostly by behavior therapy based on conditioning and learning. The
second wave focuses more on our cognitions, so the way we think. This was also the
wave out of which Beck's therapy developed. The third (and current) wave being
developed focuses more on the mindfulness and acceptance of our cognitions.
Mindfulness-based cognitive therapy (MBCT) attempts to improve one's emotional
well-being by increasing the awareness of how our automatic responses to thoughts,
sensations and emotions can be distressing. This is done by achieving a mental state
with a focus on the present-moment while maintaining a non-judgmental attitude.
MBCT has been shown to have a positive effect on reducing many symptoms, among
which are anxiety and depression symptoms. Another third wave variant of cognitive
behavioral therapy is acceptance and commitment therapy (ACT). ACT teaches one
to 'simply' accept any thought or feelings a person might experience, compared to
traditional CBT which focuses on changing these thoughts. When someone applies
ACT and accepts their thoughts and feelings, they are not distressed by the negative
valence they give to these thoughts, and therefore they might be more successful in
clarifying their values and taking action on them. ACT teaches one to 'simply' accept
any thought or feelings a person might experience, compared to traditional CBT
which focuses on changing these thoughts.

What are humanistic therapies?

Humanistic therapies place emphasis on the client as a 'whole' person, such as in
holistic therapies, and focus primarily on the individual and his feelings. The therapy
should be built on a good client-therapist relationship that allows cooperation and
should enable the client to feel in control of solving his own problems. The most
successful therapy of this approach is the client-centered therapy, in which the
therapist demonstrates empathy and unconditional positive regard to help the client
develop into a well-adjusted, happy individual. The therapist takes the role of the
listener and thereby helps the client to grow and move from one phenomenological
state to another.

What are family and systemic therapies?

The family therapy is helpful if psychopathology is caused by communication and
specific conflicts between family members. The systems theory attempts to re-mold
the relationships within a family, especially the relationship between the two
parents, so it can function well again. In therapy it is explored how the problem
affects functioning of the family and usually the emphasis does not lie on the cause
of the problem but rather why it is maintained. The goal is to identify patterns of
interaction in the family that are unknown to the members. The therapist will then
offer them other ways of responding to each other that are more effective.

What is drug treatment?

As a common first line treatment, drug treatments come in various forms.
Antidepressant drugs are prescribed against depression and mood disorders,
anxiolytic drugs treat symptoms of anxiety and stress, and antipsychotic drugs deal
with symptoms of psychosis and schizophrenia. The first drug against depression,
which increased the amount of norepinephrine and serotonin available for synaptic
transmission, was called tricyclic antidepressants. This was around the year 1960,
and other antidepressants that came on the market during that time were the
monoamine oxidase (MAO) inhibitors. If a patient with major depression has not
responded to any medication, MAOIs can be effective for some. Bipolar depression
and panic disorder can also be treated effectively with MAOIs. Newer types of drugs
that have developed (e.g., against depression), such as fluoxetine, sertraline,
paroxetine and citalopram, are collectively referred to as selective serotonin
reuptake inhibitors or SSRIs. They affect the uptake of only serotonin and produce
fewer side effects than for example tricyclic antidepressants that yield the same
effects in reducing symptoms of depression. Recent studies have suggested that
antidepressants are only more effective than placebos for those suffering from major
depression, and that they are not more effective than placebos for people suffering
from milder versions of depression. Prevalent disorders of anxiety, such as specific
phobias, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder
(GAD), and post-traumatic stress disorder, can be treated with benzodiazepines.

Due to the development of antipsychotic drugs the prognosis and view of sufferers
of schizophrenia has changed a lot with the time spent in psychiatric institutions
having come down to 2 months, when before the introduction of the drug in 1980
the patients spent most of their lives in a psychiatric institution. Antipsychotic drugs,
reducing high levels of dopamine in the brain, can target the major positive
symptoms but also the major negative symptoms, but also have side effects (e.g.,
blurred vision, muscles spasms) that lead the patient to stop taking the drug often
times. Even though drug treatment is mostly effective, they give an individual the
constant feeling of having a disease and being dependent on the drug to alleviate
symptoms. There is also evidence that holds that drug treatment worsens a disorder
seen over long-term and increases likelihood of relapse. Drug treatment paired with
psychological treatment yields most effective results.

What are different modes of treatment delivery?

What is group therapy?
Group therapy is a form of therapy that is useful if an individual benefits from
comfort provided by the other members and from the presence of other people that
share the same problem and that can help to treat certain psychopathologies in
which being surrounded by people plays a role. Different forms of group therapy are
experimental groups and encounter groups in which self-growth is fostered through
disclosure and interaction and self-help groups in which a common problem is the
basis and members support each other through the sharing of information.

What is counselling?
Counseling provides the opportunity for personal-growth and productivity of an
individual. This approach has become popular in the last 20-30 years, also because
of the greater demand of support and treatment. Counseling can also help in
resolving problems of underlying psychopathology. Counselors differ in approaches
they use and also specialize in specific areas. This gives the names to counselors
such as mental health counselor, marriage counselor or student counselor, and often
there is direct service provided for people with specific medical conditions and their
caretakers.

What about digital technologies such as computerised CBT, e-

therapy, and virtual reality exposure?
Computerised CBT works with software packages that can be used independently by
clients. Two CCBT packages are recommended by the UK Department of Health,
Beating the Blues for moderate to mild depression, and Fear Fighter for managing
panic and phobia. Beating the Blues was found to be more effective than a GP
treatment for depression and anxiety.

With the rise of the internet, e-therapy has evolved into an effective add-on to
conventional therapy. Treatment can be continued over distance; the client's
behaviour can be monitored daily, and family members of the client can
communicate that way with the therapist as well. Furthermore, the client can initiate
contact with the therapist easier, which is especially good if the client is shy in
personal interviews or lives in a remote area. Drawbacks of online communication
are miscommunication, effective intervention when a client is experiencing a crisis
and difficulty to ensure confidentiality.

Finally, in the last 20 years, the use of virtual reality environments to assess and
treat a range of mental health problems has become significantly more widespread.
Virtual reality refers to an interactive computer environment that allows the user to
experience a particular environment and also interact with that environment. Virtual
reality exposure (VRE) is useful in helping the therapist to identify environmental
factors that may trigger symptoms and is predominantly used as a safe form of
exposure therapy.

Mental health problems not only affect the people suffering from it, but also the
economy. Much money is spent on mental health care and lost because of
individuals suffering from mental problems. Because of this, many countries are now
working hard to supply better access to therapies such as CBT, which has proven its
efficacy. Improving Access to Psychological Therapies is a program by NHS which
provides services across the UK for people suffering from anxiety or depression
disorders. In order to do this, they:

 Train many practitioners therapies such as CBT, and these people get
known as psychological well-being practitioners (PWPs)
 Improve the access to treatment and reducing its waiting times
 Increase the client choice and satisfaction
The money that is spend on programs like these are thought to be well returned by
the money saved because of people gaining more access to therapy, which results in
more people returning back to work.

How is treatment evaluated?

Evaluating treatment is not as easy as it sounds, as one has to take into
consideration that different approaches judge differently of what a successful
therapy is and what characterizes that success. A therapy in that sense is effective if
it was helpful to the client. Nevertheless, objective criteria to assess success of
therapies are sought, because the aim is to provide the most effective support for
clients and to determine how long-lived the effects of a therapy are and prevention
of relapse.

Which factors affect evaluation of treatment?

A client's rating that therapy was effective does not mean that there has been a
therapeutic gain, and if there has been a therapeutic gain it does not mean that this
was an outcome of the specific type of therapy used. A treatment high in internal
validity means the treatment is effective due to the principles it contains. There are
several factors that can influence the effectiveness of a treatment, such as
spontaneous remission, placebo effects, and unstructured attention, understanding,
and caring.

What is spontaneous remission?

Spontaneous remission can be a confounding factor when assessing the
effectiveness of a treatment, because it means that over time the people with
disorders will get better anyways, without structured treatment. The rate of
remission is currently 30%.

What are placebo effects?

When individuals expect to get better by taking a medication for example, they
simply get better just by the expectation of improvement. When this happens the
placebo effect occurs, but it only holds for a short time and actual psychotherapies
show more improvement.

What about unstructured attention, understanding, and caring?

Befriending is a way how to compare effects of structured therapy with the effects of
simple social support (attention, understanding and caring) to see if it is the
principles contained in the structured therapy that produce improvement.
Befriending acts as a control condition in which the therapist applies social support
but does not directly target symptoms. Topics of the interview are usually neutral
(e.g., hobbies).

Which methods can be used to examine what

treatments are effective?
Some forms of therapy do not start with the assumption that the success can be
quantitatively or objectively measured, because they focus on the reconstruction of
the client's world. Nevertheless, being able to assess treatment is important to
provide some sort of a benchmark measure. There are several ways in which the
effectiveness of treatments can be assessed, such as randomized controlled trials,
and meta-analyses and reviews.

What are randomized controlled trials?

Randomized controlled trials (RCTs) use a variety of control conditions and possibly
also other forms of treatment to see how they compare to the treatment being
assessed. Random assignment is used to place participants into a control group,
either a no treatment or a waiting-list control group, an expectancy and relationship
control group and, a comparative treatment group. A therapy is said to possess
internal validity and be effective if it is more effective than groups 1 and 2 and at
least as effective as group 3 named above.

Limitations:

 Dropouts are common, especially in no treatment conditions.

 RCTs take a lot of time and are expensive.
 Some participants may like some types of therapy better than others, and
in random assignment this is not controlled for.
 Objectivity is hard to obtain in RCTs, and there is often explicit or implicit
bias.

What are meta-analyses?

The question of whether psychotherapy treatment is more effective than no
treatment at all has been investigated by meta-analysis and results of a large-scale
study reveal that psychotherapies indeed show greater effectiveness than not
treating an individual at all. Yet, the types of psychotherapies did not differ in their
effectiveness.

What can be concluded about the effectiveness of

treatments?
Most contemporary, accepted therapies seem to be more effective than no therapy,
but when compared to each other, no therapy is significantly better than the other.
This is also known as the Dodo Bird Verdict, an expression from Alice's Adventures
in Wonderland.

Characteristics that can be commonly found in successful therapists include giving

good feedback, helping clients gain self-efficacy and autonomy and supporting
clients so they can understand their own thoughts and further their relationships. In
a large-scale study where clients were asked to rate their satisfaction of the
psychotherapy, they reported:

 Significant benefit from the therapy

 There was no difference with psychotherapy plus medication
 The types of therapists were equally effective and
 The longer the treatment was the more they gained from it
Ch5: What are clinical practices?

What are the economic costs of mental health

problems?
At least 1 in 4 people in the UK experience a diagnosable problem each year. Mental
health problems cost the economy around £105.2 billion in the UK each year. Apart
from the fact that it can cause suffering for the people themselves, it is important
that good care is available given the costs.

What about mental health professionals?

The general practitioner is often the first point of contact for mental health care.
General practitioners can often already provide an initial assessment and, for
example, prescribe medication. In addition, GPs can refer to more specialized care,
depending on the problem. Community mental health nurses (CMHNs) or community
psychiatric nurses (CPNs) are registered nurses who specialize in mental health
issues and possess a range of skills.

When an individual is referred for a more detailed assessment, they often go to a

psychiatrist or a clinical psychologist. A psychiatrist is a medical practitioner
specializing in diagnosing and treating mental illness. A clinical psychologist are
graduates in psychology and have had at least three years of intensive training after
college to learn the skills necessary for clinical practice. In addition, they specialize
in assessing and treating mental health issues.

In addition, counsellors, psychotherapists, occupational therapists, social workers,

and licensed mental health professionals are involved in mental health care.
Counsellors are trained in talk therapy, supporting clients in dealing with the issues
in their lives. Psychotherapists are involved in treating mental health problems more
through psychological means than medical means. Occupational therapists specialize
in evaluating and (re)training skills used in daily life. Social workers specialize in the
social needs of the client, such as housing. Licensed mental health professionals
provide treatments to clients to help them cope with mental health issues in their
daily lives. Often work is conducted in a multidisciplinary team (MDT), in which
workers from all kinds of different disciplines participate who are specialized in
different aspects of care.

What mental health services exist?

Most people with mental health problems can be treated on an outpatient basis,
which means that these people can live in the community and receive treatment at a
health centre, day clinic or larger general practice. However, some may require
inpatient hospital care, meaning treatment is voluntary in a hospital. In addition to
psychiatric hospitals, there are regional security units for people involuntary under
the Mental Health Act, for people coming out of prison under the Mental Health Act
and for people coming from a normal hospital because they need treatment in a
safer environment.
⇧

How is mental health care organised?

The care must be structured so that the different skills of the professionals can focus
on the different problems that exist. In the United Kingdom, care is currently
organized around different groups, for example children and young people with
physical and mental health problems and people with brain damage or neurological
disabilities.

What is the recovery model?

Physical illnesses are easier to cure than mental health problems. The recovery
model is a broad approach to treatment that recognizes the influence and
importance of socio-economic status, work and education and social inclusion in
helping to recover. It's a holistic approach. There are several key features of
recovery:

 Heap
 A safe base
 Developing self-awareness
 Supportive relationships
 Empowerment and Inclusion
 Coping strategies;
 Phrase, developing a goal

What are the most important skills and

competences of the psychologist?
The clinical work of a psychologist normally consists of four phases: assessment,
formulation, intervention and evaluation. Assessment is the first stage of trying to
understand a client's problems, what might be causing these problems and how they
are maintained and how the client would like to change. Often this is followed by a
diagnosis, which is a classification of the client's symptoms according to diagnostic
criteria. Mainly, the clinical interview is used to obtain information in the
assessment. This is followed by the formulation phase, in which clinical information
is used to explain the client's problems and develop a plan for treatment. The third
phase is the application of the intervention, a psychological treatment based on the
formulation. This can be based on different theoretical approaches and in
consultation with the client. Finally, evaluation is the phase in which it is examined
whether a treatment has the desired effect. This can be done in discussion with the
client or with the help of questionnaires.

What is the reflective practitioner model?

Despite the fact that not all clinical psychologists are happy with the scientist-
practitioner label (because they use alternative philosophical approaches, for
example), they are generally expected to use a reflective practitioner model in their
work. This is a key competence in which one reflects on one's own experiences in
working with a client and on the interaction with the client. The advantages of this
are that it facilitates the development process to become an autonomous, qualified
and self-managing professional, that it offers the opportunity to develop in the work
and to reflect on the needs of each individual client and that it stimulates self-
motivation and self-directed learning.

How does the regulation and continuing of

professional development take place?
The Health and Care Professions Council (HCPC) is a body responsible since 2009 for
regulating and maintaining a register of clinical psychologists in the UK, ensuring
they meet specified standards of training, skills, behavior and health. This register
also specifies that 'clinical psychologist' is a protected title, meaning that this title
can only be used if the person has received appropriate training and is registered
with a regulatory body relevant to the title. If a clinical psychologist is qualified to
join the registry, he or she is expected to engage in continuing professional
development (CPD) throughout their career: the commitment of licensed therapists
to regularly update knowledge of recent advances in treatment techniques.

What does clinical psychologist training look like?

In the United Kingdom, the first requirement to become a clinical psychologist is to
have completed a degree in psychology or equivalent study so that they are eligible
for graduate basis for chartered membership (GBC) of the British Psychological
Society. After obtaining this qualification, you can apply for a place in a clinical
training course, which has high requirements to achieve. Good research skills are
also an important quality. Applications for clinical training courses are regulated in
the UK by the Clearing House of Postgraduate Courses in Clinical Psychology
(CHPCCP).

Clinical training can be divided into three components:

1. Academic component: consists of learning all theory about psychological

problems.
2. Clinical Internship Component: Consists of gaining experience working
under supervision.
3. Research component: consists of developing research skills.
Ch6: What are anxiety and stressor-related problems?
What are anxiety disorders?
An anxiety disorder is “an excessive or aroused state characterized by feelings of
apprehension, uncertainty and fear” (Davey, 1993). An anxiety response might not
be in proportion to a certain threat or may be a state experienced that is not
triggered by any obvious threat and may disrupt the ability of an individual to live a
normal life due to constant emotional distress. Six of the main anxiety disorders
discussed in this chapter are: specific phobias, social anxiety disorder, panic
disorder, generalized-anxiety disorder (GAD), obsessive-compulsive disorder (OCD),
and post-traumatic stress disorder (PTSD). The diagnosis is based on subjective
experience of anxiety that occurs so regularly that it disturbs every-day living.

What is comorbidity?
An individual experiences comorbidity if they experience several anxieties disorders
whose symptoms overlap and this occurs quite frequently in anxiety-disorders.
Diagnostic categories share common aspects:

 Physiological symptoms are present in panic disorder and in specific

phobias
 Cognitive biases play a role in most anxiety disorders
 Dysfunctional perseveration plays a role in various prominent
psychopathologies
 In many anxiety disorders certain early experiences are part of the
aetiology

What are Specific Phobias and what is their

prevalence?
An individual who reacts with unreasonable, excessive and persistent fear to a
specific object or situation suffers from specific phobia. Even though the individual is
aware of the irrationality of their fear, they have dysfunctional phobic beliefs that
explain reasons for why they are afraid and react how they do. In therapy these
beliefs can be challenged. Specific phobias are quite common, and recent surveys
have suggested that 20% of all adults will experience some sort of diagnosable
specific phobia in their life. Women have a lifetime prevalence of 16%, which is
higher than the men's 7% lifetime prevalence.

Common phobias include animal phobias (snakes, spider, rats, mice, creepy-
crawlies), social anxiety disorder, dental phobia, water phobia, height phobia,
claustrophobia, and BII (blood, injury, inoculation fears). The DSM-5 divides these
specific phobias into five groups by the source of the fear: 1) blood, injuries and
injections 2) situational fears 3) animals 4) natural environment and 5) other
phobias. There is a high comorbidity rate within each category. Different cultures
bring along different clinical phobias, with 'fear-relevance' being determined by
specific culture factors. This is the opposite of the biological view, which holds that
there are universally feared stimuli and events created through evolution.
⇧

What is the aetiology of Specific Phobias?

A common debate is whether phobias are learned or acquired through evolution. A
view held today is that different ways of acquisition go with different phobias.
Phobias under the psychoanalytic view are defenses against anxiety coming from id
impulses that were repressed. This is a way of avoiding confrontation with the real
conflict. Symbolic interpretation of case histories in psychoanalysis can serve as a
source of insight.

The popular study of “Little Albert” (1920) still stands today as an example of
classical conditioning as an explanation for phobia. Yet, criticism of the classical
conditioning explanation is:

 While the classical conditioning approach says traumatic experiences are

necessary for conditioning, some phobics cannot remember such an
event at the point when they acquired their fear.
 Even if an individual experiences a traumatic event, it does not
necessarily mean that a phobia will be acquired.
 Phobias are usually limited to a specific group of stimuli, even though in
the simple conditioning model all stimuli should be equally likely
conditioned. Also, stimuli that pose a danger that did not exist before,
such as an electricity outlet, are less likely to be associated with aversion
or danger, even though they pose a potential source of danger as well.
 The clinical phenomenon of incubation cannot be applied to the simple
conditioning model. Instead of growing fear with more and more
encounters of the stimuli, the conditioning model postulates that
extinction should rather occur.
 At least some phobias can be explained by the occurrence of traumatic
conditioning experiences, but not all.

People acquire phobias of life-threatening stimuli that have always existed, but
rarely of stimuli that pose a danger that have only recently evolved. The first theory
by Seligman called biological preparedness proposes that if we avoid stimuli that
have been dangerous to our ancestors, we will have a greater chance of surviving.
An experiment showed that people are more easily conditioned with a picture of a
fearful stimulus together with an electric shock than if it is a picture of a non-fearful
stimulus and are more resistant to extinction. The second theory by Poulton and
Menzies argues that adult phobias can be explained by a failure of normal
habituation, which usually occurs in childhood when children are first frightened of a
stimulus but after several exposures the fear disappears. The evolutionary account is
not easy to verify, because of possible post-hoc construction of evolutionary
explanations. According to the adaptive fallacy any stimulus can be explained by
coming up with a threatening consequence for it.

With functional neuroimaging techniques, we can look at specific brain regions

playing a role in specific phobias. The key structure mediating fear responses to
phobic stimuli is the amygdala. It is involved in forming and storing memories
associated with emotionally relevant events. It coordinates this with info from
subcortical nuclei and higher cortical areas and then relays feedback to the
thalamus, which coordinates motor responses. It has also been seen that BII phobia
and dental phobia are different in the way that they affect the brain, since it can
result in a decrease of parasympathetic response resulting in fainting.
Phobias are acquired in different ways depending on the type of phobia. Not all
phobias are acquired through the occurrence of a traumatic event and might be
acquired over long-term and gradual experiences that the individual is not always
aware of (mostly in animal and height and water phobias). There is evidence that
disgust, a food-rejection emotion, plays a role in small animal phobias and blood-
injury-injection phobia. The disease-avoidance model states that an individual with
high level of disgust sensitivity is more prone to acquiring an animal phobia. Also,
there is evidence for a link between specific phobias and panic and panic disorder.
Comorbidity rates lie between 40 and 65%, meaning that people with specific
phobias also often suffer from panic, especially those with situational phobias.
Claustrophobia and height phobia have close links to panic disorder, because
sufferers also hold anxiety expectations and focus on bodily sensations. In height
phobia ambiguous bodily sensations are experienced as threatening, which is
common in panic disorder.

How can Specific Phobias be treated?

Exposure therapy offers an individual suffering from a specific phobia to overcome
their dysfunctional beliefs by experiencing that they do not take place when exposed
to the feared stimuli. This form of therapy together with cognitive therapy
techniques can yield results in just a 3-hour session.

What is a Social Anxiety Disorder and what is the

prevalence?
Individuals experiencing social anxiety disorder fear social situations and try to avoid
these because they are afraid of negative evaluation or that they will embarrass
themselves. Sufferers may also experience problems with depression and substance
abuse. The lifetime prevalence rate lies between 4 and 13% (for western societies),
with females being affected more than males. Onset is in the early to mid-teens,
usually before turning 18. From all main anxiety disorders, it has the lowest
remission rate. There are cultural differences in prevalence rates, with Southeast
Asian countries showing lower rates than Western countries.

What is the aetiology of Social Anxiety Disorder?

Social anxiety disorder is not put in the same category as simple phobias in DSM-5
because social anxiety is central to the aetiology of social anxiety disorder and
information processing and interpretation biases are involved. Social anxiety
disorder can be compared to generalized anxiety disorder (GAD) in its prevalence as
being the most common anxiety disorder.

There is more and more evidence that genetics might reflect a component of social
anxiety disorder. Twins’ studies reveal moderate genetic influence and parents with
social anxiety disorder often times have children with social anxiety disorder.
Submissiveness, anxiousness, social avoidance, and behavioral inhibition (where
children seem quiet and isolated) seem to have a genetic component in social
anxiety disorder. A different account proposes that social anxiety disorder shares
genetic components with other anxiety disorders. Yet, the possibility is proposed
that there is an inherited and unique element specific to social anxiety disorder that
makes up 13% of the variance in social fears. There is evidence that children that
have an inhibited temperament style are more likely to acquire social anxiety
disorder. Because social anxiety disorder occurs at such an early age in comparison
to most main anxiety disorders, there is the argument that developmental factors
contribute to the acquisition of social anxiety disorder. Individuals suffering from
social anxiety disorder have parents that control them more, discipline them using
shame as a tool, are in general colder and do not socialize as much. If those are
actual causal factors cannot be said at the moment. Sufferers of social anxiety
disorder believe more than any other group of sufferers of anxiety disorders that a
negative social event will occur, which makes them avoid social situations. Also, they
are more critical when judging their own performance and do not process positive
social feedback as easily. This supports the maintenance of dysfunctional beliefs that
a social phobic hold. When self-focused attention occurs during a social
performance, a social phobic directs attention onto himself and his anxiety, and this
leads to their belief that people can see how anxious they feel inside. They take on
an observer's perspective rather than a personal perspective. This is known as self-
focused attention, which in a way acts as a distractor from the actual task and
prevents the individual from best performance. After a social event, a social phobic
engages in post-event rumination in which critical self-evaluation is practiced.

How can Social Anxiety Disorder be treated?

An effective way of treating social anxiety disorder can occur by administering
cognitive behavior therapy and pharmacological treatment. CBT treatments that are
effective include:

 Exposure therapy, in vivo or with the therapist playing a stranger.

 Social skill training with modelling, behavioral rehearsal, corrective
feedback and positive reinforcement.
 Cognitive restructuring, challenging dysfunctional beliefs and reducing
self-focused attention.

The best approach is combining pharmacological treatment (MAOIs, SSRIs,

benzodiazepines and beta-adrenergic blockers have all been found to be effective)
with cognitive-behavioural therapy, with the former providing immediate gains and
the latter ensuring long-term effectiveness.

What is panic disorder and agoraphobia and what

is the prevalence of these disorders?
In panic disorder a person repeatedly experiences panic or anxiety attacks. They are
accompanied by physical symptoms that occur in great variety (e.g., dizziness,
nausea, heart palpitations). Many will experience a feeling of terror or
depersonalization, a feeling of being disconnected from one's body or surrounding.
The diagnosis of panic disorder is made when the attacks occur repeatedly and
unexpectedly, and when the individual suffers from at least one month of concerns
of experiencing another attack. Panic attacks may either occur through association
with a specific situation or they occur unpredictably. In an attack a peak is reached
within 10 minutes consisting of intense fear and the development of a number of
symptoms. Panic disorder often occurs together with agoraphobia, because the
person tries to avoid unsafe, public places where an attack could occur, and
therefore they often stay home. Agoraphobia is a separate diagnosis represented in
the DSM-5 and is characterized by feelings of fear and/or anxiety of a place where
the individual feels either trapped or unsafe, with a strong urge to return to a safe
place like home. Sufferers often do not leave the house, or only rarely with trusted
friends and family. Due to this fear of leaving their safe place, they become severely
disabled in daily life and often have to rely on others to assist them with basic tasks
like grocery-shopping.

Onset occurs in early adulthood or in adolescence, often after a stressful life period.
Prevalence rates lie between 1.5 to 3% for panic disorder and 0.4 to 3% for
agoraphobia, with women suffering more often from either of them. There is a
cultural difference in manifestation and variance in prevalence of the disorder. In
Western cultures individuals deal with panic disorder by employing avoidance and
withdrawal strategies, while Latinos show their distress in an external form (e.g.,
screaming).

What is the aetiology of Agoraphobia and Panic

Disorder?
Biological factors were often a focus in finding causes for panic disorder, but now it
has become acknowledged that psychological and cognitive factors also contribute to
the aetiology and maintenance. Because agoraphobia only recently become a
distinct disorder in the new DSM-5, not much research has been spent on its
aetiology. Therefore, the following theories are focused on panic disorder.

Hyperventilation plays a central role in panic attacks. Through the rapid breathing,
the blood pH level is raised, and body cells receive less oxygen, which in turn
produces cardiovascular changes that ultimately create symptoms of panic attacks.
These symptoms are recognized by the individual as anxiety. Evidence for this
comes from biological challenge tests that artificially create panic attacks.
Suffocation alarm theories propose that increased CO2 intake may activate an alarm
system that is overly sensitive to suffocation and therefore produces the typical
anxiety of a panic attack. More than patients of other anxiety disorders, patients of
panic disorder often report problems with a feeling of suffocation and shortness of
breath during phases of anxiousness. Yet, when told to hold their breath, they do
not experience more anxiety than control subjects, meaning a more sensitive
suffocation alarm system is not present. Interpretation of the physiological changes
seems to be a critical point of the causal factor in panic disorder, as induced
symptoms only create a full panic attack for individuals that have suffered from
repeated panic attacks before.

Norepinephrine plays a role in the aetiology of panic disorder. The proposition of

overactivity in the noradrenergic neurotransmitter system holds that there is a
deficiency of gamma-aminobutyric (GABA) neurons in patients with panic disorder
and GABA neurons have the task of inhibiting noradrenergic activity.

Goldstein and Chambless (1978) have worked with the classical conditioning
approach, according to which a predictor of a panic attack is the internal conditioned
stimulus (CS), established by the experienced internal cue (e.g., dizziness). Bouton,
Mineka, and Barlow argue that anxiety precedes an attack, which is the learned
reaction (CR) to detected cues (CS), and that panic is a way of handling the existing
trauma.

Anxiety sensitivity explains that sufferers of panic disorder acquire a set of beliefs
that symptoms will bring about consequences that will cause them harm, which in
turn leads them to fear anxiety symptoms. Non-clinical controls or individuals with
different anxiety disorders score significantly lower on the Anxiety Sensitivity Index
than individuals with panic disorder.

Often times bodily sensations are ambiguous and panic disorder sufferers interpret
these sensations directly as threating, making it a catastrophic misinterpretation of
bodily sensations. This causes the anxiety which leads to a panic attack. Individuals
with panic disorder pay more attention to bodily sensations. The expectancy of the
attack is critical, as when participants were given compressed air, which they were
told was CO2, they had a panic attack, nevertheless. Hence, there is a cognitive bias
in the interpretation of and reaction to bodily symptoms.

Even though some sufferers experience many panic attacks, they often do not seem
to realize that the feared outcome never happens. This happens because of
developed safety behaviors, which are certain behaviors that are automatically done
by sufferers when they believe they are having a panic attack. This automatic
behavior is then thought of to be the reason why some catastrophic outcome didn't
occur, therefore they continue doing it every time, resulting in the maintenance of
anxiety. Because of this big role they play in the maintenance of anxiety in panic, it
is one of the key behaviors that should be modified attacks or eliminated in
therapies.

How can a panic disorder be treated?

Effective treatments include psychoactive medication (usually as first line
treatment), tricyclic antidepressants and benzodiazepines, structured exposure
therapy, and cognitive behavior therapy (CBT). In exposure therapy, the bodily
experiences that precipitate a panic attack are induced and physical and cognitive
techniques can be used to deal with the symptoms of panic in a safe condition.
Cognitive therapy aims to achieve success by having the individual learn through
information and experiences that their beliefs are dysfunctional and that their
responding is faulty. A program would include educating the individual about the
nature and physiology of panic attacks, breathing training for controlling
hyperventilation, cognitive restructuring therapy, interoceptive exposure, and the
prevention of safety behaviours.

What is a Generalized Anxiety Disorder (GAD)?

People with generalized anxiety disorder consistently worry about future events due
to the anxiety they experience in regard to them. Worrying is no longer experienced
as a normal reaction to some events but becomes chronic and is directed to issues
that other people would not even consider a threat. The individual feels their
worrying is not under control, neither being able to control beginning nor end of a
bout of worry. They also engage in catastrophizing (magnification) of worries and
the problem does not seem to get better, but rather worse through the continuous
worrying. Physical symptoms such as fatigue, muscle tension, nausea, headache and
trembling may also be present. A diagnosis of GAD based on the DSM-5 can be
made if the person exhibits:

 Unreasonable much fear or anxiety relating to multiple areas such as

health, finance, family, work, school
  Fear relating to at least two of the above-mentioned areas and
accompanying severe anxiety lasting for at least three months
 Restlessness, agitation or muscle tension is seen besides anxiety
 Behaviors such as frequent reassurance seeking, avoiding areas of
activity relating to anxiety, and procrastination or excess effort preparing
activities are also seen as a result of the anxiety

There is a high comorbidity rate with other anxiety disorders and depression and
there are double as many women suffering from GAD as men. The lifetime
prevalence rate of GAD is more than 5%. GAD is also associated with a significant
impairment in the sufferer's psychosocial functioning, role functioning, health-related
quality of life and work productivity.

What is the aetiology of Generalized Anxiety

Disorder (GAD)?
There is the suggestion that there is an inherited component in GAD. Yet, because of
only modest evidence of a specific genetic component, most focus is on the
psychological and cognitive accounts. However, some recent neuroimaging studies
have shown that the prefrontal brain areas are implicated in extreme worry, and
that some areas important in emotional regulation seem to be less active,
suggesting that a diminished capacity for emotional regulation could be associated
with GAD.

There is experimental evidence that sufferers of GAD pay more attention to

threatening stimuli and information, with information processing biases supporting
the maintenance of bouts of worries and perceived threats. Anxious individuals also
show a threat-interpretation bias, meaning that they interpret ambiguous stimuli
more often as threatening or negative. Attention is pre-attentionally directed to
threatening stimuli, to verbal stimuli and pictures of threatening emotional faces.
Opposing to that, people that are not anxious deliberately avoid attending to
threatening stimuli. Information processing biases may be the cause for experienced
anxiety. Evidence from studies inducing information processing biases show that this
leads to changes in state anxiety and to threatening interpretation of new stimuli. It
was thought that anxiety causes threat-interpretation biases, but it seems to be the
other way around, learned threat-interpretation biases result in elevated levels of
anxiety. Therefore, attention bias modification (ABM) was created, which is a
treatment where biases are reversed.

Individuals with GAD hold the dysfunctional belief that by worrying they can prevent
future catastrophes, which motivates them to continue worrying. Another account
holds that this chronic worrying takes the function of a distractor from other
negative emotions or phobic images that are even more stressful. This can be
supported by the evidence that little physiological or emotional arousal is produced
by worrying. Another theory focuses on metacognitions, which are overarching
processes responsible for our thinking. Metacognitions are responsible for adaptive
thoughts of worry in order to anticipate and avoid problems and if they occur, find
solutions. However, sufferers from GAD have developed beliefs about worrying
which makes it distressing on one hand, but they also find worrying positive as it
helps them avoid and solve problems.
Worriers do not tolerate uncertainty; they are perfectionists and feel responsible for
negative outcomes. The individual tries to resolve the problems, but this gets
hindered through feelings of doubt to successfully solve the problem.

How can a Generalized Anxiety Disorder (GAD) be

treated?
A crucial point is deciding which treatment works best for successful therapy
outcomes of GAD. Psychological therapies, such as CBT or self-help programs are
usually the best option for a long-term treatment success, but if the patient
experiences suicidal intentions or other extreme stress, medication can be used for
first management of the problem. Also, it should be considered what approach is
effective at what point in treatment, regarding symptom severity and what the client
prefers.

Anxiolytics such as benzodiazepines are often thought of as the best prescribed drug
for anxiety GAD. However, more than 50% are prescribed antidepressants (SSRIs or
SSNIs) as they have been proven effective, and 'only' 35% are prescribed
benzodiazepines. The use of antidepressants makes sense because they are better
tolerated by patients, and anxiety is often comorbid with depression.

Psychological treatments are developed out of behavioral and cognitive

methodologies, and an example is stimulus control treatment, which works by
helping the client minimize the contexts in which they can worry, such as only at a
certain time of day or in a specific location.

These elements are included in CBT to provide relief from cognitive biases and
dysfunctional beliefs:

 Self-monitoring: clients become aware that they cognitively construct

future events and that these are not real and hence will most likely not
occur
 Relaxation training: these types of techniques, such as progressive
muscular relaxation, yield the same effects as some forms of cognitive
therapy
 Cognitive structuring: dysfunctional thoughts and biases are challenged
and replaced with more accurate thoughts. Achieving this can be aided by
the use of an outcome diary. Another form is metacognitive therapy,
where metacognitive beliefs are challenged
 Behavioral rehearsal: coping strategies are applied when a worry is
triggered. This can be done through imagined or actual rehearsal

What is obsessive compulsive disorder?

An individual suffering from obsessive-compulsive disorder (OCD) experiences
obsessions and compulsions, the former being known by intrusive and recurring
thoughts and the latter by repetitive or ritualized behavior patterns. The thoughts
are seen as uncontrollable by the individual and he or she engages in rituals to
prevent a negative outcome. The ritualized behavior is also seen as a way to reduce
stress and anxiety. This can take place in the form of repetitive behaviours (e.g.,
hand washing, checking) or mental acts (e.g., counting, repeating words mentally).
The sufferer knows that these excessive compulsions are irrational and experiences
the obsessions and compulsions as unpleasant. Common obsessions are fear of
contamination, unwanted sex, thoughts about harm, and fear of accidents.

Lifetime prevalence of OCD is about 2.5%, with more women being affected. OCD is
characterized by onset in early adulthood or early adolescence. This is true
regardless of cultural background, with the exception of more religious and
aggressive obsessions being present in Brazilians and Middle Easterners. OCD is now
a separate chapter in the DSM-5, and the criteria for it are:

 Presence of obsessions like unwanted and repeated thoughts, urges or

images which the individual wants to ignore and/or
 Experiencing compulsions compelling the sufferer to carry out and repeat
certain behaviours or mental activities
 The sufferer believes that these actions must be carried out in order to
prevent some sort of catastrophic outcome, which is illogical and has no
connection to the behaviour
 Compulsions and obsessions cause difficulty in a person's life and
consume one hour or more of a person's day

What are other OCD-related disorders?

Other OCD-related disorders include body dysmorphic disorder (BDD), hoarding
disorder, hair-pulling disorder, and skin-picking disorder. Body dysmorphic disorder
refers to an obsession with ones perceived flaws or defects in their physical
appearance. Hoarding disorder refers to a sufferer's difficulty discarding possessions
resulting in a living area severely congested by clutter. Hair-pulling disorder
(trichotillomania): refers to the compulsive act of pulling out one's own hair. Lastly,
skin picking disorder: recurrent picking of the skin resulting in skin lesions.

What is the aetiology of obsessive-compulsive

disorder?
OCD can begin after a traumatic brain injury, creating a neurophysiological deficit
that produces the 'doubting' characteristic of OCD. The frontal lobes and basal
ganglia seem to play a role in this. Another account of 'doubting' holds that basic
information processing and executive functioning are impaired in sufferers of OCD,
alongside with spatial working memory, spatial recognition, visual attention, visual
memory, and motor response inhibition deficits. There is also the argumentation
that compulsions are produced from genetically stored and learned behaviors that
cannot be inhibited by the brain, mostly involving the inhibitory pathways projecting
via basal ganglia.

With 'doubting' being a main component in OCD, it is suggested that OCD might
involve a general memory deficit, and also less confidence from the client's side that
the memory reviewed is correct and whether a memory was real or imagined.
However, recent evidence shows that doubting in OCD may not be due to a deficit in
memory, but due to a general deficit in executive functioning instead. It is also
consistent with much evidence showing that the lack of confidence in one’s recall is
a consequence of the compulsive checking, so the more one checks, the less
confident they end up being about what they checked.

Clinical constructs are constructs that describe a combination of thoughts, beliefs,

cognitive processes, and symptoms that are seen in psychopathology. These
constructs are then observed to see how symptoms are affected by cognitive
factors. Three constructs now looked at are inflated responsibility, thought-action
fusion, and mental contamination.

A main feature of OCD is that sufferers feel that they hold responsibility for the
content of their thought. They also believe that there are potentially harmful
consequences to their obsessional thoughts. Another dysfunctional belief is that of
inflated responsibility, which means an individual believes he can prevent harm and
that it is his or her responsibility to make sure that this negative outcome does not
occur. In an experiment, inflated responsibility was induced, which subsequently
caused an elevated amount of compulsive checking. Believing that one's thoughts
are like actually performing them or that one's thoughts will come true, is known as
thought-action fusion. It is commonly seen in OCD and is best described as thinking
that one's thoughts can (in some way) directly affect whatever happens in the world.
If the believed action is negative, trying to suppress the thought and action can be
quite effortful, causing significant distress in the person.

Feelings of 'dirtiness' caused without any physical touch can be provoked by

thoughts of specific images or memories, or they can be provoked by emotional
experiences like humiliation, betrayal or degradation. These thoughts cause mental
contamination and can be a reason why one has to compulsively wash themselves.
Individuals with OCD engage in thought suppression if they encounter an intrusive
thought. The 'rebound effect' says that suppressing thoughts will make them come
back in greater frequency once suppression is stopped. Suppression of intruding
thoughts creates a negative emotional state which becomes associated with the
intruding thought. Experiencing this negative emotion at some other point in time
will then elicit the intrusive thought.

In OCD a critical feature is that of perseveration, meaning an individual with OCD

engages in longer perseveration of an activity than non-OCD sufferers. They
themselves recognize it as excessive and unpleasant. The mood-as-input hypothesis
explains that the current mood is a way of measuring whether a task was completed
with success or not. Regarding the nature of OCD, the sufferer feels a strong
negative and anxious mood during the task, which leads him or her to feel that they
never successfully completed it. The 'stop-rule' says one must continue until the
task is completed successfully, which is perpetuated by the inflated responsibility.
Inflated responsibility has to occur with negative mood together though so an
individual will persevere at a compulsive activity.

How can OCD be treated?

The most effective treatment is exposure and ritual prevention (ERP), which consists
of two components. The first component aims at graded exposure to what elicits the
distress. In the second component, the goal is to prevent the client from following
their rituals, by which anxiety is extinguished and dysfunctional beliefs are
disconfirmed. When rituals are abolished, anxiety is not negatively reinforced
anymore. Long-term effectiveness of the treatment lies at 75% and it is flexible in
its application.
⇧

What is cognitive behaviour therapy (CBT)?

There is a 30% drop out rate in exposure and ritual prevention (ERP) due to the fear
of exposure to what triggers OCD in the individual. In CBT, the dysfunctional beliefs
such as responsibility appraisal, the over-importance of thoughts, and exaggerated
perception of threat are challenged.

What are pharmacological and Neurosurgical

Treatments?
Even though pharmacological treatments, usually serotonin and SSRIs, are effective,
they have a high relapse rate when medication is not continued. Tricyclic
antidepressants are effective if OCD occurs together with depression. Psychological
treatment such as ERP has equally good short-term effects as drug treatment, does
not produce side effects and yields better results in the long-term. Neurosurgery
such as cingulatomy is a last resort treatment when all other approaches have
failed.

What is a Post-Traumatic Stress Disorder (PTSD)

and Acute Stress Disorder (ASD)?
In post-traumatic stress disorder (PTSD) a causal factor for the symptoms is the
identification of exposure to a specific fear-evoking event. PTSD is caused by
symptoms that follow a fear-evoking traumatic event (e.g., war, rape, abuse). The
symptoms are grouped in three categories: increased arousal and reactivity,
avoidance responding, negative changes in mood & cognition and intrusive
symptoms. In the DSM-5, severe (but not life-threatening) stress has been added
under the possible causal factors in PTSD, which sparked controversy due to
facilitating the faking of symptoms. The diagnostic criteria are:

 Death or threatening death is experienced to oneself or is being

witnessed
 Flashbacks or intrusive images or thoughts of the traumatic event are re-
experienced.
 Stimuli that are associated with the trauma are avoided
 Two or more changes to mood and/or thought processes (e.g., feeling
disconnected, reduced interests, inability to remember moments of the
traumatic event)
 Constant experiencing of symptoms for over a month such as increased
arousal, with sleep difficulty, anger outbursts, concentration difficulties,
hypervigilance and startle response. This causes the individual to be
impaired in occupational or social functioning
 Symptoms worsened or started after the traumatic event and last for at
least a month

At least between 1 and 3% of people experience PTSD at one point in their lifetime,
with women being more vulnerable to developing PTSD and culture differences
existing between Caucasian disaster victims and Latinos or African Americans.
Acute stress disorder (ASD) is very similar to PTSD but characterized by a shorter
duration (3 days to a month). The symptoms exhibited are basically the same of
PTSD. There is debate whether or not ASD is a disorder or just a normal way of
reacting to some disturbing events. ASD is also seen as a potential precursor for
PTSD by some, whether this is true is not yet determined.

What is the aetiology of PTSD?

There are five main theories which aim to explain PTSD, all concentrating on
different features of the disorder: avoidance and dissociation, conditioning theory,
emotional processing theory, 'mental defeat', and dual representation theory.

Studies have led to finding a genetic element to PTSD, and the heritability
component has been estimated to be 30%. Therefore, it has been suggested that
PTSD develops from an interaction between a biological vulnerability and an extreme
traumatic experience. Some biological causes for a vulnerability to PTSD are
speculated to be:

 An underdeveloped hippocampus (of which it is known to be critical in

relating memories to emotions)
 Failure of areas like the ventromedial frontal cortex in controlling fear
centers such as the amygdala
 Heightened startle responses due to genetics, and fear-related hormonal
secretion

Since not all people develop PTSD following a life-threatening event, some
individuals must be vulnerable to developing it. Factors that contribute to this
include feelings of responsibility for the traumatic event, having experienced
instability in the family life, history of PTSD in the family, higher levels of anxiety or
suffering from another psychological disorder. People with high intelligence are a lot
more resistant to PTSD than people of low intelligence, which can be led back to the
ability to develop coping strategies. Also, the experiences which are reported by the
victims indicate how information about the trauma was processed and stored.

Individuals exhibiting avoidance or dissociation coping strategies are more likely to

develop PTSD. Avoidance coping strategies are seen in individuals who actively try
not to think about their trauma. Feeling detached from one's mind and body is
known as dissociation, and if an individual experiences this coping strategy right
before or during a traumatic experience, they are known to be of higher risk for
developing PTSD.

The conditioning theory works with the explanation of classical conditioning, saying
that when individuals encounter cues that were associated with place and time of
the trauma, they trigger the same experience as that of the trauma.

A PTSD sufferer will avoid contexts that will trigger associations to the trauma. It
becomes difficult for cues associated with the trauma to be associated with positive
associations again. Because the event holds such a strong significance, the
associations formed are unlike those from everyday experiences. This is called the
emotional processing theory.

If an individual adopts the mental defeat view, then they take on the role of feeling
like a victim and see the world as negative and also recall the trauma according to
those feelings and views. Maladaptive behaviors and cognitive strategies may be
adopted that support the maintenance of PTSD. An account by Ehlers and Clark
holds that the sufferers do not see the event as part of their life, because they feel
they are not in control over it. They feel as if they cannot change the course of their
life anymore and that the traumatic event has changed it in a permanent way.

In the dual representation theory, there are two separate memory systems, the
verbally accessible memory (VAM) system and situationally accessible memory
(SAM) system, the former recording conscious memories from the time of the
trauma and the latter registering information that was not consciously recognized
because it occurred too brief. The SAM system hence stores sensory and response
information. Evidence supports this theory, both systems being linked to the
amygdala and findings showing that PTSD sufferers explain the flashback periods in
an elaborate and detailed way, frequently mentioning death, horror, fear, and
helplessness.

How can PTSD be treated?

Treating PTSD has two aims. Preventing the development of PTSD and if this is
(partly) unsuccessful because symptoms do appear, treatment of the symptoms. If
the latter is the case, most treatments rely on some form of exposure like flooding,
EMDR and cognitive restructuring.

In order to prevent an individual from developing PTSD after a traumatic life event,
there has been an established intervention called psychological debriefing, or
immediate and rapid debriefing, which is administered within 24-72 hours of the
occurrence of the event. Techniques such as critical incident stress management are
used where the individual can express his feelings and experiences, is reminded that
he is a normal person that had to experience such an event and can learn coping
strategies. Yet, psychological debriefing does not separate people that would not
develop PTSD in the first place from those that would and that need long-term
support. Also, there is lacking evidence of the effectiveness of rapid debriefing.

The extinction of associations between trauma cues and fear responses and the
disconfirmation of dysfunctional beliefs is aim of the effective exposure therapy.
Exposure is achieved by the client depicting the situation in a written narrative or
with computer-generated imagery. Imaginal flooding is a further technique in which
the client is supposed to visualize the traumatic event for a long period of time. This
is often paired with graded in vivo exposure. Exposure therapies are more effective
than medication and social support, as studies show. In another critically judged
form of PTSD treatment, called eye-movement desensitization and reprocessing
(EMDR), the client follows the therapist's finger, moving backwards and forwards,
while concentrating on a traumatic image or memory. The fearful images are
thereby reconstructed and deconditioned.

In cognitive restructuring the aim is to change the individual's dysfunctional beliefs

about the world and themselves, acquired from the trauma, and exchanging
negative or intrusive thoughts. Foa and Rothbaum suggest that the two
dysfunctional beliefs an individual with PTSD holds are: “The world is a dangerous
place” and “I am totally incompetent”. Chronic PTSD is the result of avoiding
situations which could disprove the dysfunctional beliefs. While exposure therapy
disconfirms these beliefs, cognitive therapy aims to change PTSD-related cognitions,
but findings show that a therapy combining these two approaches does not achieve
changes in dysfunctional cognitions.
Ch7: What are depression and mood disorders?

What are depression and mood disorders?

Everyone experiences periods of sadness from time to time. This can be the result of
various reasons, especially losses and failures, but most of us are able to shake it off
after a short period of time. However, for some getting rid of these depressing
feelings is much harder, and these feelings will affect other domains of their live,
making depression a mood disorder affecting emotional, motivational, behavioral,
physical, and cognitive domains. Mania is the emotion opposite of depression, and it
is bound by boundless, frenzied energy and feelings of euphoria.

Depression affects the emotional domain as depressed individuals often report

negative emotional experiences such as hopelessness and sadness. Those suffering
from depression show several motivational deficits, like the lack of interests in
activities they used to enjoy, not taking initiative anymore and reporting that they
simply don't care anymore. Behavioral symptoms seen in depression are sleeping for
long periods of time, no interest in leaving the house and reporting lack of energy.
Depression can even be seen in the posture and movements of people, as are other
physical symptoms such as a wide variety of sleeping problems, headaches,
indigestion, constipation and several others. The most disabling feature of
depression are its cognitive symptoms. The negative thoughts that arise from
depression are negative views of themselves, the world around them and their own
future. These pessimistic thoughts can give rise to new problems, such as impaired
thinking, concentrating and decision-making, possibly leading to feelings of
worthlessness, shame and guilt. These thoughts can lead to suicidal thoughts,
because they might think the world is better off without them. The two main types
of depression are major depression and bipolar disorder.

How is Major Depression diagnosed and what is its

prevalence?
One of the two main types of depression is major depression. It is noted by
relatively long periods of clinical depression causing significant suffering in the
patient, and also impairing their social and/or occupational functioning. Another
term used for major depression is unipolar depression. Due to changes in the DSM-
5, major depression is now diagnosed only when a single major depressive episode
has occurred, and the symptoms must have caused clinically significant impairment
or distress in social, occupational, or other types of functioning. A major depressive
episode consists of the presence of five (or more) depressive symptoms during a
period of two weeks. Some of these symptoms include a depressed mood most of
the time, significant weight changes unrelated to dieting, lack of energy, feelings of
worthlessness or guilt,

Mood disturbances can also occur less intense but still impairing someone's life
significantly, like when one is diagnosed with dysthymic disorder, where the person
experiences a depressed mood on more days than not, for at least two years. These
individuals often experience many symptoms of major depression, but these tend to
be less severe.
Some disorders occur comorbid with depression: premenstrual dysphoric disorder,
which is a condition suffered from by some women where severe depression is
experienced some days prior to the start of their menstrual cycle, seasonal affective
disorder (SAD), suffered by regularly feelings of depression in winter where a
remission is seen the next spring or summer, and chronic fatigue syndrome (CFS),
which is a disorder distinguished by depression and fluctuations of mood together
with some physical symptoms such as muscle pain, chest pain, headaches, noise
and light sensitivity , and extreme fatigue. Lastly, because anxiety is very comorbid
with depression, many sufferers from depression are diagnosed as suffering from
mixed anxiety/depressive disorder.

Depression occurs very often and is known to have a steady rise of incidence over
the last 90 years. The prevalence rates differ however across different cultures,
which may be due to many reasons:

 Different measurement methods used by different researchers

 The social stigma attached to depression especially in non-western
countries
 The challenge in the measurement of the abstract concept of depression
 The tendency of the west to express psychological symptoms in physical
symptoms (somatisation)

What is the aetiology of depression and mood disorders?

Genetics are thought to play an important role in the development of major
depression. First-degree relatives of people suffering from major depression are
seen to experience depression symptoms two to three times more often. Twin
studies also suggest that depression is more likely to be due to shared genes instead
of shared environment, with a heritability estimated to be between 30% to 40%.
However, specific genes responsible for depression have yet to be found.
Abnormalities in the levels of neurotransmitters have been shown to be associated
with mood disorders. For instance, low levels of serotonin, norepinephrine, and
dopamine are often linked to major depression. Medications prescribed in the 1950's
for high blood pressure sometimes led to depression, this was found to be due to the
lowering of serotonin levels in the brain by these medications. This led to the
development of tricyclic drugs (TCA) and monoamine oxidase inhibitors (MAOI),
both of which block the reuptake of both serotonin and norepinephrine. Tricyclic
drugs work by blocking the reuptake (in the presynaptic neuron) of serotonin and
norepinephrine, therefore leading to higher quantities of these neurotransmitters
active in the synaptic cleft. A newer alternative are the selective serotonin reuptake
inhibitors (SSRIs), which targets only the serotonin levels in the brain. The thought
that specific neurotransmitter levels are responsible for depression is quite
simplistic, and many theories suggest quite complex mechanisms. A recent theory is
that depression is due to an imbalance between multiple neurotransmitters.

The prefrontal cortex is known to be important for the representations of goals and
the means to achieve them. Lower activity in this area is seen in depressed people,
and this may lead to a lack of the ability to anticipate incentives, which is commonly
seen in those suffering from depression. Activity in the anterior cingulate cortex
(ACC) is seen when behavior requires effortful emotional regulation in order to
achieve an outcome. Lower activity in this region may represent the lack of will to
change, also seen in those who are depressed. One of the functions of the
hippocampus is to learn the context of affective reactions, and a lack in this function
might lead to dissociating negative affect from their contexts, making people feel
sad independently from the context. The hippocampus also plays an important role
in the adrenocorticotropic hormone secretion, which will be mentioned in more detail
later. Finally, the amygdala is crucial for direction attention to emotionally salient
stimuli, for instance when your attention is needed for a potential threat. Increased
activity in the amygdala, which is seen in depression, may lead to the person
prioritizing threatening information and associating it with negative thoughts.

Cortisol is an adrenocortical hormone and is known to be secreted in times of stress.

The before mentioned hippocampus is important in the adrenocorticotropic hormone
secretion, and a dysfunction in the hippocampus might therefore lead to high levels
of cortisol. Another big influence in the regulation of cortisol is the hypothalamic-
pituitary-adrenocortical (HPA) network, which is our biological system managing and
reacting to stress and triggering the secretion of cortisol when stress is experienced.
A lack of inhibitory control over this network is linked to depression, and about 80%
of hospitalized sufferers from depression show a poor regulation of this HPA
network. An increase of cortisol might enlarge the adrenal glands, which results in a
lowered level of serotonin neurotransmitters.

It is clear that depression has an inherited component, and that levels of brain
neurotransmitters play a crucial role in the maintenance of depression. Specific brain
areas are also known to be important in the aetiology of depression, and
neuroendocrine factors are seen to be associated with it. However, not everything
can be explained with biological factors. Biological factors may be the direct cause of
symptoms, but psychological processes could be the trigger to those biological
factors.

The most used psychodynamic view of depression is the one of Freud and Abraham,
which states that depression is a person's response to loss, and especially the loss of
a loved one. The first stage is introjection, which states that a person in the
introjection stage regresses to the oral stage of their development, which allows
them to integrate the identity of the person they have lost. Regression to the oral
stage also allows the person to direct the feelings they hold of the loved one towards
themselves, which can be feelings such as anger or guilt. The individual can start to
experience self-hatred, which quickly develops into low self-esteem, resulting in
feelings of hopelessness and depression. A problem with this view is that not all
depressed people have lost a loved one, to which Freud coined the concept symbolic
loss, in which other types of losses are viewed by the person as equally important as
losing a loved one. This can lead to regression to the oral stage and trigger potential
memories of bad parental support during their youth. Now we view poor parenting
as a more likely cause of depression, and parental loss is not a prerequisite
anymore. There is a link between depression and having experienced affectionless
control, which is a type of parenting where there is a lack of warmth combined with
high levels of overprotection.

Depression is highly characterized by a decrease of motivational and initiative-taking

behaviour, together with a lack of positive feelings about their future. Based on
these characteristics of depression, some theorists suggest that depression results
from a lack of reinforcement of positive and adaptive behaviors, leading to a
decrease of the existing behaviors, which is illustrated by the inactive and withdrawn
behavior seen in depression.

Depressed individuals tend to be less skilled at communicating with others and tend
to transfer their negative mood to others, resulting in the reinforcement of
depression. This social reinforcement is because people will respond more negatively
towards depressed individuals, because of the poor social skills depressed people
often show. This also led to interpersonal theories, which argue that the
maintenance of depression is because of the reassurance that depressed individuals
keep on seeking that is subsequently not given by family and friends, because they
are approached in such a negative way by the sufferer. This reassurance is often
given, but because depression makes one doubt the reassurance, they keep on
trying to confirm the reassurance, which is why family and friends might end up
rejecting the reassurance at some point.

Beck's cognitive theory about depression is very influential, and it states that
depression might be caused by biases in the way we think and process information.
Beck claims that depressed people have developed many negative schemata, which
are beliefs that tends to make someone view the world and themselves more
negatively. These negative views have a big influence on the selection, encoding,
categorization and evaluation of information that we encounter, and this is often
long lasting. Beck also states that this negative approach of interpreting everything
around us develops because of negative childhood experiences and can start again
in adulthood due to some stressful experience. The negative triad is a theory stating
that depressed people hold negative views of themselves, their future and the world.
These negative beliefs result in self-fulfilling prophecies, making the people interpret
events negatively because they believe they are negative. There is evidence that
these cognitive biases indeed exist as:

 Attentional biases to negative stimuli, especially if they are depression

related
 Memory biases, where depressed individuals recall more negative words
than positive, again this applies mostly to depression-relevant material
 Interpretational biases, making them interpret ambiguous events more
negatively

Research suggests two types of negative schema. The first one is focused on
dependency and the second one on criticism. Depression triggered by losses is
characteristic of dependency self-schemas, and depression triggered by failure is
seen with criticism self-schemas. Pessimistic thinking (the thinking that nothing can
improve in situations) is often thought of to be characteristic of depressed
individuals, but research has shown that people suffering from depression are
actually much more accurate at evaluating control over situations and evaluating the
impression they made on others.

Seligman proposes that negative life experiences give rise to a 'cognitive set' which
makes the person learn to become helpless, depressed and lethargic, this is known
as the learned helplessness theory. The level of uncontrollability of these negative
life events is important, and the more uncontrollable a situation, the more
pessimistic beliefs the person will adopt. Battered woman syndrome is an example
where learned helplessness of an abused woman's situation results in their belief
that they are powerless, making them express symptoms of depression. The original
learned helplessness theory does not explain why experience with negative events
may actually help performance, and that passivity in battered woman syndrome may
actually be a learned response to avoid abuse. Because of these difficulties,

Attribution theories state that people are more likely to become depressed because
of certain attributional styles that consist of negative thinking, like attributing a
negative event to factors that aren't easily changed, therefore thinking that they are
powerless. There are multiple ways in which life events can be attributed:

 One can interpret an event as internal (personal cause) or external

(environmental cause)
  An event can be seen as stable (lasting over time) or unstable (short
lasting) factors
 Something can be global (relatable to many domains of life) or specific
(only to a specific part of life)

Depressed people tend to think of negative life events as internal, stable and global,
and think of positive events as external, unstable and specific. The repeated use of
negative attributional styles will lead to more and more perceived helplessness over
time.

Attributing negative events for global and stable reasons combined with negative life
events is suggested to increase the level of vulnerability to symptoms such as
retarded initiation of voluntary responses, lack of energy, apathy and psychomotor
retardation, which are all symptoms of hopelessness. Hopelessness theory states
that individuals show the expectation that positive outcomes won't occur, that
negative outcomes will occur and that no change can be made about this.
Hopelessness theory is quite similar to the previously mentioned attributional and
helplessness theories, but hopelessness theory suggests that factors like low self-
esteem also play a role. Hopelessness can therefore be predicted by a negative
attributional style, negative life events and low self-esteem. Hopelessness can be
used to predict suicidal tendencies and especially completed suicide. Some
limitations to the hopelessness theory are:

 Many studies supporting it are carried out on healthy or mildly depressed

individuals
 A majority of the studies conducted on the model cannot generate
evidence for a causal role of hopelessness thoughts on the development
of depression, because the studies are correlational in nature
 The model only explains symptoms related to hopelessness, and other
DSM-5 required symptoms of depression are not explained
 Some evidence shows that the prevalence of negative attributional styles
can decrease after one recover from depression

Rumination is an individual's tendency to repeatedly mull over the experience of

depression and to find out its possible causes. Indulging too much in these
ruminating activities can cause and predict depressive episodes and relapses.
Rumination seems to be caused by meta-cognitive beliefs that it is necessary in
order to resolve one's depression.

What is Bipolar Disorder?

A person suffering from bipolar disorder has extreme mood swings. On one side of
the spectrum, one experiences a state of depression, and on the other side there's
the manic state, which is characterized by forced speech, extreme energy, short
attention span, excessive talking and shifting from topic to topic. Someone in a
manic state can become angry when 'confronted' with their state, and irritability is
quite common. A manic state can last for days or weeks, and the onset can be quite
quick.

What is the diagnosis and prevalence of Bipolar Disorder?

The DSM-5 differentiates between bipolar disorder I and bipolar disorder II. The
first, bipolar disorder I, is characterized by full alternating episodes of major
depression and mania. Bipolar disorder II is slightly different, since it does contain
major depression episodes, but then followed by hypomania episodes. A hypomania
episode is a milder version of a mania episode, and an episode of hypomania does
not have to be impairing the 'sufferer'. Prolonged episodes of hypomania can
however lead to full blown mania. A milder form of bipolar disorder is cyclothymic
disorder, where the individual suffers from mood swings for at least two years, and
the mood swings consist of mild depression to hypomania symptoms like euphoria,
happiness and excitement.

What is the aetiology of Bipolar Disorder?

Bipolar disorder has an inherited component, since it has been estimated that about
7% of first-degree relatives of those suffering from bipolar disorder, also have
bipolar disorder themselves. Concordance studies have shown that on average,
sharing all genes (as seen in monozygotic twins) more than doubles a person's risk
of developing bipolar disorder compared to dizygotic twins.

The neurotransmitters norepinephrine and dopamine also play an important role in

bipolar disorder, just like in depression. The role of serotonin however seems to be
not that important in bipolar disorder. A commonly used medical treatment for
bipolar disorder is the combination of the antipsychotic olanzapine and the
antidepressant SSRI fluoxetine or Prozac.

The depression episodes in bipolar disorder seem to be triggered by many of the

same triggers that are also seen in major depression, like the loss of a loved one or
failures in life. The triggers for a manic episode vary, and often seem to be due to
an increased reaction to rewarding situations, like a positive life event. Other
triggers seem to be antidepressants, unusual circadian rhythms or disrupted sleep
patterns, stressful life events, the exposure to intense expressions of emotions by
family or caregivers, and seasonality, since manic episodes tend to increase in
spring or summer.

How can Depression and Mood Disorders be

treated?
Treating depression and mood disorders can be done with biological-based
treatments, like electroconvulsive therapy (ECT), an old treatment where an electric
current volt through the patients, or with the use of psychological therapies.
Emphasizing the method of treatment according to the severity of the symptoms an
individual is experiencing is often preferred. These stepped-care models are
implemented to make sure that a treatment is effective and not too invasive when
it's not necessary. An example of a stepped-care model could be:

 Not simply responding with medication right away, and assessing the
individual properly
 Use medication only when there is more evidence that it will be effective,
in the case of depression this would count for moderate to severe
depression
 Mild depression is best treated with short behavioral and cognitive
interventions

⇧
What are biological treatments?
There are currently three main types of medications for the treatment of depression:

1. Tricyclic Antidepressants (TCAs)

2. Monoamine Oxidase Inhibitors (MAOIs)
3. Selective Serotonin Reuptake Inhibitors (SSRIs)

Tricyclic drugs and MAOIs elevates levels of both serotonin and norepinephrine,
while SSRIs only work specifically on serotonin levels. Tricyclic drugs have been
seen to work for 60-65% of individuals taking it, and this is 50% of those taking
MAOIs. Tricyclic drugs and MAOIs are known to be quite effective, but the downside
are that they come with many possible side effects. The newer SSRIs are known to
be effective in 55-60% of the cases but come with much little side effects and are
harder to overdose on. A downside to SSRIs is that they seem to take longer to have
an effect, and they might increase the risk of suicide. Relapse is common when
individuals quit drug therapy, and it is therefore advised to combine drug therapy
with psychological therapies for the maximum result and the smallest risk of relapse.

Bipolar disorder is treated differently, with the traditional treatment being lithium
carbonate. There are many theories as to the mechanisms of lithium on the
symptoms of bipolar disorders, but a clear reason is unknown. The disadvantages of
lithium treatment are that ending a treatment often increases the chance of a
relapse, and since lithium is a toxic substance, the often-prescribed dosage tends to
be close to the toxic level. An overdose can constitute delirium, convulsions, and
occasionally death.

ECT consists of the passing of an electric current through the head of a patient for
about half a second, which often results in a temporary relief from symptoms of
severe depression. A serious side effect of electroconvulsive therapy is the possibility
of both anterograde and retrograde amnesia which can last up to 7 months. Besides
the possible serious amnesia, many people also tend to not be jolly about the fact
that a strong electric current is being passed through their brains. The relief of
depression often doesn't last long, since a relapse of depression has been seen after
the small duration of only four weeks of relief. Some even state that any kind of
direct trauma to the brain would give relief of depression for a considerable amount.
Despite the criticisms, electroconvulsive therapy is still an effective treatment in
some cases,

What are psychological treatments?

The psychodynamic view of depression; that depression develops out of anger
projected inwards instead of toward a loss, is the basis of the psychoanalysis, where
the goal is to achieve insight into an individual's anger and release the anger
towards themselves. Finding the long-term source of one's depression is done with
various techniques to explore conflicts and investigate problematic relationships with
attachment figures (e.g., parents). An example is dream interpretation, which helps
the person recall early experiences of (symbolic) loss, which may be a source of
conflict. The efficacy of psychodynamic therapy is not clear, as it is hard to study
because therapists often have a different view of psychodynamic principles. One
study however showed that psychoanalysis may be as effective as CBT, but another
study found no long-term efficacy.
Social skills therapy focuses on supporting the depressed individual with acquiring
appropriate social skills and attempting to reduce the amount of maladaptive social
skills, and assuming that it will help alleviate symptoms of depression. Social skills
training has shown to improve social skills and decrease the amount of depression
symptoms.

The loss or lack of pleasant rewards as the reason for depression is the main point in
behavioral activation therapy. It focuses on increasing the access to pleasant
rewards and events in a depressed individual's life, therefore taking the focus away
from negative events. Behavioral activation therapy consists of monitoring daily
events that are pleasant or unpleasant and behavioral interventions. Social skills
training and time management are also taught in behavioral activation therapy. It
has been shown that cognitive change is just as likely to occur from behavioral
activation therapy as from cognitive interventions.

According to Beck's cognitive theory of depression, depression is maintained by

dysfunctional negative beliefs, which turns into a negative schema which the
individual uses to view itself, the world and the future. The most widely used
therapies for treating depression are developed from this theory of Beck and are
often named cognitive therapy or cognitive retraining. Cognitive retraining works in
three steps, which are:

1. Assist the individual in identifying negative beliefs and thoughts

2. Challenge these beliefs and thoughts as dysfunctional, illogical or
irrational
3. Help the person replace these negative thoughts with more adaptive and
rational ones

Overgeneralization is often seen in depressed individuals, and these irrational

patterns of thinking that one specific failure relates to one's ability in other domains
are identified by the cognitive therapists and are challenged to be irrational. Asking
the client to monitor negative automatic thoughts helps with the identifying them
and possibly replacing them with more rational thoughts. Another method used to
correct the individuals negative thinking is reattribution training, which is a
technique which attempts to get individuals to relabel their difficulties in a more
optimistic and constructive way, rather than in a negative way.

Cognitive therapy has been shown to be very effective in treating the symptoms of
depression, and at least as effective as drug therapy. However, the chance of a
relapse is smaller with cognitive therapy, compared to drug therapy. The
combination of both drug therapy and cognitive therapy still appears to be the
superior treatment of depression.

What is meant by nonsuicidal self-injury (NSSI)?

Direct and deliberate bodily harm without any suicidal intent is deliberate self-harm.
It is now covered under the new DSM-5 category non-suicidal self-injury which
describes intentional self-inflicted injury without suicidal intent. Deliberate self-harm
is mostly seen in adolescents, and the motive is often when they are alone and
experiencing negative feelings. It is often done as a means of soothing oneself or a
way to seek help. Vulnerable groups include depressed adolescents, individuals with
interpersonal crises (e.g., those suffering from substance abuse, eating disorders,
psychosis) and those who have a history of previous self-harming. One of the few
effective forms of preventing deliberate self-harm is with cognitive behavioral
therapy and problem-solving therapy,

How can suicide be predicted?

The best predictor of suicide seems to be if someone matches the concept of
hopelessness, which was described earlier. Women appear to be three times more
likely than men to attempt suicide, but men 'complete' suicide four times more often
than women. This is because men more often take a more lethal method (e.g.,
jumping or weapons) than women, which more often choose methods like
attempting suicide with pills or cutting themselves. The prevalence rate of suicide in
youth has risen a lot, for reasons unknown, although the following factors may be
relevant:

 Nowadays, teenagers are exposed to more life stressors earlier, and often
lack the coping mechanisms that adults have
 Suicide is also a sociological phenomenon, and media attention to suicide
are known to increase suicide rates for teenagers
 The strong relationship between suicide, depression and substance abuse
(and the fact that teenagers are more exposed to drugs and alcohol now)
may influence the increasing suicide and self-harm rates

What are risk factors for suicide?

As mentioned before, the best predictor of self-harm or suicide, is a history of earlier
self harm or attempted suicide. Yet these people only account for 20 to 30%, so
other risk factor have been identified so we can more effectively prevent suicide.
Risk factors are:

 A diagnosis of depression, borderline, panic disorder, schizophrenia,

alcoholism, and substance abuse
 Hopelessness and low self-esteem
 Physical disability and poor physical health
 Low socio-economic status

Stress seems to be a very common predictor seen in suicide, and negative life
events often precede suicide. Different types of life events are seen across different
age groups. For teenagers and adolescents, relationship issues and interpersonal
conflicts are often the trigger. Financial issues are most often the reason of suicide
in middle age, and disability and (lack of) physical health for those in later life.

A genetic component exists in suicidal behaviour, as the inherited component may

be up to 48%, according to twin and adoption studies. Low levels of serotonin
metabolites in the brain have been associated with suicidal behaviour, and since this
may partially be controlled by inherited components, which could explain the
heritability of suicidal tendencies.

How is suicide identified and prevented?

Surveys suggest that 47% of those who attempted suicide, actually did not want to
die, but that their attempt was a cry for help. Intercepting people who do not
actually wish to die but find no other way of conveying their cry for help, is very
important in the prevention of suicide. Approaches like educational programs or
hotlines help some, but often only specific groups (young women in this case). Other
approaches to suicide prevention are developed, and the most common ones are to
train general practitioners to identify and treat suicidal intentions, improving the
access to care for those at risk of suicide, and restricting the access to suicide. The
latter might be hard in many cases but restricting locations for hanging in at-risk
living facilities might be the way to go.
Ch8: What are Schizophrenia Spectrum Disorders?

What is the nature of psychotic symptoms?

The first four of the five characteristics of a diagnosis of schizophrenia spectrum
disorders listed in the DSM-5 are known as positive symptoms. These reflect an
excess or distortion of normal functions, or extra feelings that are usually not
present (e.g., delusions). The fifth characteristic represents negative symptoms,
which are a loss or diminishment of normal functions (e.g., lack of emotional
expression).

What are delusions?

Thoughts and beliefs that are firmly held, but yet false, are known as delusions.
Delusions are usually misinterpretations of experiences or perceptions that become
fixed and not likely to be changed, even when the individual is challenged with
evidence of their conflicting thoughts. That delusions are often defended with logic
makes clinicians suggest that delusions may result from an inability to integrate
perceptual input with existing knowledge, when the rational thought processes are
still intact.

There are six main types of delusion found in individuals experiencing psychosis:

1. Persecutory delusions (paranoia) are delusions in which the person

believes they are being spied upon, persecuted or that they are in
danger, usually due to some conspiracy
2. Grandiose delusions make the person believe that they are a person with
fame or power or with exceptional abilities
3. Delusions of control are seen when individuals think their thoughts,
actions or feelings are being controlled by some external force (e.g.,
aliens) and that these thoughts are controlled through some device
controlling their brain
4. Delusions of reference result in the person believing that external events,
normally seen as independent, are referring to them
5. Nihilistic delusions make the person think that either some part of the
world or themselves does not exist anymore (e.g., they are dead) or that
some major catastrophe will occur
6. Erotomaniac delusions are rare beliefs that a person (often of a higher
social status) falls in love with them. This can result in stalking some
celebrity.

What are hallucinations?

Sensory abnormalities across multiple modalities (e.g., auditory, olfactory, and
visual) are known as hallucinations. Most reported hallucinations are known to be in
the auditory modality. These auditory hallucinations usually manifest as voices, and
can be experienced as two or more voices conversing, commands to the individual to
act in certain ways, or a voice commenting on the individual's thoughts. All these
voices are perceived as distinct from a person's own thoughts. Imaging techniques
have shown that when an individual reports hearing these voices, there is a neural
activation in the brain areas involved in the perception of sounds and speech
generation. The second most common form of hallucinations are visual, which vary
from simply perceiving colors and shapes that are not present to seeing specific
things such as individuals who aren't there. Hallucinations can also occur in other
modalities such as tactile and somatic (e.g., burning or tingling skin) or olfactory
and gustatory (e.g., unusual tasting food or smells that are not present). Some
individuals believe their hallucinations are real, but many also don't.

This led to the suggestion that psychotic episodes are related to a reality-monitoring
deficit, meaning that it may be difficult for a sufferer to distinguish whether some
belief or percept is real, and whether they created it or if someone else did.

A study where individuals had to remember words generated by themselves or by

the experimenter found that individuals diagnosed with schizophrenia differed from
controls in three aspects:

1. They found more items belonging to the generated list of words when
they were not
2. They were more likely to say that words generated by themselves were
actually generated by the experimenter
3. They reported that spoken items were presented as pictures

This suggests that those suffering from schizophrenia have a reality monitoring
deficit, which results in a problem between distinguishing what actually occurred and
what not, and that they have a self-monitoring deficit, meaning they have trouble
distinguishing between thoughts and ideas generated by themselves and ones
generated by others.

What is disorganised thinking?

Disorganised thinking is usually noticeable in the individual's speech, with some
common features recognizable when a person is experiencing psychotic symptoms.
Most common is derailment or loose associations, seen when the individual is
jumping quickly from topic to topic during a conversation. Answers to questions may
be tangential, where the response is not quite or only slightly relevant to the
question. Speech can become very unstructured and even incomprehensible when
'clanging' is exhibited, where the speech is based upon sound instead of concepts
(e.g., rhyming or alliteration). More examples of incomprehensible speech are
neologisms (made-up words) and word salads (very disorganized sentences where
phrases have no link at all). The disorganization of speech in schizophrenia spectrum
disorders seems to be due to the individual's difficulty inhibiting associations
between thoughts and therefore jump from idea to idea, and that they have
difficulty understanding the broader context of a conversation. This leads to a
sometimes very detailed speech with many words and ideas and it being
grammatically correct, but it will result in little substantive content, known as
poverty of content.

What about abnormal motor behaviour?

Unusual behavior present in schizophrenics can be seen in a variety of ways, such as
very childlike behavior or behavior inappropriate in a specific context (e.g.,
masturbating in public). The behavior can be unpredictable, they may show trouble
with goal-directed activities (e.g., maintaining hygiene) and the person may seem
agitated (e.g., shouting). The appearance of a person can also be strange or
inappropriate in specific contexts (e.g., only wearing underwear in the streets).
Catatonic motor behaviors are seen in several ways:

 Catatonic stupor: a significant decrease in a person's reactivity to the

environment.
 Catatonic rigidity: a rigid and immobile posture.
 Catatonic negativism: resisting any attempts to be moved.
 Catatonic excitement or stereotypy: excessive, purposeless and
unnecessary motor activity consisting of stereotyped movements.

What is meant by negative symptoms?

Some negative symptoms found in schizophrenia spectrum disorders are:

 Diminished emotional expression (or affective flattening) consists of a

reduction in many characteristics of emotional expression, such as eye
contact, voice intonation, facial expressions related to emotions and head
and hand movements related to emotions.
 Avolition is the inability to do normal daily goal-oriented activities, which
may result in little interest in social activities or work.
 Alogia is the lack of verbal fluency when an individual gives only brief and
empty replies to questions.
 Anhedonia is seen when individuals are unable to recall pleasurable
events and show a decreased ability to experience any pleasure from
normally positive stimuli.
 Asociality refers to the lack of interest in social interactions, possibly due
to the withdrawal from social interactions in general.

How are Schizophrenia Spectrum Disorders

diagnosed?
The DSM-5 categorizes schizophrenia spectrum disorders along a continuum of less
severe to disabling, while taking into account the number, duration, and severity of
symptoms. The diagnostic criteria for four of these schizophrenia spectrum disorders
are explained below. It is important to note that all symptoms must not be
attributable to some sort of substance or medication.

What is Delusional Disorder?

A delusional disorder is characterized by one or more delusions lasting over a
month, and it has several subtypes:

 The persecutory type is the most common subtype in which the individual
believes they are being cheated on, conspired against, spied on,
 poisoned, followed, harassed, or obstructed in the attainment of long-
term goals.
 Another subtype is the erotomanic type, where the person believes
another person of higher status is in love with them or making romantic
advances towards them.
 The grandiose subtype is seen in individuals who believe they have some
great power, insight or wealth. Grandiose beliefs often contain a religious
or spiritual content.

Apart from these delusions, sufferers often behave quite normal and display no
bizarre behaviour. The delusions can however be detrimental to any social or work
lives, and mood problems are also common in individuals diagnosed with delusional
disorder.

What is Brief Psychotic Disorder?

When an individual is suddenly (within a 2-week period) experiencing at least one of
the main psychotic symptoms, one can speak of a brief psychotic disorder. These
main psychotic symptoms are delusions, disorganized speech, hallucinations or
abnormal psychomotor behaviour. The sudden change is likely to cause emotional
turmoil or overwhelming confusion in the sufferer, and the disturbance lasts one day
to a month before one return back to normal behaviour.

What is Schizophrenia?
Schizophrenia is diagnosed when the disturbance influences major life areas (such
as work, social or romantic), and no single symptom is characteristic of the disorder.
The disturbances last at least 5 months and are caused by at least two of the
following: delusions, hallucinations, disorganized speech, highly disorganized or
catatonic behaviour, or negative symptoms. Prodromal symptoms are symptoms
that precede the active disturbance phase, and residual symptoms are ones that
may follow the active disturbance phase, examples of which are negative symptoms
or social isolation. Other symptoms seen in schizophrenics may be depressed mood,
anxiety or anger, inappropriate affect (laughing at inappropriate moments),
disturbed sleep patterns and low interest in eating. Individuals may also show a lack
of insight into their condition and be hostile or aggressive. The latter is more
common in younger male sufferers and individuals with a history of violence,
substance abuse, impulsivity or non-adherence to treatment. Usually, schizophrenics
are not aggressive and more likely to be the receiver of violence instead of the one
that exerts it.

What is Schizoaffective Disorder?

When one also displays mood problems such as depression or mania alongside
schizophrenia symptoms, a diagnosis of schizoaffective disorder is possible. The
psychotic symptoms must remain for 2 weeks or more after the mood problems are
(temporarily) gone. Schizoaffective disorder can seriously affect occupational
functioning and may also restrict social functioning. Difficulties in caring for
themselves and an increased risk of suicide is also associated with schizoaffective
disorder.

What is the prevalence of Schizophrenia Spectrum Disorders?

The lifetime prevalence rate of schizophrenia seems to be around 0.3 to 0.7%, and
it seems to arise most in the age group of 15 to 35 years. It is one of the most
disabling medical disorders with a mortality rate of up to 50% higher than normal
and sufferers tend to die ten years younger on average. Also, about 10% of
sufferers commit suicide. Despite improvements in treatment, about 80% of those
diagnosed will suffer lifelong impairment, and about the same amount will have no
job.

The prevalence seems to be about the same across the world, only the course of
schizophrenia appears to be less severe in developing nations. Some important
factors contributing to this may be beliefs about the origins of psychological
disorders or the supporting role of family. Rates of diagnosis of schizophrenia are
usually higher in some ethnic groups, which may be due to racial disparities in the
treatment of mental health. Immigration or a family history of immigration seems to
be an important risk factor, especially immigrants from developing countries. This
may be due to experienced stress from language difficulties, poor housing,
unemployment and low socio-economic status. Schizophrenia occurs as much in
males as in females, but females tend to have a later onset and less hospital
admissions, possibly resulting from higher levels of social role functioning prior to
their illness. Delusional disorder is estimated to have a lifetime prevalence rate of
0.2%, and this is 9% for brief psychotic disorder.

What is the course of psychotic symptoms?

Development of psychotic symptoms is usually through the succession of three
stages:

1. The prodromal stage

2. The active stage
3. The residual stage

What is the prodromal stage?

The majority of individuals developing psychotic symptoms show signs of symptoms
during their late adolescence or early adulthood. For some the onset is quick, but for
most it is a long process where normal functioning deteriorates over a period of
around 5 years. This slow process of deterioration is known as the prodromal stage.
The prodromal stage consists of a slow withdrawal from one’s normal life and their
social interactions, and shallow and inappropriate expression of emotions and a
deterioration in work, personal care or academics (research shows that even gray
matter loss may occur in areas mediating social cognition).

A psychosis usually develops during late adolescence, which is a basic fact. This
specific time period may be best explained with the diathesis-stress model, stating
that a disorder develops out of a biological vulnerability with an environmental
trigger. A majority of individuals showing symptoms of psychosis experience
stressful life-events in the prior three weeks. The transition from adolescence to
adulthood is known to be one of the most stressful periods in a person's life, and this
may therefore be the reason why so many psychoses develop during this time
period. A theory is that psychotic symptoms may appear when a person fails to cope
with normal maturation, resulting in social exclusion and other psychotic symptoms.

What is the active stage?

The active stage follows the prodromal stage, and this is when the person shows
unambiguous symptoms of a psychosis, which are delusions, hallucinations,
disordered communication and speech, or full-blown symptoms characteristic of the
disorder.

What is the residual stage?

Usually recovery is a gradual process, but symptoms can continue to show over a
long period of time. When one ceases to show any prominent signs of positive
symptoms, the individual has reached the residual stage. Negative symptoms may
still show during the residual stage, and it has been shown that relapse is common
in schizophrenia spectrum disorders. Stressful life events or returning back to a
stressful environment from some sort of hospitalization is a big predictor of relapse.
Not taking treatments or medication is also traceable as the cause for a relapse.
Reasons for not adhering to treatments may vary from lack of insight, history of
substance abuse, negative attitudes towards medication or poor therapeutic
relationship.

What is the aetiology Psychotic Symptoms?

Psychosis consists of a broad range of varying symptoms, and not a single one is
sufficient enough to diagnose a condition like schizophrenia. Therefore, the aetiology
also varies, with explanations from different domains including the biological,
psychological and sociological domain. Understanding psychosis is often attempted
with the diathesis-stress perspective. This means that psychosis is thought to be
explained due to partly a biological vulnerability to developing psychosis, and an
environmental stressor being the decider whether or not this vulnerability will turn
into a psychosis. Environmental stressors can be many things, such as dysfunctional
relationships, troubled youth, educational demands and many more. Explaining
psychosis is mostly done by looking at the specific features of a psychosis,

What are the biological theories of psychotic symptoms?

Concordance studies have shown that psychotic symptoms have an inherited
predisposition. Developing schizophrenia when a family member has a schizophrenia
diagnosis, depends on how closely they are related to each other. Because family
members not only share some genes but also share environments (which can be a
stressful one), one can also develop schizophrenia due to that environment and not
due to their genes. Therefore, research on monozygotic and dizygotic twins has
been done, which has shown that heritability is about 80% for schizophrenia,
making it the most heritable psychiatric disorder.

Of course, there are problems with twin studies, some of them being that MZ twins
are always the same sex, that MZ twins might be treated differently than DZ twins
because MZ twins look identical, and that MZ twins have shared prenatal influences
due to their shared placenta, which is not the case for DZ twins. These problems are
tackled by studying the offspring of monozygotic twins, which has shown that the
number of children (of MZ twins) developing psychotic symptoms are approximately
the same (16.8% with parent diagnosed vs. 17.4% with parent not diagnosed),
irrespective of whether their parent is diagnosed with schizophrenia or not.

Another method of looking at the genetic role played in the development of

schizophrenia, is to use adoption studies. These focus on the fact that children do
share genetic material with their parents but are raised in a different environment. A
study found that 16.6% of children adopted from their schizophrenic mother showed
symptoms of psychosis, while the control group (consisting of children adopted from
non-schizophrenic mothers) showed no symptoms. Studies also showed that the
adopted environment also played an important role, where adopted children of
mothers diagnosed with schizophrenia were more likely to develop it themselves if
their adopted environment had dysfunctional communication patterns, thus more
evidence for the diathesis-stress model.

Finding which specific genes are responsible for conditions, characteristics or other
qualities are done with molecular genetics. Genetic linkage analysis is one of the
main methods and works by looking at an individual's characteristic of which a gene
location is known (e.g., eye colour) and comparing it to the inheritance of various
psychotic symptoms. So, if some characteristic follows the same pattern within a
family as some psychotic symptom, it can be reasonably assumed that the genes
controlling both are probably on the same chromosome. Another technique is
genome-wide association studies (GWAS) finds rare mutations, which could possibly
give rise to psychotic symptoms. Mutations resulting in 'copy number variations'
(CNVs), which refers to an abnormal deletion or duplication in one's DNA,

Although these techniques can be extremely useful, it must be remembered that

some genes are responsible for really specific functioning which is indeed related to
schizophrenia, but which is also often seen in many other disorders (e.g., deficits in
executive functioning). Many people suffering from a schizophrenia spectrum
disorder don't share the underlying genetic factors, yet still share their symptoms,
showing once again the heterogeneity of schizophrenia disorders. Also, some of the
studies linking genes to schizophrenia have been did not be replicated.

It is known that communication in the brain is largely done by neurotransmitters,

therefore cognition and behavior are very dependent on them working efficiently.
Therefore, researchers think that many problems seen in schizophrenia could be
caused by a malfunction in the workings of brain neurotransmitters. A very known
and prominent biochemical theory of schizophrenia is the dopamine hypothesis,
which argues that symptoms of schizophrenia are associated with an excess of
activity of the neurotransmitter dopamine. Arguments for this hypothesis are:

 Drugs that alleviate (positive) symptoms of psychosis (e.g.,

antipsychotics like phenothiazines) act by blocking dopamine receptor
sites in the brain, thus reducing dopamine activity.
 Amphetamine psychosis, excessive use of amphetamines leading to
symptoms characteristic of psychosis, was found to be caused by
amphetamines raising dopamine activity in the brain, thus further proving
that excess dopamine can lead to psychosis-related symptoms.
 Brain imaging indicates that excessive levels of dopamine is released
from areas such as the basal ganglia in those diagnosed with
schizophrenia.
 Higher levels of dopamine and more receptor sites for dopamine
(especially in the limbic area) are found in deceased individuals
diagnosed with schizophrenia.

Two dopamine pathways in the brain especially important in schizophrenia spectrum

disorders appear to have different roles when it comes to the role they play in the
generation of symptoms.

First there is the mesolimbic pathway, starting in the ventral tegmental area and
projects to the hypothalamus, amygdala, hippocampus, and nuclear accumbens.
This pathway is known to have an excess amount of dopamine receptors in those
diagnosed with schizophrenia. This excess of dopamine receptors is responsible for
the positive symptoms, and thus often alleviated with medication blocking these
receptors. The second pathway, the mesocortical pathway, also starts in the ventral
tegmental area, but projects to the prefrontal cortex, and it appears that dopamine
neurons may actually be underactive in the prefrontal cortex. This may be the cause
for the negative symptoms, since the prefrontal cortex is known to play a role in
many of the behavior associated with negative symptoms (motivation, planned
behavior etc.).

Some things that don't completely fit the dopamine hypothesis, are the fact that
antipsychotic drugs usually start working after six weeks, even though they are
known to block dopamine receptors just hours after intake. Also, many new effective
antipsychotics only have minimal effects on the brain's dopamine levels and focus
more on other neurotransmitters. It is also known that other neurotransmitters that
play a role in psychosis symptoms are serotonin, glutamate and GABA, which makes
sense since these neurotransmitters all interact and influence others (e.g., dopamine
release in the mesolimbic pathway is regulated by serotonin).

Individuals with psychotic symptoms appear to have a structurally different brain

when compared to healthy controls. These differences are there when psychotic
symptoms first start, thus it is not necessarily a result of the symptoms. The
differences also continue to develop over the person's lifetime. Some important
structural differences are:

 Enlarged ventricles
 Reduced gray matter in the prefrontal cortex
 Functional and structural abnormalities in the temporal cortex and the
structures surrounding it, such as reduced volume in the hippocampus,
basal ganglia and limbic structures

Enlarged ventricles result in an overall reduction of cortical gray matter. This

enlargement of the ventricles seems to continue over time with chronic
schizophrenia, and it is also clear when psychotic symptoms first start showing. The
reduced gray matter in the prefrontal cortex is associated with the negative
symptoms in schizophrenia, as the prefrontal cortex is important in many executive
behaviours such as planning, motivation, planned behaviour, problem-solving and
memory. Impairments in these fields are seen in sufferers, and sufferers exhibiting
the negative symptoms show less metabolic rates in the prefrontal cortex. Recent
research shows that deficits in prefrontal functioning may not only be due to less
neurons, but due to disrupted connections between the synapses in pathways of
other neurotransmitters.

Abnormalities in the temporal cortex, limbic structures, basal ganglia and the
cerebellum are all seen in sufferers from schizophrenia and are most associated with
the positive symptoms. Reduced volume in the temporal cortex and hippocampus
have also been associated with the symptoms seen in sufferers, and hippocampal
function and the role it plays in memory and pattern completion are both associated
with those functions' disruption in schizophrenia. These structural differences seen in
those diagnosed with schizophrenia suggest that different symptoms, positive or
negative, may be relatable to different deficits in brain areas.

The cause of these brain abnormalities is not quite clear, but the prenatal period of
an individual's life seems to be contributing to abnormalities in the brain. Brain
damage occurring after the third trimester is usually self-repaired, yet this does not
seem to be the case for schizophrenia sufferers, therefore brain damage must have
occurred prior to the third trimester in schizophrenia. Birth complications and
infections during pregnancy are also sometimes seen to increase the risk of
developing psychotic symptoms.

What are the psychological theories of psychotic

symptoms?
Recently the interest in psychological models of schizophrenia has increased, and
this is especially true for the cognitive models viewing symptoms as a result of
cognitive biases in attention, interpretation and reasoning.

According to Freud, a psychosis is a result of a regression to an earlier ego state

resulting in a preoccupation with the self, known as a regression to a state of
primary narcissism. It is thought to be caused by cold, distant and un-nurturing
parents, and this regression gives rise to loss of contact with reality and attempts to
re-establish contact would lead to hallucinations and delusions. Because of the focus
on dysfunctional families in the causes of schizophrenia, the concept
schizophrenogenic mother was developed. This is a cold, rejecting, dominating and
distant mother causing schizophrenia (according to Fromm-Reichmann). Empirical
evidence for these psychodynamic explanations is slim, such as the little evidence
that mothers of sufferers actually display these characteristics.

Learning theories focuses on explaining some of the bizarre symptoms of

schizophrenia, like Krasner focused on operant condition, as he said that because
sufferers often find it difficult to focus on normal social interactions, they start
focusing on the unusual and irrelevant cues in their surroundings. This is noticed by
others, so the behaviour gets attention and so the behavior gets reinforced, and
finally the behavior is strengthened. Another behavioral theory arguing that unusual
behavior could be learned, is the fact that extinction can occur when an individual
diagnosed with schizophrenia experiences a decrease in attention or reward when
displaying the behaviour.

Attentional abnormalities are commonly found in schizophrenia, such as under-

attention (inability to focus on relevant aspects of the environment) or over-
attention (attending to irrelevant aspects too much). The orienting response, a
normal attentional process consisting of physiological changes when presented with
a novel or prominent stimulus, shows abnormalities in 50% of cases of
schizophrenia. These deficits have been shown to be correlated with negative
symptoms such as blunted effect and withdrawal. Over-attention in schizophrenia is
when a person attends to many cues in their environment and they are unable to
filter these out, which leads to sufferers being very distractible, and therefore
scoring lower on cognitive tests when distractions are present. They score higher on
tests where being easily distracted leads to better performance, like with the
negative priming test. The over-attendance to distractions correlates highly with
positive symptoms.

Paranoid schizophrenia occurs over 50% of the time with cases of schizophrenia,
and this sub-type of schizophrenia which is noted by delusions of persecution is
therefore of great interest. These thoughts of persecution may be explained by the
fact that sufferers are 20 times more likely to have experienced some threatening or
confrontational event, therefore they might be more wary of these events. Cognitive
biases may also be responsible for paranoid delusions, and the four types are
explained below.
Evidence shows that individuals experiencing paranoia delusions show attentional
biases towards cues with emotional meaning or cues that are paranoia relevant.
Then again, research shows that sufferers of delusions of persecution are slower to
recognize angry faces than controls and fixate less on salient features of the face.
This might be a defense mechanism the person has developed, where an avoidance
strategy makes the person avoid allocating attention to threatening stimuli.

People with delusional beliefs appear to have a bias towards attributing negative life
events they experience to external causes. A study found that when experiencing
paranoid delusions, individuals attributed negative events to stable and global
reasons, yet they did attribute positive events internally and negative events
externally (the latter seems to only count when there is a perceived threat to the
self).

A reasoning biases commonly seen in persons with delusional disorders is that of

jumping to conclusions. Individuals make a decision about some event based on less
evidence than normally, which leads to an early acceptance and belief of paranoid
thoughts, resulting in delusional symptoms. The threat-anticipation model of
paranoid and persecutory delusions attempts to answer how these reasoning biases
are caused. The model argues that there are four factors important in contributing to
the formation of persecutory thoughts:

1. Anomalous experiences (e.g., hallucinations) which lack an obvious

explanation
2. Depression, anxiety and worry causing a bias towards thinking and
interpreting events
3. Reasoning biases causing the individual to find confirming evidence
instead of questioning these anomalous experiences
4. Social factors which could add to feelings of threat, fear, anxiety and
suspicion

Hearing voices are not necessarily a psychotic symptom, but the interpretation of
these auditory hallucinations depends on whether or not the voices are negative or
not. Diagnosed individuals perceive voices as more dominating, distressing and
uncontrollable when compared to healthy individuals hearing them, and this distress
is what characterizes voices as a symptom of psychosis. A theory as to how these
voices are interpreted is that they start as an overstimulation of the auditory neural
networks, and the failures in detecting signals lead a person to believe the voices
are real, meaningful and not generated by themselves. The deficits in working
memory and executive functioning common in schizophrenia may also cause the
person to be unable to suppress the voices or use logic with top-down reasoning to
suppress them, causing more distress.

Inferring the beliefs, intentions and attitudes of others is known as the theory of
mind. A deficit in TOM is characteristic in autism, but it appears to possibly also play
a role in schizophrenia, as a study found that individuals suffering from persecutory
delusions found it harder to inter the mental state of a character in a joke. An
inability to infer other people's intentions may lead to suspicious thoughts and fear
that others may be hiding their intentions. TOM deficits are seen across
schizophrenia spectrum disorders and can be detected at various stages of the
development of a disorder, as well as in the prodromal stage.

⇧
What are the sociocultural theories of psychotic
symptoms?
Higher rates of schizophrenia diagnosis are usually found in the lower socio-
economic class, resulting in two sociocultural theories of schizophrenia. The
sociogenic hypothesis states that individuals in a lower socio-economic class are
more likely to experience more life stressors such as financial problems,
unemployment, poor educational levels etc. These stressors can then evoke a
psychosis in those people vulnerable for one. However, studies have found that
people diagnosed with schizophrenia are just as likely to have parents of high socio-
economic status compared to having parents of low socio-economic status, despite
the fact that the diagnosed person is more likely to be of low socio-economic status
economic status themselves.

An alternative explanation therefore is that individuals' low socio-economic status is

a result of their disorder, instead of it being the cause of their disorder. This occurs
due to the downward drift sufferers experience when symptoms lead them into
unemployment, exclusion from social situations and poverty. Drifting to a lower
socio-economic status because one's disorder is known as the social-selection
theory, where there are more schizophrenia-diagnosed individuals in the lower
socio-economic group because of their disorder. A final social factor in schizophrenia
is that sufferers are often treated differently when they are labeled with a disorder,
and that they may also see and treat themselves differently because of this label.

Poor communication between parents and children is often also seen as a risk factor,
and it is argued that a psychosis could develop when communication is ambiguous
and double binds the child. The double-bind hypothesis states that a parent may
show a loving display of affection at one moment, and then reject it because it may
be seen as a weakness. This leaves the child confused and in a conflicted situation,
which could end up in a withdrawal from social interaction. Communication deviance
(CD) is a construct describing forms of communications that are difficult to follow
and often leaving a person puzzled. It includes abandoned or ceased sentences,
inconsistent references to situations, using phrases wrongly and the use of strange
logic. CD has shown to be a predictor of developing psychotic symptoms in children,
independent of biological predispositions. The construct expressed emotion (EE) is
also strongly linked to the development and relapse of psychotic symptoms. EE
consists of a family environment which is hostile and critical and where family
members are intolerant of the patient's problems. Family members who display
these kinds of behaviors are also often seen to have the attributional style where
they blame the sufferer for their own problems.

How can psychosis be treated?

With the right tools, many people suffering from psychotic symptoms can cope with
their daily struggles and live close to a normal life. However, many sufferers are
unable to achieve this, and continue to have problems for very long. Relapse is very
likely, as it has been found that around 81% of people who recovered from their first
episode will relapse within five years. Relapse is very dependent on whether or not
the sufferer adheres to treatment. Discontinuing medication increases the risk for a
relapse by close to five times, and dependence on illegal drugs is also a big risk
factor for potential relapse.

⇧
What are biologically based treatments of
psychotic symptoms?
Electroconvulsive therapy, which consists of passing an electric current through the
head for a very short duration, used to be a common form of treatment and is only
used today when other treatments don't work and if the psychotic symptoms are
comorbid with depression. A prefrontal lobotomy involves separating the pathways
between the lower brain areas and the frontal lobes. It was used to make disruptive
and violent patients calmer and easier to treat. Because of its high fatality rate (up
to 6%) and the fact that it affected the patient's intellectual and emotional
responsiveness a lot, it became questioned in the 1950s and later discontinued.

Neuroleptics or antipsychotics are one of the most effective forms of treatment, and
especially for treating positive symptoms. There are two types of antipsychotics, first
and second generation, referring to when they were developed.

First-generation antipsychotic drugs were originally antihistamine, but it was noticed

that they also calmed people. The use of them on patients with severe psychological
disorders showed that the psychotic symptoms dropped in these patients, so shortly
after they were widely adopted in treating schizophrenia, alleviating positive
symptoms. The first problem with these antipsychotics is that they don't cure the
problem but merely treat it, so lifelong medication is necessary. The second problem
is that these antipsychotics also have unwanted side effects. One is tardive
dyskinesia, a motor movement disorder developed by 20 to 25% of people taking
the medication, and it is characterized by symptoms of Parkinson's disease like limb
tremors or involuntary tics, which is explained by the lowering of dopamine activity.

Second-generation antipsychotic drugs (or atypical drugs) were developed more

recently, and were thought to have the following benefits over the first-generation
antipsychotics:

 They target more specific dopamine and serotonin receptors, so the effect
is more precise
 Lower risk of relapse compared to the first-generation antipsychotics
 Fewer serious side effects like motor problems
 Takers of these newer medications are more likely to continue treatment
 The newer, atypical antipsychotics also help reducing negative symptoms

Recent research has cast a doubt on these assumptions, as second-generation drugs

tend to have some of their own side effects (e.g., affected immune functioning) and
the side effects resembling Parkinson's are sometimes also seen in atypical drugs.
Studies have also found no significant differences in effectiveness when they
compared the first to the second-generation drugs, and the second generation
produced just as many unwanted side-effects as the first generation.

What are psychologically based therapies of

psychotic symptoms?
Psychotic symptoms can result in inappropriate behaviors towards friends and
family, which can make daily life even harder for sufferers. Social skills training
focuses on teaching the appropriate skills one needs in basic social interactions,
therefore hopefully reducing the risk of social withdrawal. The training consists of
role-playing, modeling and teaching one how to respond in specific social situations.
Teaching these skills and other skills such as physical gestures, eye contact, facial
expressions etc. have been shown to positively affect many things, such as overall
communication skills, coping strategies, finding work, reaching out for help when
they need it, finding accommodation and a general decrease in psychopathology.
Supported employment is a program which helps individuals find work fit for their
abilities and goals,

Cognitive therapies were thought of as inappropriate for treating psychosis, because

of the lack of insight patients have and the thought that psychosis was largely due
to biological and not psychological causes. This is not true today, and it is thought
that cognitive behavioral therapy is effective in challenging many psychotic
symptoms, so cognitive behavior therapy for psychosis (CBTp) was developed. The
negative bias that many patients hold towards their hallucinations (e.g., they are
dangerous and negative), can make the person indulge in safety behaviors such as
shouting at the voices or drinking alcohol. CBTp can help challenge these negative
biases, help identify a non-psychotic meaning for their symptoms and reduce
negative symptoms one experiences by challenging their low expectations they hold
about themselves. CBTp also helps with the adjustment when an individual returns
to the 'normal' world after hospitalization and help maintain the use of medications.
CBTp can be extended to also include helping paranoid delusional individuals
challenge their attributions concerning their delusions, which is done in reattribution
therapy. Individuals' paranoid beliefs are challenged by the therapist simply by
asking them if their belief logically makes sense, which is often sufficient. If
necessary, a 'reality test' can also be conducted, where the therapist actually tests
the belief that the patient may hold.

After being discharged from some kind of hospitalization, one can receive personal
therapy. Personal therapy is focused on teaching the skills needed with daily life
after discharge. These skills include how to identify and deal with signs of relapse,
acquiring relaxation techniques, identifying inappropriate behavioral and emotional
responses and learning better ones, identifying inappropriate thinking biases and
cognitions and how to deal with them, and learning to deal with criticism and
negative feedback from others and themselves.

Because symptoms of schizophrenia affect cognitive deficits such as attention,

memory and executive functioning, cognitive remediation training (CRT) or cognitive
enhancement therapy (CET) are used to improve these cognitive skills, which may
speed up progress in other treatments and improvement in social skills.

What are family interventions?

As mentioned before, families can play a big role in how an individual handles
psychotic symptom. Expressed emotion (EE) and communication deviance (CD) can
play a big role in whether or not a patient gets their life back on track. Family
psychoeducation focuses on teaching the family of a sufferer the nature of- and how
to deal with- schizophrenia or other psychotic symptoms. A method used to help the
family learn about everything related to psychotic symptoms (e.g., recognizing
relapse or helping with medication) is supportive family management, which consists
of counseling sessions with families sharing their experiences and thus also building
social support. Applied family management is a more intensive version of supportive
family management, where families are actively taught how to help the afflicted
family member.
⇧

What is community care?

Before the US' Community Mental Health Act of 1963, many mental health sufferers
were detained in hospitals. After the act passed, many countries followed, and now
mental health sufferers usually have the right to receive many services that help
with their affliction. Some of these cares are outpatient therapy, preventative care,
aftercare and emergency care. Assertive community treatment is a service
developed out of this change in the care of the mentally ill. Assertive community
treatment assists people with medication regimens, guidance with decisions, help
with vocational training and offering psychotherapy. Assertive outreach is a form of
care for individuals who have not yet experienced any effect with other mental
health services. Assertive outreach is focused on helping individuals with severe
mental problems, and some of the main goals are to increase social life, prevent
relapse, find accommodation and help with medication adherence. Staff of assertive
outreach meets the individual regularly over a long period and therefore hopefully
builds a solid bound with the individual. Community care helps in many domains, but
it is often hard to resource and coordinate.

Studies have found that sufferers from schizophrenia are much more likely to be
victim of murder for many reasons, some of which are that they are more likely to
live in a more dangerous part of town or they might provoke hostility because of
their symptoms. Sufferers from mental illnesses are also more often seen as
dangerous and violent in media. Some studies support this, and some studies
contradict it, and it is still not safe to say which is true, since many variables have to
be accounted for. However, one study did indicate that 99.97% of all sufferers from
schizophrenia won't exhibit any serious form of violence in any given year.
Substance abuse does seem to occur much more in those suffering from
schizophrenia, so it is a challenge for community care to tackle this problem.
Ch9: What are substance use disorders?

A substance affecting one's physiological and psychological state when introduced to

one's body is a drug. The effects of drugs vary from giving energy, relaxing,
distorting perceptions, changing moods, or change ways of thinking. Some problems
that result from the use of any kind of drug, are that they may have long-term
negative effects, drugs can be both psychologically or physiologically addictive, and
some move from less-harming drugs to more serious (illegal) substances. Lately a
rise in the use of synthetic cathinones (bath salts) has been seen.

How can Substance Use Disorders be defined and

diagnosed?
Before the DSM-5 there were two categories for defining substance and drug use.
Substance abuse is the use of substances despite one's knowledge about its
negative effects. Substance dependence is a full-blown version of substance abuse
known by cognitive, behavioral and physiological symptoms where the individual
continues use of a drug despite its significant negative effect. These two categories
are now combined in the category 'Substance Use Disorder' in the DSM-5. This
change is because many showing substances abuse not always end up showing
substance dependence, and analysis showed that substance abuse and dependence
represented one instead of two categories.

Substance Use Disorder (SUD) is characterized by at least one substance disorder

diagnosis, and its criteria fits within four broad groups:

1. Impaired control, such as taking the substance for longer than intended,
failed attempts to quit/moderate or daily activities revolve around
obtaining the high
2. Social impairment, like withdrawal from family/hobbies or drug use is
resulting in failure at work/school/social relations
3. Risky use, like taking the drug despite being in a hazardous situation and
taking the drug despite one’s awareness of the harm it does
4. Pharmacological criteria, like tolerance showing that the body is affected
heavily by the drug and showing withdrawal symptoms after not taking
the substance

Some terms often seen in the discussion of substance use and abuse are addiction
(use of drugs up until the point where one is more often high than not), cravings
(strong subjective drives to use a drug), tolerance (requiring higher doses for the
same effects), withdrawal (negative behavioral changes seen when one's body lacks
the drug) and psychological dependence (when a person changes their life
significantly to ensure continued use of the drug).

What is the prevalence and comorbidity of

Substance Use Disorders?
Lifetime prevalence rates for the US have been calculated to be 2.6 to 5.1%.
Substance use disorders are very comorbid with many other psychological disorders.
Especially mood disorders and anxiety are seen to be very prevalent in those
suffering from a substance dependence. Some argue that substance
abuse/dependency may result in a psychiatric illness, but most evidence suggest the
opposite, that substance use results from a psychiatric illness. Perhaps substances
are used to cope and alleviate the many symptoms (known as self-medicating).

What are the characteristics of specific Substance

Use Disorders?
The specific substance uses disorders that we will look at are first alcohol and
nicotine, which are then followed by substances increasing nervous system activity
known as stimulants. Then we will discuss substances known as sedatives, which
slow bodily activities and reduce pain and anxiety. Finally, hallucinogens, chemicals
altering perception, are discussed.

What is Alcohol Use Disorder?

Alcohol is extremely often used across the globe, and patterns of its use are
becoming problematic. Males drinking 5+ and females drinking 3+ drinks on a
typical drinking day are labeled as hazardous drinkers, and the number of hazardous
drinkers is rising. Another problem is the surge of binge drinking, which is basically a
very high intake of alcoholic drinks on a single occasion. Amounts of drinks required
to be considered a binge drinker depends on the country. The effects of alcoholic
drinks come from the chemical ethyl alcohol. It is absorbed into the bloodstream
through the lining of the intestine and stomach. When it reaches the central nervous
system, it works by facilitating the use of GABA, resulting in more inhibition thus
relaxation. The final effects of alcohol intoxication are motor coordination difficulties,
blurred vision and slowed reaction times. This is where the term biphasic comes
from when describing alcohol's effect, since the effects of alcohol can be both
stimulating and depressing. It is often thought that the wanted effects of alcohol
(increased sociability, reduced inhibitions and stress-alleviating) are largely due to
the users’ expectations, instead of it being truly caused by alcohol.

Longer use of alcohol can result in negative effects over time, such as larger
quantities needed for the same effect. When the body is deprived of alcohol, one can
show restlessness, inability to sleep, depression and anxiety and many more. If one
has drank heavily for years, withdrawal can lead to delirium tremens (DTs), making
the person delirious and experiencing unpleasant hallucinations, and exhibiting
muscle tremors and shaking. Heavy alcohol use for longer periods can result in
hypertension, stomach ulcers, cancer, heart failure, cirrhosis of the liver, brain
damage and early dementia. Alcohol contains calories, but no nutrients, so users can
feel full but lack vitamins and minerals, which can lead to Korsakoff's syndrome,
especially by dementia and memory disorders. Heavy drinking in pregnant mothers
can result in fetal alcohol syndrome,

Prevalence rates for dependence and abuse appear to be 12.5% and 17.8%
respectively, and dependence is seen more in younger, unmarried men of lower
socio-economic class. Alcohol abuse is often part of what is known as a polydrug
abuse, which means that more than one drug is abused at the same time (e.g.,
many heavy drinkers are smokers).

Alcohol use disorders are problematic patterns of drinking where if often passes
through stages of heavy and regular use, then alcohol abuse is exhibited and finally
an alcohol dependence is seen. Risk factors for alcohol use disorders include: a
family history of alcoholism, the experience of long-term negative affect, conduct
disorder seen in childhood, experiencing stress (especially childhood stressors), and
believing that alcohol has favorable outcomes.

Society is affected by alcohol use disorders because of the lost productivity,

spending on healthcare, crime and many other costs. Alcohol use is closely related
to motor vehicle crashes, boating accidents, drownings, crime, sexual assault, child
molestation and suicide. All of these impact society in many ways, which is why it is
important to deal with overuse of alcohol.

What is Tobacco Use Disorder?

Nicotine is the compound found in tobacco responsible for multiple effects when
affecting the brain. It increases blood pressure and heart rate, therefore having
stimulating effects. However, smokers also report less anxiety, anger and stress, so
it also has calming effects. The opposite happens when there is a lack of nicotine in
the body, resulting in increased stress and anxiety, therefore nicotine is seen as a
both psychologically and physically addictive substance. A growing body of evidence
shows that nicotine's positive effects (elevated mood, enhanced cognitive
functioning and decreased appetite) are caused by the release of dopamine in the
mesolimbic system. The calming effect that is often reported after having a cigarette
appears to be because of the reversal of withdrawal symptoms.

Nicotine follows alcohol for the second place of most used drug worldwide, and half
the users die from smoking. Approximately one third of the adult population smokes,
and this number is one in five for teenagers aged 13-15. These numbers are
dropping for developed nations and increasing for developing nations. Many smokers
(about 2/3) report wanting to quit but say they would find it too hard to go a day
without smoking, which is a criterion of the DSM-5 for a substance use disorder.

Some characteristics of tobacco use disorder are the need to smoke within 30
minutes of waking up, craving the use of tobacco, unsuccessful attempts to control
use, or tobacco use becomes more over time. When first taking tobacco, one often
experiences nausea and dizziness, these effects lessons about time as one gets
more tolerant of nicotine. Abstinence of nicotine will lead to withdrawal symptoms
(e.g., depressed mood, insomnia, restlessness, anxiety, anger, difficulty
concentrating, impatience). Tobacco use seems to be comorbid with other disorders
such as alcohol (or other substance) use disorder, depression, bipolar disorder,
anxiety disorder, personality disorder and ADHD.

Smoking is most detrimental to the user's health, and nicotine dependence is the
largest preventable cause of death. Smoking kills over 6 million people each year
and it is a significant factor in stroke, heart disease, chronic lung cancer and cancer
of the larynx, mouth, bladder, cervix, esophagus, pancreas and kidneys. It is
estimated that about half of all smoking teenagers will die from a tobacco-related
disease if they continue smoking. These serious health issues also result in huge
amounts of money spent on society's health problems caused by smoking. Not only
the smoker's health is compromised, breathing in other persons second hand smoke
(known as passive smoking) can also cause physical and psychological effects.

What is Cannabis Use Disorder?

Cannabis is obtained from the plant cannabis sativa. Hashish is the most powerful
type of cannabis, and marijuana is a weaker derivative made from dried and crusher
cannabis leaves. Cannabis effects are feelings of relaxation, euphoria, sharpened
perceptions (which might result in mild hallucinations), and increased sociability.
Less wanted effects include difficulties in concentration and memory impairment.
Higher doses can also induce stimulating effects (increased anxiety or paranoia)
despite its classification as a sedative. The (main) active ingredient in cannabis is
tetrahydrocannabinol (THC), and cannabis is thought of to not have many addictive
qualities. It works mildly stimulating by increasing heart rate, and the psychoactive
effects are caused by the cannabis working on the cannabinoid receptors CB1 and
CB2 in the striatum, hippocampus and cerebellum. These receptors are known to
regulate dopamine, which is thought to be the reason for the positive psychoactive
effects. Cannabis is used for some medical ends, but it is mainly used for
recreational purposes. Despite few harmful effects on behavior and health, it is still
an illicit drug in most countries.

Cannabis is the most often used illicit substance, and its estimated global prevalence
is about 2.6 to 5%. Use has increased significantly since the 1960s, especially in
North America, Western Europe & Australasia. Prevalence in western countries vary
from around 5 to 15%.

Because of an increase in strength of THC contents in street cannabis, more

evidence has accumulated for a cannabis abuse and dependence syndrome in users.
Withdrawal and tolerance have been seen in long-term users, some of the
withdrawal symptoms being irritability, restlessness and flu-like symptoms.
Cannabis use disorder can be diagnosed when an individual reports a reduction in
pleasure obtained from cannabis and continuing increased use. Cannabis use
disorder is usually not accompanied by some other substance disorder, and sufferers
report using cannabis to cope with mood, sleep better, and reduce pain or some
other psychological or physiological problem.

Cannabis intoxication is known by a reported 'high' feeling, followed by euphoria,

inappropriate laughter and grandiosity, sedation and lethargy, memory and
judgment problems, perception of time seems to be slowed, distorted sensory
perception and impaired motor skills. Risk factors for cannabis use disorder are age
of onset, regularity of tobacco and cannabis use, impulsivity and mood-swings, a
diagnosis of an emotion disorder or a conduct disorder during childhood, and prior
alcohol or drug dependence. Cannabis use disorder is a risk factor for other
psychiatric disorders such as anxiety and panic disorder, major depression,
schizophrenia and increased tendency for suicide. It is not certain whether cannabis
use is the cause of mental problems, or whether cannabis is used because of mental
problems. Currently both appear to be possible, as some studies have shown that
there is a causal relationship between cannabis use and the risk of developing
psychotic symptoms. So, whether one causes the other is not yet clear, as it is also
possible that there is a third variable causing both cannabis use and psychotic
symptoms (e.g., childhood problems).

Cannabis use has some effects on cognitive skills such as reduced reaction time,
decreased attention span, slower problem-solving ability, deficits in verbal ability
and loss of short-term memory. These effects can be very dangerous in certain
settings, and evidence has shown that cannabis affects driving skills and driving
safety. Cannabis users tend to underachieve, where regular users have lower IQ's,
lower educational achievement and deficits in motivation. Besides this association
with an underachievement syndrome, there is only little evidence for long-term
neurophysiological effects. Regular users do tend to end up with a lower educational
achievement and lower income. Amotivational syndrome is seen in regular users
exhibiting apathy, loss of their ambitions and more difficulty concentrating.
What are Stimulant Use Disorders?
Substances causing increased central nervous system activity, increased blood
pressure and heart rate are known as stimulants. They provide alertness, feelings of
energy and confidence and enhance thinking speed. Cocaine is one of the
stimulants, and it is a natural substance extracted from the coca plant.
Amphetamines are synthetic drugs found in the common forms of amphetamine,
dextroamphetamine and methamphetamine. Caffeine is probably the most common
stimulant, and it is usually found in coffee, tea, chocolate and some supplements.

After cocaine has been processed, it appears as a white powder which can be
snorted, injected or when its purer smoked (crack cocaine). The act of smoking
cocaine is known as free basing. When snorted, a rush of cocaine takes about 8
minutes and lasts 20 to 30 minutes. This rush is full of feelings of euphoria, energy,
and excitement. After this initial feeling, the drug affects other areas resulting in
increased arousal, alertness, and wakefulness. The main effects are due to blockage
of dopamine reuptake. Lifetime prevalence rates in developed countries is 1 to 3%,
with European rates varying from 0.5 to 6% and the US rate being estimated at
14.4%.

Because of cocaine's short duration, many doses are needed to keep the pleasurable
feelings provided by the white powder. Cocaine also tends to be an expensive drug,
so maintaining a cocaine rush is expensive and leads some users to resort to theft
and fraud. Cocaine dependence is seen when a person finds it hard to resist using
the drug when it is available, which in turn can lead to neglecting important things
such as work or childcare. Tolerance also occurs in cocaine use, as users often have
to take larger doses to achieve similar effects. Abstinence from cocaine can result in
hypersomnia, increased appetite and a negative/depressed mood. Cocaine
dependence can be accompanied with social isolation and sexual dysfunction, and it
can result in the person developing symptoms of other disorders such as major
depression or anxiety disorders.

Regular cocaine users show evidence for deficits in decision making, working
memory, and judgement. Cocaine use by pregnant mothers can cause development
deficits in the unborn child, and this is seen in a retarded development of the child in
its first two years of life, a higher chance of ADHD at age 6, and deficits in visual
motor development. This may at least partially be caused by cocaine's effect on
blood flow, causing irregularities in the placenta flow. These same cardiovascular
effects influence blood pressure and possibly aggravate existing cardiovascular
problems, which can result in heart attacks, brain seizures or death.

Amphetamines are synthetic substances stimulating the central nervous system.

Common amphetamines are amphetamine itself, dextroamphetamine and
methamphetamine, and they are very addictive. Their psychological effects include
enhanced feelings of confidence, energy and alertness, and their physical effects
include increased blood pressure and heart rate. They work by both releasing more
dopamine and norepinephrine and at the same time also blocking the reuptake of
these neurotransmitters. Tolerance builds to methamphetamine, which is smoked,
can occur extremely quickly. Withdrawal symptoms include paranoia, anxiety,
irritability, confusion, and restlessness.

Worldwide prevalence is estimated to be around 0.3 to 1.2% and is the second most
used drug. The lifetime prevalence rate of amphetamine use disorder is thought to
be 1.5%, and of all illicit drug abuse, amphetamine can be accounted for about
16%.
Amphetamines generally last longer than other stimulants (e.g., cocaine), but
tolerance builds quicker. Once a high usage dose is achieved, one can also start
experiencing temporary but intense psychological effects such as paranoia, anxiety
or even psychotic episodes. Individuals dependent on methamphetamine (thus
spending most of their time trying to achieve the drug and ignoring duties) often use
the drug for several days for a long-lasting high, followed by a couple days of
exhaustion and depressed feelings, which is then followed again by
methamphetamine use. Amphetamine intoxication starts with a high followed by
either positive (euphoria, energy, alertness) or negative (anger, aggression,
impaired judgement) effects. Physical symptoms include pupil dilation, nausea, chest
pains or in severe cases seizures or coma.

Studies have found that amphetamines may cause long-term damage to the central
nervous system. Chronic methamphetamine is seen to affect both serotonin and
dopamine systems (reflected in poor decision making in sufferers) and the
production of dopamine in the orbitofrontal cortex. This area is important in
compulsive behavior and resistance to extinction of behaviors when the reward isn't
present, which might explain why addicts find it so hard to quit even when they
don't enjoy methamphetamine anymore.

Use of caffeine is extremely common, as around 85% of the world population is

familiar with taking it. Caffeine also stimulates the central nervous system, resulting
in increased alertness and motor activity, while also fighting fatigue. More negative
effects that can also be experienced are insomnia, anxiety, headaches, dizziness,
and less fine motor coordination. Caffeine reaches its peak concentration with one
hour, but half the concentration is still present in the body six hours later, making it
a substance that might have some detrimental long-term effects if it prevents sleep.
As mentioned, daily use can have the positive effects of increasing alertness,
attention, cognitive functioning, elevated mood and fewer symptoms of depression.
However, overuse will often result in anxiety, and can sometimes result in psychotic
and manic symptoms.

What are Sedative Use Disorders?

Sedatives are known as central nervous system depressants due to their effect of
reducing the body's activity, responsiveness, pain, tension, and anxiety. Sedatives
include alcohol, opiates and alike (e.g., heroin, morphine, codeine and methadone),
and synthesized tranquilizers (e.g., barbiturates). Sedatives have serious effects on
regular users like rapidly build tolerance, severe withdrawal symptoms and high
doses leading to a disruption of the important body functions.

Juice from the opium poppy is known as opium, which is a form of opiate. Other
derivatives are the opiates morphine, heroin, 'methadone' (technically an opioid)
and codeine. Used at first as a medical end for treating pain, it quickly became
known that opiates are highly addictive. Methadone, developed by the Germans
during WWII, is a synthetic form of opiates (thus an opioid) and is known for its less
severe effects, slower onset and its ability to be taken orally. Heroin, derived from
morphine, is the current most widely used 'opiate' (also considered an opioid).
Opiates usually cause drowsiness and euphoria, but heroin also gives an ecstasy
rush at the beginning of the six-hour lasting trip, therefore making it a more popular
drug. As many good things come with a price, heroin's regular users quickly develop
tolerance, and its withdrawal effects are severe and start six hours after the person
has injected the drug. Opiates affect the brain by attaching to endorphin receptors
and signaling these receptors to produce more endorphins. Endorphins are the
body's natural painkillers as these neurotransmitters relieve pain, reduce stress and
give pleasurable sensations.

Estimated worldwide (annual) prevalence is about 0.3 to 0.5%, but these numbers
are higher for developed nations, varying from about 1.2 to 4.2%.

As mentioned, multiple times, opioids and opiates are extremely addictive to many
users. Withdrawal effects occur right after the trip ends, so about six hours after
use. Symptoms of withdrawal are anxiousness, restlessness, muscle aches, an
increase to sensitivity of pain and craving more of the drug. Severe withdrawal can
also include insomnia and fever. Symptoms generally peak after one to three days,
and last about five to seven days. Opioid use disorder is characterized by a
developed tolerance to opioids and opiates, and it is generally hard to treat due to
the severity of the withdrawal symptoms. In those diagnosed with opioid use
disorder, marital difficulties and unemployment are definitely not uncommon, just as
other drug related crimes like distribution of drugs. However, studies have shown
that many people can periodically use opioids or opiates recreationally and function
just fine. The terms 'controlled drug user' and, in the case of heroin, 'unobtrusive
heroin user' are therefore coined, which refer to a long-term drug user who has
never received specialized treatment and shows similar occupational status and
academic achievement as the general population. Due to these findings, some
theorists state that the use of opiates is linked to life stressors, and if these
stressors are only temporary, so the drug use will be.

Apart from the severe withdrawal symptoms regular users experience, other risks
are an accidental overdose due to failure of diluting pure forms of heroin, buying
heroin that contains additives that are lethal, and the risk of obtaining HIV or
hepatitis from shared needles. A US study concluded that 28% of heroin addicts died
before the age of 40, with only one third being from overdose, while over half were
from suicide, homicide or accidental death.

What are Hallucinogenic-Related Disorders?

Psychoactive drugs or also known as hallucinogens affect the users’ perceptions.
They can create sensory illusions and hallucinations or simply sharp the sensory
abilities. They are less addictive than previously mentioned substances and have
fewer effects on arousal level. The two hallucinogens discussed are lysergic acid
diethylamide (LSD) and MDMA. MDMA is a hallucinogen and stimulant at the same
time, and it is also known as ecstasy. Other common hallucinogens part of the group
phencyclidines is PCP, 'angel dust', ketamine, cyclohexamine, and dizocilpine.
Phencyclidines are known to produce feelings of separation from mind and body
when low doses are taken, and stupor and coma at high doses. Its prevalence
caused the DSM-5 to include Phencyclidine Use Disorder.

Consciousness-expanding or mind-expanding drugs are known as psychedelic drugs,

and LSD was probably the first widely used psychedelic. LSD, also known as acid, is
usually sold as tablets or capsules. Its effects start 30 to 90 minutes after ingestion,
and some of its physical effects are raised body temperature, sweating, increased
heart rate and blood pressure, dry mouth, sleeplessness and tremors. LSD's ability
of heightened perception makes some state that it allows for enlightenment about
the world. Besides heightening perception, LSD also causes hallucinations including
distorted perception of time and space, perceiving objects and people not present
and the belief that one contains skills they in reality don't have (e.g., ability to fly,
which is of course a dangerous belief). Feelings of anxiousness, fear or stress when
taking LSD can result in the exaggeration of these feelings, which then can result in
the user experiencing a bad trip. These bad trips can be started by extreme terror
and panic which can last the remaining trip. Vivid flashbacks to a trip are also known
to be experienced by regular users. LSD appears to produce its effects by affecting
serotonin in the visual and emotional brain areas.

LSD used to be more popular in the 60s and 70s, but since stimulants became a
more common recreational drug, prevalence rates have declined to 0.3 to 0.5%.

Although hallucinogens are not that addictive, some users report craving the drug
after they stopped using them. Because many hallucinogens last very long, users
often spend hours or days recovering from them. Especially MDMA is known for its
hangover the next two days after use.

MDMA is the working substance in the common drug ecstasy. Ecstasy has been a
very popular recreational drug for the last twenty years, especially in the club and
raving scenes. Its stimulating and hallucinogenic effects are produced by affecting
the release of the brain's dopamine and serotonin levels. Increased levels of
serotonin result in euphoria, sociability, well-being and enhanced perception of
sounds and colours. Effects start about twenty minutes after ingestion and last up to
six hours. High levels of dopamine, seen in regular users, can result in symptoms
like confusion and paranoia.

Average global use appears to be 0.2 to 0.6%, about the same for cocaine use.
Recent evidence show there might be a resurgence of Ecstasy in Europe and the US.
Individuals regularly taking Ecstasy usually spend many hours or days recovering
from it. The hangover includes insomnia, fatigue, headaches, drowsiness, depression
and sore jaw muscles from teeth clenching.

Inexperienced users can experience dehydration or water intoxication due to a lack

of knowledge about proper hydration. Users with prior cardiovascular problems can
be heavily affected by the drugs' increase in heart rate and blood pressure. Also,
ecstasy is a neurotoxin destroying axons where serotonin usually binds. This can
lead to long-term problems including memory deficits, sleep problems, lack of
concentration, verbal-learning deficits, and increased depression and anxiety.

What is the aetiology of Substance Use Disorders?

Many individuals using drugs do not end up with severe problems in their lives. What
differentiates these individuals from people developing a substance use disorder is
the kinds of risk factors they are exposed to, and how this affects them. Individuals
become dependent on a substance go through a series of stages. Each stage is
characterized by different risk factors influencing a possible transition to the next
stage. The three stages are experimentation (a period where an individual tries out
different drugs), regular use, and abuse & dependence, which all will be explained.
Other factors important in the development of a substance use disorder are
neurological and behavioral factors, of which examples are the neurocircuitry
associated with addiction and the conditioning of cues to cravings.

Which factors contribute to experimentation?

One of the factors predicting experimentation with drugs is whether or not the drug
is available to an individual. Two main causes for a substance availability are its cost
and whether it is legally available.
Whether a family member uses a substance or not predicts later use of an
individual, as with a person's problematic (or not) home situation. Negative
background factors predicting long-term substance use are substance use in one's
childhood home, severe poverty in one's childhood home, legal or marital problems
in the household, childhood abuse and neglect (especially sexual abuse), and
psychiatric problems in a person's household.

Peer pressure is often states as a reason for one to do something, yet actual
pressure to use a drug is not commonly seen, but social peer influence is a big
predictor for drug use. Adolescents might start using some substance so they can
self-categorize themselves to be a member of a specific group. Younger people
might want to identify more with a group and conform to the group, and adopting
behaviors seen in the group is thought to help this process. Not only can a social
group determine what substance a person might experiment with, substance use
also predicts which kind of people the person relates to. So, a regular drinker will be
more likely to hang out with other regular drinkers, and this group environment of
drinking will then again consolidate regular use.

Advertising and media exposure to substances also greatly influences young

adolescents’ chances of taking up a drug. Studies have shown that exposure to
tobacco advertisements encouraged children to start smoking, and banning these
advertisements produced a significant fall in the use of the substance in adolescents.

Which factors contribute to regular use?

A main reason for using drugs is that they alter one's mood in some kind of way.
Alcohol makes one relaxed and confident, nicotine is reported to make one calm and
relaxed, stimulants affect the brain reward pathways making one feel euphoric and
confident, and many other substances all have some pleasurable mood-altering
effect. Most of these substances all work on the same dopamine VTA-NAc pathway
in the limbic system, giving rise to a pleasurable effect. Alcohol's mood-altering
effect appears to be an arousal-dampening effect, which means that not only the
negative moods are reduced (which is often the reason why one uses alcohol), the
positive moods are also reduced. Other studies have indicated that individuals
intoxicated by alcohol have less cognitive resources available to interpret all on-
going information, so attention is narrowed to process fewer cues in one's
surrounding, and this process is known as alcohol myopia. Positive, lively situations
will therefore lead to more focus on positive affect, but negative and lone drinking
situations might lead to a bigger focus on negative emotions and thoughts. Drugs
themselves are also powerful reinforcers conditioning the positive effects of drugs to
a certain stimuli or cue which one associates with the drug. This leads to the user
craving the drug when exposed to stimuli they associate with the positive effects of
the drug, which leads to consuming more of the drug and higher rates of relapse.
but negative and lone drinking situations might lead to a bigger focus on negative
emotions and thoughts.

Individuals suffering from severe adjustment difficulties, seen in many psychiatric

disorders, can resort to drug use as a method of self-medication. Self medicating is
done in order to alleviate negative feelings with non-prescribed drugs, and self-
medication supports the view that many psychological disorders are highly comorbid
with substance use disorders. Self-medication is also frequently reported as the
reason why one uses a substance. Evidence showed that some disorders pre-date
substance use, but why users continue self-medicating despite their knowledge
about the negative long-term effects has been suggested to be due to the following
reasons: the intrinsic rewarding effects of the drug leads to physical dependence,
the users life is so negative that the positive effects of the drug outweigh the
negative effects, and a drug may not only reduce negative affect or pain, but can
also help in social situations. However, if self-medicating is truly the reason for drug
use, you would expect the drug preference to align with the disorder one suffers
from, so anxious people would use more calming substances like alcohol, but
evidence does not support this view.

The individual's expectations about a drug also significantly influence whether one
uses a drug and continues its use. Culturally generated beliefs like alcohol improving
sexual function (which is false) and alcohol increasing sociability is a predictor of
whether or not an adolescent will use alcohol and in which quantities. Also, the belief
whether or not a drug harms one can maintain regular use, as seen in smokers who
often state that it may cause cancer in others but not themselves.

Cultural factors also influence whether experimental use transitions into regular use,
and an example is whether or not it is socially normal to drink alcohol, which is the
case in many countries. Culturally determined beliefs about substances also
influence its use, like white Americans reporting less risks associated with drugs as
Hispanics or African Americans. This group of white Americans was then found to
use drugs significantly more.

Which factors contribute to abuse and dependence?

Normal use of drugs does not often lead to a dependence. Other factors like genetics
play a role in whether a person will end up abusing drugs. The heritability
component of substance uses disorders have been found to be around 0.46, and as
high as 0.78 for alcohol and nicotine dependence. MZ and DZ twin studies and
adoption studies both support the genetic role in substance dependence. One reason
for this genetic component is that environmental situations trigger substance use in
those who have a genetic predisposition. These environmental triggers are not
necessarily stressors, but also factors like peers using the substance or modelling
one’s parents. Another possibility is that genetic differences result in different
tolerance levels to drugs and different ways in how the brain responses to drugs.
This is seen in some people being easily intoxicated and others requiring many
drinks. A third reason for the genetic component in substance abuse is that some
genes affect the persons tolerance, as for example the gene ALDH2 responsible for
the speed of the breakdown of the toxic substance acetaldehyde (which results from
alcohol) into non-toxic acids. If metabolism is more slowly, one has a narrower
tolerance towards alcohol. This is supported by the fact that Asians often have a
mutant allele for ALDH2, resulting in a slower metabolism, and therefore alcohol use
disorder is twice as rare in Asians as in non-Asians.

Whether or not specific drugs have long-term cognitive effects is still not clear for
most of them. However, most substance abuse disorder sufferers are shown to have
an underachievement syndrome, which a lower IQ, lower educational achievement
and motivational deficits. It may be true that these qualities were already present
prior to drug use, and actually caused the person to use drugs. It is also possible
and sometimes shown in research that regular substance use causes intellectual and
motivational deficits, but this of course depends on the drug.

Substance users who suffer from comorbid psychiatric disorders often have more
trouble with avoiding substance abuse and dependence. This is thought to be for the
following reasons: individuals with comorbid psychiatric disorders often face more
problems and life stressors and are less likely to have good coping resources.
Therefore, these individuals resort to self-medication quicker and persons suffering
from comorbid psychiatric disorders tend not to consider drugs as problematic as
quickly as their peers, and relapse sooner.

An individual's chance of experiencing an illicit drug increase as one lives in or near

a poor neighbourhood. Lower socio-economic status is often characterized by higher
unemployment rates, less forms of recreation available, little hope of educational
achievement and exposure to drug cultures. These circumstances all contribute to
the use and abuse of drugs and maintaining possible drug dependence. Crime is also
more often seen in poor areas, and these crimes are often associated with drug use.

How can Substance Use Disorders be treated?

Treating a substance use disorder is often hard to do, since many factors need to be
accounted for. It is not only the dependence that should be challenged, but the
individual’s environment also plays a big role whether or not an intervention will be
successful. Factors like home situation, poverty and unemployment, if not
addressed, can make the individual relapse much quicker.

What are Community-Based Programs?

There are many community-based services for treating substance use disorders.
Alcoholics Anonymous (AA) is a well-known support group for individuals dependent
on alcohol. Its focus is to replace the individuals drinking group with a group that
they can relate to and that are also trying to quit drinking. Some studies have
shown that AA is an effective treatment for long-term results, but other studies did
show that it is not significantly better than other kinds of structured treatment.
Services known as drug-prevention schemes aim to prevent individuals using drugs
or to prevent experimental use turning into regular use. This is done by lecturing
communities and school, having websites available or 24/7 phone helplines. Specific
strategies of drug prevention schemes are peer pressure resistance training, helping
students resist drugs in situations when confronted with drugs, countering media
influence with campaigns and advertisements, peer leadership, which attempts to
have students transfer anti-drugs messages to peers, and changing false views that
students hold of drugs (eg alcohol is harmless). Residential rehabilitation centers are
centers allowing individuals to work, socialize and in general just live with others
who are also undergoing treatments. They also receive psychological interventions,
advice and support from professionals. Multiple studies have concluded that longer
stay results in significantly better outcomes.

What are Behavioural Therapies?

Aversion therapy is focused on changing the use of substances from a positive
experience to a negative experience. It is most used with alcohol dependence, and
classical conditioning principles are used when the individual (in this case) receive
alcohol, which is quickly followed by an aversive drug causing nausea and sickness.
Just thinking about negative events and pairing this thought with the thought of
substance use is also possible, and this is known as covert sensitization. Aversion
therapy has only limited evidence for its effectiveness, and especially in long-term
substance dependence aversion therapy seems to be limited in its effectiveness.
However, aversion therapy can still be combined with other treatments.

Helping the individual identify environmental cues and triggers leading to substance
use is known as contingency management therapy. It helps the individual identify
and avoid certain triggers, rewards them for abstinence, helps them become aware
of situations of substance use and its frequency, and setting non-abstinence goals
for the person to work on. There are multiple new variations developed as we speak,
and one variant of behavioral self-control therapy (BSCT) is controlled drinking.
Instead of helping with complete abstinence from alcohol, it puts emphasis on
controlled drinking. Its assumptions are that because alcohol use is so normal in
most western societies, it is very hard to avoid alcohol altogether. Another
assumption is that teaching one to control their drinking gives more self-esteem, a
sense of responsibility and feelings of control in other domains of their lives. Some
of these outcomes are often the reason why they started to drink first of all, so it
also treats the root cause of the substance abuse. Teaching clients to have true
control over their drinking and that relapses are normal and can be overcome has
been shown to be an effective treatment and at least as effective as total abstinence
treatments.

What are Cognitive Behavioural Therapies (CBTs)?

Substance use disorders are known for their difficulty to treat over the long-term.
Cognitive behavioral therapies are used to combat relapse and to deal with
substance use disorder when it is comorbid with other psychiatric disorders. Relapse
is often seen in up to 90% of individuals treated for their substance use. Preventing
relapse and teaching people that relapse can be fought is therefore an important
part of treatment. Two factors important in deciding whether or not a relapse will
result in regular use are the person's beliefs about relapsing, and the emotional
states that accompanied the relapse, like stress, anxiety, depression or frustration.
Addressing these two factors are done with variants of CBT that for example
challenge thoughts that one relapse is catastrophic and that they might as well get
drunk anyway (known as abstinence violation beliefs). Addressing the second factor
is done with cognitive behavioral therapies helping the client deal with negative
emotions and stress. These are known as motivational-enhancement intervention
(MET) and besides negative-mood management, they also provide communication
training, problem-solving skills, social support or other relapse prevention methods.

What is Family and Couples Therapy?

Including family and spouses in the treatment of substance use disorders can be
very helpful for several reasons. 1) many individuals abusing drugs are adolescents
and thus living at home, so family can give direct support to them, 2) often parents
of the client abuse drugs themselves, and so be part of the problem that needs to be
solved, and 3) individuals with a substance use disorder may physically, emotionally
or sexually abuse family members, so this also needs to be addressed. Family
therapies are often effective in altering dysfunctional family situations, and this form
of treatment is focused on including family members in a non-judgmental manner.
Couple and family therapies have shown to be at least as effective as individual
forms of CBT, and it is especially effective in adolescent substance use problems.

What biological treatments can be used?

The process of supervised systematic withdrawal from some substance is known as
detoxification. It is often accompanied with other drug use which helps the
detoxification process, which has the following functions: 1) reducing withdrawal
symptoms like drugs which reduce cravings, 2) preventing relapse with the use of
aversive drugs making relapse also aversive (see 'aversion therapy '), 3) blocking
the neural activity that would make a drug pleasurable, and 4) switching to a
weaker substance, which is done in methadone maintenance programs where users
take the less harmful methadone instead of more dangerous opiates like heroin.

Antabuse (disulfiram) is one of the drugs that makes alcohol intake a negative
experience by slowing bodily processes making the user nauseous or vomit. If
administered in a supervised manner, antabuse can be very effective in short-term
abstinence. Some drugs affecting endorphin receptor sites are naltrexone, naxolone
and buprenorphine. These drugs prevent opiates and opioids from having their
euphoric effect which has its origin at endorphin receptor sites. However, these
drugs must be carefully dosed and regulated, and their effectiveness is based on
however long the person is taking them. Some of these drugs appear to not only be
effective for opiates, but also for alcohol and cocaine dependency. This may be due
to the fact that endorphin receptors are intimately associated with our brain's
reward centres.

Drug replacement treatment is mostly done with opiate dependent individuals and
focuses on substituting a less severe drug for the more severe one. It is important
to realize that in the case of opiate drug replacement treatment, methadone is still a
very addictive substance and will often take long to withdraw from. Outcome studies
suggested that methadone maintenance treatment is the most effective when
accompanied with other forms of intervention like psychotherapy, drug education,
contingency management and skills training. Other positive outcomes of drug
replacement treatments are that they lower the crime that otherwise would result
from the users' need to support their dependence and reduce health risks (e.g., HIV
from infected needles). Drug maintenance therapies are mostly seen in opiate
dependency.
Ch10: What are eating disorders?

Eating disorders are complex and rooted in psychological, sociological and cultural
phenomena. Developmental and psychological processes can be vulnerability factors
in the development of eating disorders.

What is Anorexia Nervosa?

Anorexia nervosa (AN) is an eating disorder primarily characterized by a refusal to
maintain a minimal weight, a pathological fear of gaining weight, and a distorted
body image in which clients persist in the belief that they are overweight. Ten times
as many women as men have this disorder. The 12-month prevalence for women is
around 0.4%.

The DSM-5 criteria for anorexia nervosa are:

 A significantly reduced caloric intake than the body requires, leading to a

significantly underweight;
 Intense fear of gaining weight or getting fat;
 A disturbance in the way the patient views his own body, unnecessary
influence of weight or body shape on the self-evaluation.
 An objective way to measure the severity of symptoms is with the body
mass index (BMI). This can be used to measure whether an individual is
in a healthy weight class by including both the height and the weight of a
person.

The DSM-5 distinguishes between two different types of anorexia nervosa:

1. The restrictive type: in this type, self-starvation is not accompanied by,

for example, vomiting.
2. The purging type: in this type, the patient regulates his weight with the
help of purging: 'cleansing', for example by vomiting or using laxatives.

Anorexia is associated with various biological symptoms, due to its severe effect on
the body. These include:

 Fatigue, cardiac arrhythmias, hypotension, low blood pressure and slow

heart rate
 Dry skin and brittle hair
 Kidney problems and gastrointestinal problems
 Development of lanugo over the body
 Absence of menstrual cycles (amenorrhea)
 Hypothermia.

Anorexia has high comorbidity with other psychiatric disorders, such as depression,
OCD, and social anxiety disorder.

What is Bulimia Nervosa?

Bulimia nervosa (BN) is an eating disorder characterized by a fear of gaining weight
and impaired body perception in which there are recurrent episodes of binge eating
followed by periods of purging or fasting. The difference with the purging type of
anorexia is that bulimia patients are not overweight or underweight. About 90% of
bulimics are female. Life prevalence in women is between 1% and 3%.

The DSM-5 criteria for bulimia nervosa are:

 Repeated binge eating;

 Frequent inappropriate compensatory ways to avoid gaining weight, such
as vomiting, fasting or exercising excessively;
 Binge eating and compensatory behaviors occur on average at least once
a week for three months;
 Self-image is too much influenced by body shape and weight.
 The purging provides a liberating feeling after the unpleasant feeling that
an individual gets from the uncontrolled eating.
 Bulimia has high comorbidity with other psychiatric disorders, including
depression, SAD, and personality disorders.

What is Binge Eating Disorder (BED)?

Binge eating disorder (BED) is an eating disorder in which there are recurrent
episodes of binge eating that are not followed by periods of purging or fasting as in
bulimia. Therefore, patients are often overweight and often face failure in weight
loss efforts. The difference with bulimia is often difficult and depends on how often
the patient exhibits compensatory behavior. BED is also seen as a severe form of
bulimia. The lifetime prevalence of BED is around 3%, about one and a half times as
many women as men have the disorder.

The DSM-5 criteria for BED are:

 Repeated binge eating

 Binge eating is associated with at least three of the following: eating
faster than usual, eating until you are uncomfortably full, eating a lot
when you are not hungry, eating alone because you feel embarrassed
because of the amount and feel gross, depressed, or guilty after binge
eating
 Suffering from binge eating
 The binge eating is not associated with inappropriate compensatory
behaviors as seen in bulimia
 BED is associated with depression, impaired work-related and social
functioning, low self-esteem, and bodily dissatisfaction

What are cultural differences regarding Eating

Disorders?
Many studies suggest that cultural differences and changes are associated with
differences in vulnerability to developing eating disorders and thus may represent
risk factors. The emphasis placed on weight and body shape in Western cultures is
an important contributor to the development of eating disorders. Thus, bulimia
seems to arise only in individuals exposed to Western ideals.

White Latinas have thinner body ideals than black women. African American women
are also more satisfied with their body shape, so these women are more likely to
have bulimia than anorexia. Anorexia also occurs in parts of the world that are not
or little exposed to Western influences. Thus, the refusal of food does not seem to
be necessarily due to the presence of weight concerns and body dissatisfaction.

Which demographic factors play a role?

The fact that women are ten times more likely to have an eating disorder seems to
be due to the idealization of women's weight, size and body shape in the Western
media. This makes being thin an important social value. In addition, women are
more often defined by their bodies and men by what they have achieved. Eating
disorders are more common in gay men than in heterosexual men.

What is the aetiology of Eating Disorders?

Due to the complexity of eating disorders, it is known which factors are involved, but
not exactly how they influence the development of eating disorders. There are
several risk factors that will be discussed. Anorexia and bulimia often share the
same risk factors, but it is not known why an individual develops one disorder and
not the other.

What are genetic factors?

Eating disorders have a genetic component, first degree relatives of individuals with
anorexia and bulimia are more likely to have these disorders than relatives of people
not diagnosed with these disorders. Twin studies show that the genetic component is
about 40% to 60%.

Studies suggest that the genes that contribute to developing anorexia are different
from those for bulimia. This is because bulimia appears to be culture-bound, but
anorexia is not. It is therefore likely that there is a genetic component to self-
starvation in anorexia, but more research is needed.

What are neurobiological factors?

Animal studies show that lesions in the lateral hypothalamus can cause loss of
appetite, which can result in a self-starvation syndrome that is behaviourally similar
to anorexia. However, individuals with anorexia often feel hungry and hormonal
imbalances appear to be a result of the disorder rather than a cause of the disorder.

Self-starvation and maintenance of low body weight can be enhanced by

endogenous opioids that the body releases to reduce pain sensations. In addition,
low levels of serotonin metabolites (products left after breaking down serotonin) are
found in individuals with anorexia and bulimia. Serotonin makes you feel full, so
people with low levels of serotonin metabolites are prone to binge eating. Finally,
patients with anorexia and bulimia show a greater expression of the dopamine
transporter gene DAT. Dopamine transporter genes control the entry and exit of
drugs into cells. Due to the greater expression of the DAT gene, patients may be
more susceptible to the rewarding effects of eating.

What are the sociocultural influences?

Media influence is a term that describes changes in a person's attitudes, behavior
and morals that are directly influenced by the media. For example, body
dissatisfaction appears to be related to watching certain TV shows. Another
important factor is 'food and eating fashion'. The more low-calorie diets become the
trend, the greater the risk of developing eating disorders. In addition, obese people
are attributed all kinds of negative characteristics, which only increases the fear of
becoming fat.

Body dissatisfaction (BD) is the gap between one's real and ideal weight and body
shape. This dissatisfaction easily triggers bouts of dieting: a restricted eating
regimen followed for weight loss or medical reasons. BD and diets are important
vulnerability factors in developing eating disorders, but not enough. There are
enough people who think that their body deviates from the ideal body but are happy
with this. Also, many people who suffer from BD do not develop an eating disorder.

What is peer influence?

Peer influences is a term that describes changes in a person's attitudes, behavior
and morals that are directly influenced by peers. Eating and dieting habits can be
significantly influenced by close contact with peers. However, it is difficult to
determine whether these influences determine attitudes towards food and body
shape and have a significant influence on the development of eating disorders.

What is family influence?

Minuchin's family systems theory states that a patient is entrapped in a
dysfunctional family structure that increases the development of an eating disorder.
These families have one or more of the following characteristics:

 Enmeshment: Parents are pushy, overinvolved in their children's affairs,

and dismissive of their child's emotions and emotional needs
 Overprotection: here family members are too busy with the upbringing
and the well-being of others, the child can experience this as excessive
control by the parents
 Rigidity: there is a tendency to maintain the status quo in the family
 Lack of conflict resolution: families avoid conflict or are in constant
conflict
 Mothers of children with eating disorders are themselves more likely to
have dysfunctional eating patterns and psychiatric disorders. In addition,
these mothers are often critical of their daughters' appearance, weight
and attractiveness, compared to mothers who do not have children with
eating disorders.

The factors described together are called familial factors. However, it is not the case
that these factors are causal in nature, it is likely that other (for example, biological
or psychological) factors are required to ultimately trigger the development of an
eating disorder.

What are the experiential factors?

Negative experiences can be vulnerability factors for developing eating disorders. A
specific risk factor is childhood sexual abuse. Sexual abuse increases the risk of
anorexia and bulimia. However, it is difficult to determine how this influences the
development of eating disorders, as sexual abuse is also a risk factor for a variety of
other psychiatric disorders. It is possible that negative experiences can trigger other
forms of psychopathology that mediate the development of eating disorders. An
eating disorder can also be a way to deal with emotional and identity problems.
Finally, an eating disorder can allow a person to develop a coherent self-image by
focusing attention on a specific aspect of life.

What are the psychological and dispositional factors?

Several studies have identified personality traits characteristic of individuals with
eating disorders. These include:

 Perfectionism
 Shyness
 Neuroticism
 Low self-esteem
 High introspective awareness
 Negative or depressed affect
 Dependence and being unassertive.

Negative affect refers to the full spectrum of negative emotions. That this is a
characteristic of anorexia and bulimia patients is in line with the fact that mood
disorders are often comorbid with anorexia and bulimia. There is disagreement
about whether negative affect is a cause or effect of eating disorders. There is both
evidence that it is a consequence of the disorder and that it plays an active role in
generating symptoms such as body dissatisfaction.

Low self-esteem means that a person values himself negatively. Low self-esteem
predicts eating disorders in women and is therefore not just a consequence of it. In
addition, eating disorders such as anorexia are sometimes seen by researchers as a
way to combat low self-esteem by having control over a specific area of life: eating.

Perfectionism is setting incredibly high standards of performance, with excessive

self-criticism. Perfectionism can be self-oriented, where a person sets high standards
for themselves, and it can be others-oriented, where a person tries to live up to the
high standards set by others. Perfectionism can be adaptive, where a person tries to
achieve the best possible outcome, and it can be maladaptive, where a person tries
to achieve impossible goals. Perfectionism is strongly associated with body
dissatisfaction and the pursuit of being thin. In addition, it is also a characteristic of
many other psychological disorders.

What are the cognitive deficits?

Eating disorders can be conceived as involving either too much or too little control
over eating behaviour. This leads to the possibility that cognitive control of eating
behaviour may be impaired in some conditions. In the case of BED, many
associations have been found between uncontrolled binge eating, and deficits in the
cognitive processes that are required to control and regulate behaviour. For
example, individuals with BED perform worse on tests of executive functioning, show
ineffective inhibitory control of the prefrontal cortex, and demonstrate a negative
relation between working memory and body weight. Other cognitive deficits are:
  Deficits in emotional regulation
 Poor top-down regulation and inhibition of food cravings
 Impairments of working memory caused by increased levels of anxiety
and depression in obese individuals that worsen executive function
performance when control of eating is required.

What are Transdiagnostic Models of Eating

Disorders?
The transdiagnostic cognitive-behavioural model is a model of eating disorders that
posits that a dysfunctional system of self-evaluation is central to the maintenance of
eating disorders and that self-worth is defined in terms of control overeating,
weight, and shape, which in turn leads to a restricted diet. Other subordinate
mechanisms that maintain eating disorders in this model include low self-esteem,
clinical perfectionism, interpersonal problems, and mood intolerance.

How can Eating Disorders be treated?

Eating disorders are difficult to treat. There are several challenges involved:

 Patients often deny that they are ill or have a disorder. 90% of people
with diagnosable problems therefore do not receive treatment.
 Patients with severe eating disorders often require both medical and
psychological treatment. In the case of anorexia, hospitalization and
prevention of death by self-starvation are often necessary, among other
things.
 Eating disorders are often highly comorbid with other psychological
disorders, making treatment complex.

There are pharmacological treatments, family therapy, and CBT. Self-help groups
and alternative delivery systems are also used. Alternative delivery systems give
patients access to services that may not receive other forms of treatment. This
includes, for example, treatment and support via telephone therapy, email, the
internet, computer software, CDs and virtual reality techniques.

What pharmacological treatments are there?

Pharmacological treatments are drug-based treatments for psychopathology.
Because anorexia and bulimia patients are often also depressed, antidepressants are
often prescribed. The best results in bulimia have been achieved when
antidepressants were used in combination with CBT. Pharmacological treatments for
anorexia are much less successful than for bulimia. Pharmacological treatments
have a higher drop-out rate than psychological therapies and all sorts of side effects.

What is family therapy?

One of the most commonly used therapies for eating disorders is family therapy.
This comes from the previously discussed family systems theory, which states that a
patient is entrapped in a dysfunctional family structure that increases the
development of an eating disorder. With therapy, the dysfunctional characteristics
can be discussed and treated.
The Maudsley approach is a multi-stage family therapy for eating disorders. The first
phase focuses on how the family can help solve the problems they encounter, the
second phase helps the family to challenge the symptoms of the eating disorder, and
the third phase develops family relationships and activities as recovery takes place
found it.

What is Cognitive Behavioural Therapy (CBT)?

For bulimia, the most recommended therapy is CBT. CBT for bulimia is based on the
transdiagnostic cognitive model discussed earlier. There are three stages of CBT
needed to deal with bulimia symptoms and underlying dysfunctional cognitions:

 Meal planning and stimulus control

 Cognitive restructuring to discuss dysfunctional beliefs about weight and
shape
 Developing methods to prevent relapse

There is also an 'enhanced' form of CBT that can be used for all eating disorders.
This focuses on the motivation to change and helping to gain weight and discussing
psychological problems related to weight and shape.

CBT has been successful in treating bulimia for several symptoms. The advantages
here are that improvement can be seen immediately and that the therapeutic effect
of the treatment remains for at least five years after treatment.

What are Prevention Programs?

Prevention programs are treatment programs that try to prevent the onset of
psychopathology before the first symptoms are visible. Programs taught in schools
seek to:

 Teach vulnerable populations about eating disorders, their symptoms and

causes;
 Help individuals to reject media and peer pressure to be thin; and
 Identify risk factors for eating disorders, such as dieting, body
dissatisfaction, and so on.
Ch11: What are sexual problems?

How can pathological sexual problems be defined?

Because opinions are divided about what is and what is not acceptable behaviour, it
is difficult to define what is 'normal'. However, there are two factors that are
important in identifying psychopathology in sexual behavior and gender identity:

 A sexual activity or gender problem is suitable for treatment if it is

frequent, chronic, distressing to the individual and affecting interpersonal
relationships
 Some direct their sexual activity at individuals who do not participate in
the activity or cannot legally consent to it (e.g., paedophilia)

For the diagnostic criteria, it is not always necessary that only the individual with the
sexual problem experiences distress. Sometimes, it is hard to determine whether
sexual problems are psychopathological, or not.

What are sexual dysfunctions?

Since the 1960s and 1970s, there has been more openness about sex and sexual
activity. This opened up the opportunity to do more research into this.

There are four phases in the normal sexual cycle:

1. Desire
2. Arousal
3. Orgasm
4. Resolution

Sexual dysfunctions can occur in all these phases, except for the last phase, no
specific disorders have been described. There are the sexual pain disorders that can
occur at any stage.

How can sexual dysfunctions be diagnosed?

Sexual dysfunctions are problems in the normal sexual cycle that prevent an
individual from experiencing sexual pleasure. It is always important to include age in
the diagnosis. Sexual activity and performance often decline with age. Other factors
such as culture and religion should also be considered.

There are three disorders that occur in the first two stages of the sexual cycle: male
hypoactive sexual desire disorder, erectile dysfunction, and female sexual
interest/arousal disorder.

Male hypoactive sexual desire disorder is characterized by an absence or decreased

interest in sexual activity or erotic/sexual thoughts. Prevalence is about 6% among
young men and 41% among older men. DSM-5 criteria for this disorder are:
  Incessant or recurrent inadequate sexual/erotic thoughts or desires for
sexual activity for at least six months, causing distress to the patient;
and
 The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition.

Erectile dysfunction is characterized by an inability to maintain an erection during

sexual activity. About 10% of men report erection problems and this increases to
20% in men over 50 years old. DSM-5 criteria for this disorder are:

 At least one of the following occurs in 75% of sexual activity for at least
six months, causing patient distress: difficulty getting an erection during
sexual activity, difficulty maintaining an erection to the end of sexual
activity, and reduction in the stiffness of the erection.
 The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition.

The female sexual interest/arousal disorder is characterized by a combination of

decreased sexual interest and lower arousal. DSM-5 criteria for this disorder are:

 Decrease or lack of interest in sexual arousal/openness, where at least

three of the following are present for a period of at least six months,
causing distress to the patient:
 Lack of or decreased interest in sexual activity
 Lack of or decreased interest in sexual/erotic thoughts or fantasies
 None or decreased initiation of sexual activity and no responsiveness of
the partners to attempted sexual activity
 None or decreased arousal or pleasure during sexual activity for at
least 75% of the time
 A lack of or diminished sexual interest in response to all internal and
external sexual cues
 A lack of or diminished genital or non-genital sensations during sexual
activity at least 75% of the time
 The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition

There are three disorders that occur during the orgasm phase: female orgasmic
disorder, delayed ejaculation and premature ejaculation.

What is Female Orgasmic Disorder?

Female Orgasmic Disorder is one of the most common disorders treated. Depending
on various factors, the prevalence is between 10% and 42%. DSM-5 criteria for this
disorder are:

 Delay, infrequency, or absence of orgasms or decreased intensity of

orgasm in at least 75% of sexual activity for a period of at least six
months, causing distress to the patient
  The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition

What is delayed ejaculation?

Delayed ejaculation is the permanent or recurrent delay in ejaculation following a
normal sexual arousal phase. This occurs in less than 1% of men. DSM-5 criteria for
this disorder are:

 Delay, infrequency, or absence of ejaculation in at least 75% of sexual

activity for a period of at least six months, causing distress to the patient
 The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition.

What is premature ejaculation?

Premature ejaculation is having an orgasm with minimal sexual stimulation. This
occurs in about 1% of men. DSM-5 criteria for this disorder are:

 Continuous or recurrent patterns of ejaculation at approximately one

minute of vaginal penetration and before the patient desires it during at
least 75% of sexual activity for at least six months
 The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition

Pain can occur at all stages of the sexual cycle. A new diagnostic category has been
created for this in the DSM-5: genito-pelvic pain/penetration disorder. The criteria
for this are:

Persistent or recurrent problems with at least one of the following for at least six
months:

 Sexual vaginal penetration

 Vulvovaginal pain or pelvic pain during or prior to vaginal penetration
 Distress due to vulvovaginal pain or pelvic pain during or prior to vaginal
penetration
 Contraction or tightening of the pelvic floor muscles during vaginal
penetration
 The sexual dysfunction is not better explained by non-sexual mental
disorders or relationship problems or other stressors and is not due to the
effects of medication/substances or any other medical condition.

What are the risk factors for sexual dysfunctions?

Menopause is an important risk factor for female sexual interest/arousal disorder.
Aging, depression, smoking and medical conditions such as diabetes and
cardiovascular and genitourinary disorders are risk factors for dysfunction in men.
Education also has an influence: men who are more educated are more likely to
have early ejaculation and less educated men are more likely to have erectile
dysfunction. Childhood abuse is also a risk factor for sexual dysfunction. Finally,
sexual dysfunction is more common in women than in men (43% versus 31%).

What is the aetiology of sexual dysfunctions?

From the psychoanalytic point of view, vaginismus is seen as women expressing
hostility towards the man and, in premature ejaculation, when men express hostility
towards the woman. Vaginismus is the involuntary contraction of the muscles
around the vagina during vaginal penetration. Of all people seeking treatment for
sexual dysfunction, 15%-17% suffer from vaginismus.

Masters and Johnson's two-factor model has two major components that contribute
to sexual dysfunction:

1. A learned or conditioned factor in which negative early events produce a

learned fear response to sexual activity, such as psychosexual trauma,
religious and social taboos, shameful early experiences of sex, or
excessive alcohol consumption (in men); and
2. The spectator role that individuals take in response to their fears.

However, it is not yet entirely clear how these two components interact. Although
people with sexual dysfunctions are known to suffer from performance anxiety, it is
not known whether this is a cause or consequence of the dysfunction. Performance
anxiety is the fear a person has that he will not be able to achieve an acceptable
level of sexual performance, causing a person to distance himself from it and not be
able to get aroused.

Interpersonal problems can also be the cause of sexual dysfunctions. If negative

emotions are central to a relationship, other emotions such as fear, and mistrust will
interfere with the development of positive feelings required in the desire and arousal
phase of the sexual cycle. It is also possible that one of the partners or both
partners have little or no knowledge and experience. It is difficult to say whether
these problems are really the cause of the dysfunctions, but it is true that couples
therapy is often successful.

Sexual experiences are satisfying if the individual is open to experiencing positive

emotions during the sexual activity. Negative emotions interfere with sexual
performance and depression and anxiety are risk factors for sexual dysfunction.

One view of the causes of sexual dysfunction is that it is due to a combination of

direct and indirect factors. Direct factors directly affect sexual functioning, such as
performance anxiety and communication problems between partners. However,
these direct problems can arise from indirect (remote) factors, such as feelings of
shame and guilt about sexual activity, feelings of inadequacy, feelings of conflict
caused by lifelong stress, and so on.

There are also biological factors that can be of influence on sexual dysfunction,
namely:
 1. Dysfunction caused by an underlying medical condition, such as
dyspareunia: genital pain that may come before, during, or after sexual
intercourse
2. Dysfunction caused by abnormalities in sex hormones, such as
testosterone (steroid hormone that stimulates the development of male
secondary sex characteristics), oestrogen (steroid hormone that
stimulates the development and maintenance of female secondary sex
characteristics), and prolactin (pituitary hormone that stimulates milk
production after the birth of a child)
3. Changes in sexual receptivity with aging

Finally, there are socio-cultural factors that can cause sexual dysfunction. Cultures
often have 'rules' about sexual behaviour. These rules can cause conflict and sexual
dysfunction. For example, poverty, financial problems and unemployment are linked
to erectile dysfunction in men and in some cultures, society asks women to suppress
their sexuality.

How can sexual dysfunctions be treated?

There are two specific techniques to help clients with premature ejaculation. The
first is the stop-start technique, in which the partner stimulates the penis until the
client signals to climax and tells the partner to stop. The second is the squeeze
technique, where the client's partner squeezes the tip of the penis hard just before
ejaculation.

The tease technique is a method intended to remedy erectile dysfunction or

orgasmic disorders. Here, the partner caresses the client's genitals, but stops when
the client becomes aroused or close to orgasm. In this way, it is taught to
experience sexual pleasure without having to achieve an orgasm. For people with
arousal or orgasm problems, targeted masturbation training is often helpful, using
videos, diagrams and sometimes erotic material to teach how to achieve an orgasm.

Couples therapy is a treatment for sexual dysfunction that involves both partners
and discusses issues. Sex skills and communication training is a treatment method
in which a therapist can help clients gain a more expert perspective on sexual
activity and where the therapist effectively communicates about sex with partners
and reduces fear of giving in to sexual activity. Self-instructional training is also
used to teach the client to use positive self-instruction at various times during sexual
activity in order to guide their behavior and reduce anxiety. In addition, appropriate
guidance is necessary, because sexual dysfunction often underlies negative events.
Talking about this can help relieve the symptoms.

What are the biological treatments?

The most well-known drug treatments for sexual dysfunctions are the PDE-5
inhibitors Viagra and Cialis, both used to treat erectile dysfunction. These drugs
relax the smooth muscle in the penis which improves blood flow and promotes
erection.

Yohimbine is also used to treat erectile dysfunction by facilitating the excretion of

noradrenaline in the brain. This seems to solve brain neurotransmitter problems that
cause erectile dysfunction. SSRIs are used for premature ejaculation. Hormone
replacement therapy is used if there are low oestrogen levels in women or low
testosterone levels in men.

Mechanical devices have also been developed to help with erectile dysfunction. A
penile prosthesis is an example of this. This consists of a fluid pump that is placed in
the scrotum and a semi-rigid rod that is placed in the penis. Squeezing the pump
releases fluid into the rod, making the penis erect. An alternative to this is the
vacuum erection device (VED). This is a hollow cylinder that is placed over the
penis. The client removes the air from the cylinder using a hand pump, which draws
blood into the penis, causing an erection.

What are paraphilic disorders?

Paraphilic disorders represent sexual needs and fantasies involving unusual sources
of gratification. Some paraphilias involve the person's own activities and some
involve erotic targets. It is difficult to draw a line between what is normal and
abnormal. Most people do not want to act on their fantasies and are happy to limit
their sexual interest in paraphilic activities to watching erotic or pornographic
material. In addition, behaviour is only labelled as abnormal if a person's sexual
tendencies are linked to a specific type of stimulus or behavior.

What is a Fetish Disorder?

A fetish disorder is described in the DSM-5 by the following criteria:

 Recurrent and strong sexual arousal over a six-month period through the
use of inanimate objects or a strong specific focus on non-genital body
parts in fantasies, needs, or behaviors. This causes distress or
impairment in social, occupational, and other areas;
 The fetish is not limited to dressing as in cross-dressing or to objects
such as vibrators and other genital stimulators.
 Fetishes are often limited to items associated with sex, such as bras or
feet. Some show the phenomenon of partialism, where there is a
fascination with a specific object or part of the body to the point that
normal sexual activity is no longer involved.

What is a transvestite disorder?

Cross-dressing disorder is described in the DSM-5 as experiencing persistent strong
sexual arousal from dressing as the opposite sex as part of fantasies, needs, or
behaviors for at least six months. This causes distress or impairment in social,
occupational, and other areas. About 2.8% of men and 0.4% of women report a
cross-dressing episode in their lifetime.

What is Exhibitionism?
Exhibitionism means that a person has sexual fantasies about showing the genitals
to a stranger. The disorder occurs in approximately 2% to 4% of men. The DSM-5
criteria for this disorder are:

 Sustained strong sexual arousal by exposing the genitals to an

unsuspecting public for at least six months as part of fantasies, needs, or
behaviors;
 The patient has acted according to these needs in non-consenting
individuals or the needs cause distress or impairment in social,
occupational, and other areas.
What is Voyeurism?

Voyeurism is described in the DSM-5 with the following criteria:

 Sustained strong sexual arousal from observing an unsuspecting person

naked, undressing, or engaging in sexual activity for at least six months
as part of fantasies, needs, or behaviours
 The patient has acted according to these needs in non-consenting
individuals or the needs cause distress or impairment in social,
occupational, and other areas
 The patient is at least 18 years old

The lifetime prevalence of voyeuristic activities is approximately 12% in males and

4% in females.

What is frotteurism?
Frotteurism is described in the DSM-5 with the following criteria:

 Sustained strong sexual arousal from touching or rubbing against an

unauthorized person for at least six months as part of fantasies, needs,
or behaviors;
 The patient has acted according to these needs in non-consenting
individuals or the needs cause distress or impairment in social,
occupational, and other areas.

About 10% to 14% of men seen for paraphilic disorders meet these criteria.

What is Pedophilia?
Pedophilia is the sexual attraction to children normally 13 years or younger. The
DSM-5 criteria for this disorder are:

 Sustained strong sexual arousal from fantasies, needs, and behaviors

that include sexual activity with children 13 years of age or younger
 The patient has acted according to these needs in non-consenting
individuals or the needs cause distress or impairment in social,
occupational, and other areas
 The patient is at least 16 years old and at least 5 years older than the
child involved
 The patient is not in late adolescence in a sexual relationship with a 12-
or 13-year-old child.

The highest probable prevalence of pedophilia in men is between 3% and 5%. Often,
pedophiles do not feel that what they are doing is wrong.

There are several unofficial subtypes of pedophilia. First, some pedophiles limit
themselves to immediate family. Incest differs from other forms of pedophilia in that
it concerns older, (almost) adult children and that it is often accompanied by a
normal heterosexual sex life. Pedophiles who do not engage in incest, but are
aroused by sexually immature children, are also referred to as preference molesters.
Second, pedophiles never actually intend to hurt their victims. Child rapists are
pedophiles who do hurt and sometimes even kill their victims and only get sexual
satisfaction through this. Most pedophiles proceed in a standard way, which involves
going through several steps: (1) choosing an open,
In the US, 12% of men and 17% of women have been sexually touched as children.
Many victims experience long-term psychological problems because of this.

What is Sexual Masochism and Sexual Sadism?

In a sexual masochism disorder, an individual becomes sexually aroused by
humiliation. The DSM-5 criteria for this disorder are:

 Sustained strong sexual arousal from being humiliated, tied up or beaten

or from suffering for at least six months as part of fantasies, needs or
behaviours
 The needs cause distress or impairment in social, occupational, and other
areas

In a sexual sadism disorder, an individual becomes aroused by the suffering of

others. The DSM-5 criteria for this disorder are:

 Sustained strong sexual arousal from the physical or psychological

suffering of others for at least six months as part of fantasies, needs, or
behaviors;
 The patient has acted according to these needs in non-consenting
individuals or the needs cause distress or impairment in social,
occupational, and other areas.

Often masochism and sadism go together because one person likes to be hurt and
the other likes to see another person suffer. Masochists often cause their own
suffering, as in hypoxyphilia, where an individual uses a noose or plastic bag to
induce oxygen deprivation during masturbation.

About 5% to 10% of people are involved in sadomasochistic activities at some point

in their lives.

What is the aetiology of paraphilic disorders?

First, being a man is a risk factor. For example, there are 20 times as many male
masochists as there are female ones. In addition, a link has been found between
being heavily involved in sexual activities (hypersexuality) and paraphilias, such as
exhibitionism, voyeurism, masochism and sadism.

Much research has been done on the risk factors for pedophilia. Both remote factors
(including childhood sexual abuse) and direct factors (including depression) can play
a role in this. Psychopathology can be a contributing factor in triggering pedophile
behavior.

What is the psychodynamic perspective on paraphilias?

In this view, paraphilias are seen as either defense mechanisms to protect the ego
from repressed fears, or fixation on a pregenital stage in development. For example,
fetish and pedophilia can be seen as behaviors of individuals who find normal sex
too frightening, perhaps because of castration anxiety (a psychological complex in
which a man fears being castrated), and voyeurism as a behavior that protects
against having to deal with a relationship, which is often part of a sexual life.
How does classical conditioning explain paraphilias?
A simple explanation for paraphilias is that unusual sexual desires result from early
sexual experiences associated with an unusual stimulus or behavior through
associative learning.

How do abuse and neglect play a role in

paraphilias?
Childhood abuse and neglect are important predictors of developing psychological
problems and paraphilias later in life. This can cause, among other things, low self-
esteem and an inability to form lasting relationships, which in turn can lead an
individual to seek sexual satisfaction in ways that do not require a normal sexual
relationship or involve children who are still underdeveloped so that the individual is
not at a disadvantage. However, not all individuals with paraphilias have
experienced abuse and neglect, so it is not a requirement.

How do dysfunctional beliefs, attitudes, and

schemas play a role in paraphilias?
Cognitive biases are beliefs that sexual offenders have that allow them to justify
their sexual transgressions. For example, pedophiles believe that children want sex
with adults, making their behavior socially acceptable and not harmful to the child.
Sex offenders or rapists often have developed integrated cognitive schemas that
guide their interactions with their victims and justify their behavior, known as
implicit theories. Five types can be distinguished, including the views that:

1. Women are unknowable

2. Women are sex objects
3. The male sex drive is uncontrollable
4. Men are naturally dominant over women
5. The world is a dangerous place.

What biological theories are there regarding

paraphilias?
Because the majority of individuals with paraphilias are male, paraphilias are
believed to be caused by abnormalities in male sex hormones or by imbalances in
brain neurotransmitters responsible for regulating sexual behavior. For example,
androgen is the main male sex hormone. Unusual sexual behavior, such as
committing impulsive sexual transgressions, may be due to imbalances in this
hormone.

There are also some brain regions that show abnormalities, such as in sadism,
exhibitionism, and paedophilia in the temporal lobe.

⇧
How can paraphilic disorders be treated?
Treatment is complicated by the fact that criminal behavior is often involved, so that
there is not always fairness, that clients often enjoy their behavior and by cognitive
biases. Most treatments use a multifaceted approach.

What behavioral techniques are there?

Aversion therapy can be used to break the positive association between
inappropriate stimuli and sexual arousal. This form of therapy can be used in a
covert conditioning form, where the client's imagination is used to associate sexual
stimuli with negative outcomes.

Masturbation saturation is a treatment where the client is asked to masturbate in

the presence of arousing stimuli. Right after he cums, he should start masturbating
again. This will lead to a decrease in the erotic value of the first arousing stimuli.
Orgasm redirection is a treatment that replaces inappropriate or distressing sexual
activity with arousal from more usual stimuli.

What cognitive treatments are there?

Cognitive treatments aim to help the client identify and challenge dysfunctional
beliefs, often in the form of CBT. The Sex Offender Treatment Program uses CBT
methods to treat incarcerated sexual offenders. Risk factors such as sexual
preoccupation, sexual preferences for children and a lack of emotional intimacy with
adults are mentioned.

What does relapse prevention training entail?

Relapse prevention training helps clients identify conditions, situations, moods, and
types of thoughts that may trigger paraphilic behaviors.

What hormone and drug treatments are there?

Antiandrogenic drugs are used to reduce levels of sex hormones and thus decrease
sexual desire. Medroxyprogesterone acetate and cyproterone acetate are examples
of this, these drugs specifically lower testosterone levels.
Ch12: What are personality disorders?

What is the categorical approach to Personality

Disorders in DSM-IV-TR and DSM-5?
A personality disorder (PD) is a disorder characterized by persistent, inflexible,
maladaptive thought patterns and behaviors that develop in adolescence or early
adulthood and significantly impair functioning.

The DSM-IV-TR organized personality disorders into three categories: (1)

Odd/Eccentric Personality Disorders, (2) Dramatic/Emotional Personality Disorders,
and (3) Fearful/Anxious Personality Disorders.

What problems are there with the categorical approach?

There is evidence for a dimensional approach to personality disorders. Everyone
experiences certain characteristics associated with personality disorders, such as
mood swings. Therefore, personality disorders can be called extreme forms of
personality dimensions rather than disorders. There is a lot of overlap, certain
characteristics are reflected in several personality disorders. A number of personality
disorders are rare, and it is therefore not helpful to describe them as an independent
category. Lastly, personality disorders are often not very stable over time. This also
suggests that a dimensional approach is more appropriate.

What is the DSM-5’s Alternative Model?

The alternative diagnostic model contains three discrete types of personality ratings:

1. Level of Personality Functioning: Disturbances in self and interpersonal

functioning are at the core of personality disorders, with the severity of
the impairment giving an indication of whether the individual has more
than one personality disorder;
2. Personality Trait Domains and Facets: Five personality trait domains are
specified: negative affectivity, detachment, antagonism, disinhibition, and
psychoticism on which a patient is scored; and
3. Personality Disorder Types: Diagnosis is based on the previous two steps:
Antisocial PS, Avoidant PD, Borderline PD, Narcissistic PD, Obsessive
Compulsive PD, and Schizotypal PD.

What are personality disorders and how are these

diagnosed?
The DSM-5 criteria for personality disorders in general are:

 A persistent, rigid pattern of thoughts and behavior that differs

significantly from the expectations of the culture in which the person
 lives, manifested in at least two of the following areas: cognition,
affectivity, interpersonal functioning, and impulse control.
 The pattern is constant and long-lasting and can be traced back to
adolescence or childhood;
 The pattern leads to distress or limitations in social, work-related or other
areas of life; and
 The symptoms are not better explained by other mental disorders or due
to the effects of a substance or other medical condition.

What are Odd/Eccentric Personality Disorders

(Cluster A)?
The eccentric personality disorder cluster contains three subtypes:

1. Paranoid PD
2. Schizoid PD
3. Schizotypal PD

What is Paranoid Personality Disorder?

A paranoid PD is characterized by a persistent pattern of suspicion and mistrust of
others. Innocent comments are interpreted as threatening and the intentions of
others as malicious. The DSM-5 criteria for this PS are:

A general distrust of others insofar as their motives are perceived as malicious,

indicated by at least four of the following:

 Suspicions that others are abusing, hurting, or deceiving him/her

 Fixation on unwarranted doubts about reliability from friends
 Unwilling to trust others, due to a fear that the information could be used
against him/her
 Sees hidden threats in non-threatening words or events
 Carries lasting grudges
 Sees attacks on his/her character or status that others do not see and
quickly reacts angrily
 Has persistent suspicions about the fidelity of the sexual partner
 The symptoms are not only present during a psychotic disorder

What is Schizoid Personality Disorder?

Individuals with schizoid PD are often described as 'loners' who do not express a
normal range of emotions and experience little reward from activities. The DSM-5
criteria for this PD are:

A persistent pattern of separation from social relationships and a limited range of

emotion expression in relational situations, indicated by at least four of the
following:

 Dislikes or does not want close relationships,

 Prefers solitary activities
 Has little or no pleasure in sexual experiences with another
 Takes no pleasure in activities
 Has no close friends or confidants other than immediate family
  Insensitive to praise or criticism from others
 Emotional coolness, detachment, or flat expression
 The symptoms are not only present during another psychotic disorder.

What is a Schizotypal Personality Disorder?

A schizotypal PD is characterized by eccentric behavior, manifested in odd thinking
and communication patterns. The DSM-5 criteria for this PD are:

An enduring pattern of social and relationship deficits, evidenced by difficulty with

and diminished ability to form close relationships, and disturbances and
idiosyncrasies in behavior, manifested in at least five of the following:

 Beliefs or perceptions that are irrelevant or insignificant

 Strange beliefs that influence behavior that do not fit the subcultural
norms
 Strange perceptions of what is happening around the person
 Vague thoughts and words
 Suspicious or paranoid ideas
 Inappropriate or limited emotion expression,
 Eccentric behaviour or appearance
 Has no close friends or confidants other than immediate family
 High social anxiety despite familiarity
 This pattern is not part of schizophrenia or any other psychotic disorder

A problem with this PD is that it has high comorbidity with the other personality
disorders, mainly paranoid PD and avoidant PD. In addition, there is evidence that
schizotypal PD is strongly related to schizophrenia and is also a risk factor for it.

What are Dramatic/Emotional Personality

Disorders (Cluster B)?
The dramatic/emotional personality disorder cluster contains four subtypes:

1. Antisocial PD
2. Borderline PD
3. Narcissistic PD
4. Histrionic PD

Many personality disorders are characterized by impulsivity. The DSM-5 describes a

number of impulse-based problems separately:

 Intermittent Explosive Disorder: This involves episodes of inability to

control aggressive impulses, often resulting in criminal offenses.
 Kleptomania: Inability to control impulses to steal objects.
 Pyromania: There are recurring patterns of arson for pleasure,
satisfaction or relaxation.

What is Antisocial Personality Disorder?

An antisocial PD is characterized by impulsive behavior and lack of remorse and is
strongly linked to criminal behavior. The terms sociopath and psychopath are also
used to describe this disorder. The DSM-5 criteria for this PD are:
A pattern of indifference to and violation of the rights of others manifested in at
least three of the following since age 15:

 Failure to conform to social norms and frequent illegal behavior

 Lying, impersonating or deceiving others for personal gain
 Inability to plan ahead or impulsiveness
 Irritability and aggression leading to physical fights
 Indifference to the safety of self and others
 Consistent irresponsible behaviour
 Lack of remorse
 The person is at least 18 years old
 The antisocial behavior is not associated with symptoms of schizophrenia
or mania

Research from 1998 suggests that ADHD is a risk factor for developing antisocial PD.
However, more recent research shows that there is only a weak link between ADHD
and antisocial personality disorders.

Antisocial personality disorders are strongly associated with criminal and antisocial
behavior. Predictors of criminal and antisocial behavior are: conduct disorder,
persistent aggressive behavior before age 11, fighting and hyperactivity, low IQ and
low self-esteem, persistent lying, running away from home, vandalism, truancy,
unstable family life, school failure, smoking/alcohol use /drug use/problems with the
police/sex before the age of 15, having a parent with an antisocial PD and having a
background of violence, poverty and conflict in the family.

What is Borderline Personality Disorder?

Borderline PD is described in the DSM-5 as the long-term instability of relationships,
self-esteem, and behaviors with high impulsiveness beginning in early adulthood,
manifested in at least five of the following:

 Desperate efforts to avoid real or imagined abandonment

 A pattern of unstable and intense interpersonal relationships, fluctuating
between praise and depreciation
 Constantly unstable self-image and identity distortion
 Potential impulsivity to self-harm in at least two areas, such as sex,
substance abuse, or reckless driving
 Recurrent suicidal behaviour or self-mutilation
 Emotional instability due to mood reactivity
 Inappropriate, intense fear or difficulty controlling anger
 Stress-related paranoid idealization or severe dissociative symptoms

What is Narcissistic Personality Disorder?

Narcissistic PD is described in the DSM-5 as a persistent pattern of grandiosity, need
for admiration, lack of empathy, beginning in early adulthood, manifested in at least
five of the following:

 A great, exaggerated sense of self-importance and self-development

 Preoccupation with illusions of unlimited success, power, beauty, or ideal
love
 Believe that he/she is special and can only be understood by people of
equal 'specialness'
 demands excessive admiration
  Has unreasonable expectations of beneficial treatment
 Exploit others for personal gain
 Lacks compassion and can't identify the needs and feelings of others
 Often jealous of others and believes others are jealous of him/her
 Is conceited and shows self-righteous behavior and attitudes

What is Histrionic Personality Disorder?

A histrionic PS is characterized by seeking attention and feeling uncomfortable or
unhappy when an individual is not the centre of attention. The DSM-5 describes this
PS as a continuous pattern of high emotionality, attention seeking, beginning in
early adulthood, manifested in at least five of the following:

 Feeling unhappy in situations where he/she is not the centre of attention

 Excessive, sexually suggestive or provocative behavior in interactions
with others
 Show rapid swings and superficial expressions of emotions
 Often uses personal appearance to draw attention to self
 Has an excessively impressionistic and devoid of detail manner of
speaking
 Is self-dramatic, very theatrical and uses exaggerated emotion
expression
 Is easily influenced by others
 Feels relationships as much more intimate than they really are

What are Anxious/Fearful Personality Disorders

(Cluster C)?
The anxious personality disorder cluster contains three subtypes:

1. Avoidant PD
2. Dependent PD
3. Obsessive Compulsive PD

What is an avoidant personality disorder?

Avoidant PS is described by the DSM-5 as a persistent pattern of social restraint,
feelings of inadequacy, and hypersensitivity to criticism, beginning in early
adulthood, manifested in at least four of the following:

 Avoiding activities that involve a lot of interpersonal contact because of

fear of criticism or rejection
 Not wanting to approach others unless there is assurance of approval and
being liked
 Restraint in intimate relationships because of fear of ridicule or
embarrassment
 Fixation on disapproval or rejection in social situations
 Inhibition in new relationships due to feelings of inadequacy
 Feeling socially incompetent, unattractive or less than others
 Strongly reluctant to participate in new activities because of possible
embarrassment
Some clinicians believe that avoidant PD and social anxiety disorder can be grouped
together in a broader social anxiety spectrum.

What is Dependent Personality Disorder?

Dependent PD is described in the DSM-5 as an unavoidable and extreme need to be
cared for, leading to submissive and clingy behaviors and separation anxiety
beginning in early adulthood, manifested in at least five of the following:

 Inability to make everyday decisions without unnecessarily high levels of

advice and validation from others;
 Needing others to take on most of the responsibilities of daily life;
 Difficulty expressing disagreement with someone for fear of losing
support;
 Difficulty doing or initiating things yourself;
 Feeling uncomfortable or scared when left alone because of a fear of not
being able to take care of themselves;
 Urgently seeking a new supportive relationship when the previous one
ends;
 Being unrealistically obsessed with fear of being left alone to fend for
oneself.

What is Obsessive Compulsive Personality Disorder?

Obsessive Compulsive PS is described in the DSM-5 as a persistent pattern of
preoccupation with orderliness, perfection, and mental and interpersonal control, at
the expense of flexibility, openness, and efficiency, beginning in early adulthood,
seen in at least four of the following things:

 An obsession with details, rules, lists, organization, or schedules that

loses the core of the activity
 Perfectionism that interferes with task completion
 Excessive dedication to work up to self-prohibition from social and
recreational activities
 Inflexibility in morals, ethics and values
 Inability to throw away worn-out or worthless objects despite having no
emotional value
 Reluctant to pass things on to others unless they want to do it exactly as
he/she asks
 Hoards money and is reluctant to use it
 Is rigid and stubborn.

What is the prevalence of personality disorders?

There is uncertainty about the actual prevalence of personality disorders, due to
issues with (1) the reliability of diagnosis, (2) potential gender bias in the diagnosis
of certain disorders and (3) the weak temporal stability of personality disorders.
Data from various studies show that the prevalence in the general population is
between 10% and 14%.

There are several risk factors for developing a PD, including being part of a low
socioeconomic class, living in the inner city, being a young adult, and being
divorced, widowed, or never married. In addition, being physically, verbally or
sexually abused in childhood is a risk factor for developing a PD, especially
borderline PD.

What is the aetiology of personality disorders?

What psychodynamic approaches are there?
It is reasoned that causes of paranoid and schizoid personality disorders lie in the
relationship with the parents. In a paranoid PD, the parents would be demanding,
distant, rigid, and dismissive. In a schizoid PD, parents would have rejected or even
abused the child, as a result of which the child cannot give or receive love.

How are cluster A disorders related to schizophrenia?

There is evidence that cluster A personality disorders are strongly related to
schizophrenia and together form a schizophrenia spectrum disorder. For example, a
genetic link has been discovered between cluster A disorders and schizophrenia. In
addition, the brain abnormalities and physiological abnormalities in cluster A
disorders are very similar to those found in schizophrenia. Limitations in cognitive
and executive functioning are also comparable in cluster A disorders and
schizophrenia.

What is the aetiology of Odd/Eccentric Personality Disorders

(Cluster A)?
One of the best predictors of antisocial PD is a diagnosis of childhood conduct
disorder. More specifically, there are three pathways that predict antisocial PD:

1. An overtly aggressive path that progresses from bullying to fighting to

serious violence;
2. A hidden aggressive path that progresses from lying and stealing to
serious property damage;
3. An authority conflict path that develops through varying degrees of
oppositional and defiant behavior.

There are several developmental factors that contribute to having an antisocial PD.
It seems that modeling and imitation lead to the learning of antisocial behavior.
Psychodynamic approaches argue that the absence of parental love in childhood
creates an inability in the child to trust others. Twin and adoption studies indicate
that genetic factors influence the development of and antisocial PD. The heritability
is between 40% and 69%. However, these studies also show that environmental
factors play an important role.

Cognitive models postulate that individuals with antisocial personality disorders have
developed dysfunctional schemas, which are dysfunctional beliefs that perpetuate
problematic behaviors. An example of such a schema is the "abandoned and abused
child" mode, in which the child develops feelings of pain, fear of abandonment, and
inferiority, among other things.

Finally, there are physiological and neurological factors to mention. First, individuals
with antisocial personality disorders show a reduced anxiety response. Second, they
respond to emotional or distressing stimuli with slower autonomic arousal,
suggesting they can ignore threatening stimuli more easily than most people. Third,
often no fear response can be learned in aversive conditioning. In addition, there is
reduced prefrontal brain function.

What is the aetiology of Dramatic/Emotional Personality Disorders

(Cluster B)?
There are several risk factors for developing a borderline PS. Most relate to
childhood difficulties, especially problematic parenting, such as physical verbal and
sexual abuse, rejection, or unloving parents.

There is evidence for a genetic component in the development of borderline PS. Low
levels of serotonin and dopamine dysfunction can also contribute to the development
of the disorder. Neuroimaging techniques also show that, among other things, there
are abnormalities in the frontal lobe and the limbic system in patients with
borderline PS. The disorder often occurs together with bipolar disorder, which means
that they are also placed together in a bipolar disorder spectrum.

There are several psychological theories that attempt to explain borderline

personality disorders. Some forms of psychodynamic theory, such as object relations
theory, argue that patients have received inadequate support and love from
important persons such as parents, resulting in an insecure ego, leading to lack of
self-confidence and fear of rejection. This theory also states that individuals with
weak egos use the splitting defence mechanism, meaning they view people, events,
or things in a black and white way. In their experience, people are good or bad,
without a grey area in between.

Psychodynamic theories state that individuals with narcissistic PD have childhood

experiences with cold, dismissive parents who rarely expressed praise for their child.
Therefore, clients try to look for confirmation.

This PS is strongly associated with an antisocial PD. However, individuals with a

narcissistic PS can be distinguished from an antisocial PS by their sense of
grandiosity and self-importance. Little is known about the aetiology of histrionic
personality disorders. The dramatic displays of emotion and attention-seeking
behavior would be manifestations of an underlying conflict. Psychodynamic theories
differ on the causes of the underlying conflict.

What is the aetiology of Anxious/Fearful Personality Disorders

(Cluster C)?
An avoidant PS is strongly associated with, among other things, introversion,
neuroticism, low self-esteem, pessimism and with increased emotional reactivity to
threat. There also appears to be a genetic component, the chance of an avoidant PS
being two to three times greater if it runs in the family. The disorder is closely
related to social anxiety disorder, which would allow them to be grouped together
under a broader social anxiety spectrum.

Psychodynamic theories have developed aetiology models for dependent PD that are
very similar to those for depression, as symptoms of dependent PD are reduced by
taking medications used to treat depression. For example, object-relationship
theorists argue that dependence and fear of rejection come from neglect or loss of a
parent in childhood. In addition, a dependent PD often has comorbidities with
various anxiety disorders.

There is very little research on the aetiology of obsessive-compulsive personality

disorder. It is known that underlying vulnerability factors are often related to a
parenting style with psychological manipulation and guilt induction. An interesting
fact is that the comorbidity of an obsessive-compulsive PS with OCD is only 22%,
while there is a large overlap between these two disorders.

How can personality disorders be treated?

There are several factors that make treating personality disorders difficult:

 Individuals with personality disorders are often unaware that their

behavior is problematic and often do not know that they may need
treatment
 Individuals with personality disorders are often predisposed to many
other psychiatric disorders. This makes treatment difficult because
individuals are more disturbed and require more intensive treatment,
many personality disorders consist of ingrained behaviors that are likely
to create difficulties in the future that can trigger symptoms of other
disorders, and many personality disorders have characteristics that make
individuals manipulative and distrustful, making it hard to establish a
good relationship with the therapist
 it is difficult to pinpoint exactly what is disturbed in personality disorders
and therefore difficult to treat; and the characteristics differ per person

In general, it can be said that an individual must acquire certain life skills, learn
emotional control strategies, and learn the skill of mentalization.

What drug treatments can be used?

Drug treatments are usually used in personality disorders to treat the comorbid
disorders, such as anxiety disorders. It has been found that antidepressants are
effective in cluster C symptoms and drugs for aggression and impulsivity in cluster B
symptoms.

What are psychodynamic and insight approaches?

Psychodynamic theories often describe problematic relationships with parents to
explain personality disorders. Insight is seen as an important mechanism in
treatment, namely exploring and resolving these experiences in development.
Object-relations psychotherapy is a treatment that seeks to strengthen the
individual's weak ego so that they can identify issues in their lives without constantly
moving from one extreme view to another.

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy is a client-centred therapy that seeks to provide
clients with an understanding of their dysfunctional ways of thinking about the world
that is particularly successful in borderline personality disorders. There are four
phases:
 1. Identifying dangerous and impulsive behaviors and helping the client deal
with these behaviors
2. Helping the client to moderate extreme emotions
3. Improving the client's self-confidence and coaching the client in dealing
with relationships
4. Promoting positive emotions

How can cognitive behaviour therapy be used?

CBT in personality disorders involves exploring logic errors and dysfunctional
schemas underlying the personality disorders. Specifically, with borderline PD, the
therapist should be aware that the client must be treated with empathy because of
sensitivity to criticism. In addition, in these patients, it is beneficial to change the
dysfunctional schemas by "re-educating" the client to build an emotional connection
with the client in order to challenge the dysfunctional schemas.

40% to 50% of clients recover after treatment with CBT.

What is schema-focused cognitive therapy?

Schema-focused cognitive therapy or schema therapy is used to address
dysfunctional ways of thinking and maladaptive cognitive schemas that develop
during childhood. This ultimately leads to a reduction in belief in the schemas and
the development of alternative perspectives.
Ch13: What is somatic symptom disorder?

How can Somatic Symptom Disorder be

characterized and diagnosed?
Somatic symptom disorders are characterized by psychological problems that
manifest as physiological distress or psychological distress caused by physiological
symptoms or characteristics. The DSM-5 criteria are:

 Demonstrate at least one somatic symptom for at least six months that
causes distress or disruption in daily life
 Unwarranted thoughts, feelings, or behaviors related to the somatic
symptoms or associated with health concerns, manifested in at least one
of the following:

1. Disproportionate and persistent thoughts about how serious the

symptoms are
2. Constant high levels of anxiety about the symptoms or health in general
3. Devoting unnecessary amounts of time and energy to the symptoms or
health concerns.

The lifetime prevalence of somatic symptom disorders is estimated to be around or

just above 1%. These disorders are strongly related to other psychiatric diagnoses,
such as anxiety disorders and depression.

What is Illness Anxiety Disorder?

Individuals with an anxiety disorder have a preoccupation with fear of having a
serious illness through misinterpretation of physical signs and symptoms. This
disorder was first known as hypochondriasis, but the criteria for this were different
(DSM-IV-TR). Approximately 75% of people diagnosed with hypochondriasis are re-
diagnosed with an anxiety disorder based on the DSM-5. The DSM-5 criteria for this
disorder are:

 Obsession with having a serious illness

 Somatic symptoms are mild or absent
 High level of anxiety about health and easily worried about health
 Performs excessive health checks or shows maladaptive avoidance
 The illness preoccupation has been present for at least six months
 The symptoms are not better explained by another mental disorder

The lifetime prevalence of hypochondriasis has been estimated at 1% to 5%.

What is Conversion Disorder?

In conversion disorder, psychological symptoms or impairments affect voluntary
motor and sensory functions, which would indicate an underlying medical or
neurological condition. The DSM-5 criteria for this disorder are:

 At least one symptom of altered voluntary and sensory function;

 Evidence of incompatibility between the symptoms and known
neurological or medical conditions;
 The symptoms are not better explained by another mental disorder; and
 The symptoms cause distress or impairment in key areas of function.

Common motor symptoms include paralysis and imbalance. Common sensory

symptoms include loss of pain sensation and deafness.

Glove anaesthesia is a symptom where numbness begins in the wrist and is

experienced evenly in the hand and all fingers. Individuals also often show la belle
indifference, meaning they are indifferent to the real symptoms, especially if the
symptoms are distressing to others. In psychodynamic circles, conversion disorder
was also known as hysteria. The lifetime prevalence of conversion disorder is
estimated to be less than 1%. There are significantly more women than men with
the disorder.

What is Factitious Disorder?

A factitious disorder is a set of physical or psychological symptoms that are
deliberately produced to assume a disease role. DSM-5 criteria for this disorder are:

 Making up physical or psychological symptoms or signs of an injury or

illness
 presenting oneself to others as ill or injured
 The cheating is obvious, despite no clear reward
 The behavior is not better explained by another mental disorder, such as
delusional disorder.

What drives caregivers and parents to deliberately cause illness, pain, and
sometimes even death when they suffer from a factitious disorder imposed on
another? Often these people are emotionally needy and need attention and praise.
This is what they get when they behave caringly and lovingly towards their sick
child. They often have a great deal of knowledge about drugs and medical
procedures, which allows them to cause the disease without being suspected.

What is the aetiology of Somatic Symptom

Disorders?
Four questions are important in explaining these disorders:

1. Are physical symptoms a manifestation of underlying psychological

conflict and stress?
2. Were physical symptoms produced in an involuntary way?
3. What is the role of childhood stress and abuse in the development of the
symptoms?
 4. How do clients get the distorted thinking and dysfunctional beliefs about
health that perpetuate the symptoms?

What are the psychodynamic interpretations?

The basis of the psychodynamic view of somatic symptom disorders is conflict
resolution, in which disturbing memories, inner conflict, fear, and unacceptable
thoughts are suppressed in the conscious mind, but emerge outwardly as somatic
symptoms. However, the idea that expressing the symptoms would relieve anxiety
or conflict management does not seem to be correct. There is a high degree of
anxiety involved in somatic symptom disorders.

What about consciousness and behaviour?

There seems to be a dissociation between an individual's behavior and their
awareness of that behavior. In conversion disorder, the client genuinely appears to
be experiencing no sensory input, although research has shown that they can
experience it but are unaware of it. An old-fashioned explanation for this is also that
attention narrows after experiencing a trauma. Oakley shows that there are many
similarities between the behavior of somatic symptom disorders and hypnosis: a
therapeutic technique in which a patient is put into a trance. In both situations,
there is no voluntary control over movements and sensations.

What are risk factors for somatic symptom

disorders?
Important risk factors are trauma or abuse or periods of severe stress and anxiety.
For example, childhood trauma increases the vulnerability for developing conversion
disorder. Family factors such as parents with somatization characteristics and
insecure attachment are also risk factors for developing somatic symptom disorders.
However, all the factors mentioned are risk factors in all kinds of different forms of
psychopathology.

What learning approaches are there?

Many individuals learn to interpret emotional symptoms as indications of physical
illness. First, many individuals have family members with an illness who express
negative feelings about it, which can be replicated by modeling. Second, expressing
emotional symptoms of illness can be reinforced by parents. For example, parents
can view underlying psychological problems as physical and encourage their children
to express them in this way. As a result, an individual may finally assume a so-called
disease role in extreme cases. In this, the role of being ill as determined by the
society to which the individual belongs is played. Taking on this role can become a
coping style to help cope with adult life.

What are the cognitive factors?

Somatic symptom disorders are perpetuated by several factors:

 Attentional biases towards physical threats

 Interpretational biases: cognitive biases in which an individual interprets
ambiguous events as threatening and as evidence of possible negative
outcomes
 Memory bias: a bias toward recalls and retrieval of disease-relevant
material
 Reasoning bias: Individuals with illness anxiety disorder tend to reject
diagnoses that are inconsistent with their own beliefs about their health.
They will continue to look for other options on the assumption that
someone will eventually agree with their own view
 Catastrophizing symptoms.

However, these things do not explain how these biases are acquired. Brown argues
that 'rogue representations' are developed, which form inappropriate models
through which information about body shapes and health are selected and
interpreted. These representations can be created by past illnesses, by having
experienced emotional states in the past with strong physical manifestations
(anxiety is associated with tremors), and by exposure to illness in others, creating a
memory model through which one's own physical sensations are interpreted turn
into.

What are the sociocultural approaches?

Sociocultural factors appear to influence both the prevalence and nature of somatic
symptoms. In some cultures, expressing physical pain is an accepted way to
communicate psychological distress, and in such cultures the prevalence of somatic
symptom disorders tends to be higher as well. In addition, with conversion disorder
there is something known as 'contagion' where the symptoms affect different people
in the same social setting or social group.

What are the biological factors?

It is known that a percentage of people with conversion disorder actually have
medical conditions that may contribute to the disorder and that individuals with
somatic symptom disorder often have a history of illness in their family.

Twin studies suggest that there appears to be a genetic component that contributes
to the development of somatic symptom disorders. However, more research is
needed into the genetics.

Brain research suggests that sensory information goes to the right brain areas but is
not registered in consciousness. In addition, there appears to be a relationship
between somatic symptom disorders and increased activity in areas associated with
unpleasant bodily sensations, reducing the tendency to be aware of these
sensations.

How can somatic symptom disorder be treated?

One of the main problems with treatment is that there is often a long period of
medical treatment first, because somatic symptoms manifest themselves as physical
or medical symptoms. This can provide anchoring of the symptoms and resistance to
psychological therapy. In addition, somatic symptom disorders are highly comorbid
with anxiety disorders and depression, raising the question of exactly what causes
what.

What is psychodynamic therapy?

Psychodynamic therapy uses procedures designed to bring repressed thoughts and
memories to consciousness so that they can be dealt with effectively. However,
symptoms are quite resistant to the psychodynamic approach. However, it is more
effective than no treatment and the greater the therapist's competence, the more
successful the treatment.

What is behaviour therapy?

Since the attention that the individual's environment often has on the symptoms,
thereby perpetuating them, the family, among others, is often asked to stop giving
this attention. In addition, relaxation training and behavioral techniques are often
useful in reducing the anxiety the individual has about the symptoms. This form of
behavioral stress management appears to be effective.

What is Cognitive Behaviour Therapy?

CBT is an effective form of therapy for treating dysfunctional beliefs and thought
patterns, especially in an anxiety disorder. It is more effective than normal medical
help, but not more effective than other treatments such as gradual muscle
relaxation. The first results of research with mindfulness-based cognitive therapy
show that this form is more beneficial than CBT.

How can drug treatments be used?

Drug treatments use pharmacological treatments to relieve symptoms of
psychopathology. In somatic symptom disorders, antidepressants (tricyclic
antidepressants, SSRIs and SNRIs) have been shown to be most effective.
Ch14: What are dissociative experiences?

What is Dissociative Amnesia?

Dissociative amnesia is the inability to remember important personal information,
which is usually of a stressful or traumatic nature. The DSM-5 criteria for this
disorder are:

 Failure to remember important personal information, often related to

traumatic or stressful events, other than normal forgetting. This stresses
or limits the individual in key areas of function
 The symptoms are not the result of substance use or any other
neurological or medical condition
 The disorder is not better explained by other mental disorders, such as
dissociative identity disorder, PTSD, or acute stress disorder.

Dissociative amnesia is associated with different types of memory disturbances.

Localized amnesia is when an individual cannot remember events that happened
during a specific time period. Selective amnesia is when an individual can remember
some, but not all, events of a specific time period. Generalized amnesia is a failure
of memory that spans a person's entire life. Such people may suddenly report to the
police or to a hospital because of disorientation. Continuous amnesia is the inability
to remember events from a specific time point to the present. Systematic amnesia
means that a specific category of information cannot be remembered, such as family
history.

The prevalence of dissociative amnesia is about 1.8%.

Post-crime amnesia can occur when the individual is in a highly adapted

physiological state due to extreme anger or the influence of alcohol or substances.
However, a criminal has good incentives to fake amnesia symptoms. Symptom
validity testing (SVT) is a way to check whether symptoms are real. Questions about
the crime must be answered, with a choice of two answers. Individuals who get less
than 40% correct are suspected of forgery because they will choose wrong answers
on purpose. While an individual should score around chance level (50% good) if
there really is amnesia.

What is Dissociative Identity Disorder?

Dissociative identity disorder (DID) is characterized by the display of two or more
identities or personality states that take turns regulating behavior (previously known
as multiple personality disorder). The DSM-5 criteria for this disorder are:

 Confusion of identity, characterized by at least two different personality

states, which is seen in some cultures as being possessed
 Recurrent interruptions in remembering everyday events, personal
information, or traumatic events, other than normal forgetting
 The symptoms cause distress or impairment in key areas of function
 The disruption is not a normal part of generally accepted cultural or
religious practices
  The symptoms are not the result of substance use or any other
neurological or medical condition.

A distinction can be made between the host identity (the identity that existed before
the onset of DID) and the alter identities (the identities that evolve after the onset
of DID). In the simplest case, two identities alternate, but the average is 13
identities. Often each identity takes on a certain area.

The prevalence of DID is about 1.5%. However, it has become more and more
common in recent years. This may be because DID has only been a diagnostic
category since the DSM-III, because it was first also diagnosed as schizophrenia,
because it has gained more attention (film Sybil), because therapists stimulate
multiple personalities through hypnosis and the power of suggestion , because
dissociative disorders are associated with trauma and interest in them grew after the
Vietnam War and finally because many symptoms can be easily mimicked.

What is Depersonalization Disorder?

A depersonalization disorder is characterized by feelings of detachment or alienation
from the self. DSM-5 criteria for this disorder are:

 Recurrent episodes of depersonalization, derealization, or both, causing

distress or impairment in major areas of functioning: depersonalization:
experiences of detachment or observing one's own thoughts, feelings,
body, or actions from a distance, and derealization: experiences of
detachment from the environment.
 During these occurrences, the individual can still distinguish real from
fake
 The disruption is not direct due to substance use
 The disturbance is not better explained by another mental disorder, such
as schizophrenia, panic disorder, or depression.

The 12-month prevalence of depersonalization disorder is approximately 0.8%.

What is the relationship Between Dissociative

Disorders and PTSD?
One in three individuals with PTSD also experience high levels of dissociation in the
form of dissociative amnesia and depersonalization. PTSD is related to dissociative
disorders in three ways. First, persistent dissociative symptoms after a traumatic
experience are an important predictor for developing PTSD. Second, dissociation is a
hallmark of complex or severe PTSD. Complex PTSD is associated with interpersonal
trauma at an early age and dissociative symptoms from that age onwards. Third,
there is the possibility that there is a specific dissociative subtype of PTSD.

What are the risk factors for dissociative

disorders?
There are several risk factors for developing dissociative disorders. Anxiety and
depression for the disorder, child abuse (physical or psychological abuse of a child),
and childhood neglect. Dissociative symptoms are also commonly seen in homeless
children and children who have run away from home who have experienced various
forms of abuse.

What is the psychodynamic perspective?

The general view of psychodynamic theorists is that dissociative symptoms are
caused by suppression. This is a defence mechanism that helps suppress painful
memories and suppress stressful thoughts.

What is the role of fantasy and dissociative

experiences?
There is evidence that dissociative disorders develop more readily in individuals who
have previously experienced dissociative or depersonalization experiences. In
addition, it is common that individuals with DID often have imaginary friends in
childhood, predisposing them to develop DID. Children would learn that they can use
such an imagined personality in times of conflict to make it better.

What are the cognitive approaches?

A central question in explaining dissociative symptoms is how it is possible that
different components of the conscious mind are detached from each other and how
certain memories can be retrieved, and certain memories cannot. Studies suggest
that attention is important for individuals to forget trauma, dividing attention among
different sources may facilitate the forgetting of emotionally relevant or traumatic
information.

An alternative explanation is in terms of how changes in physiological and emotional

state can affect memory recall. State-dependent memory is the cognitive
phenomenon whereby an individual is better able to remember an event if he or she
is in the same physiological state as when the event occurred. Thus, if an individual
has experienced severe traumatic events where changes in mood and physiology
occurred during the events, they may have difficulty retrieving memories in a less
traumatic emotional state. However, there are some problems with this statement.
First, associative amnesia is often much more severe than reported in studies of
state-dependent memory. Second, there are often problems with information
retrieval and information recognition, but state-dependent memory has been found
only in information retrieval. Third, it appears that different identities in DID can
recall autobiographical material from the other identities on a recognition test,
suggesting that dissociative amnesia in DID does not affect inter-identity memory
systems or is limited to state-dependent learning.

Another cognitive theory involves the concept of reconstructive memory, which

posits that autobiographical memory is stored as a series of discrete elements
associated with a particular experience (e.g., context, emotional state, sensory and
perceptual features). Source-monitoring skill is the ability to retrieve from memory
important elements of an autobiographical experience. A disruption in reality
monitoring (a form of source monitoring needed to distinguish mental content that
comes from experience from that that comes from imagination) can also lead to
doubt whether a memory is real. This, together with disturbances in reconstructive
memory, can lead to dissociative amnesia.

There are a number of questions that need to be asked when it comes to repressed
memories.

Can memories of childhood trauma or abuse be suppressed? Yes, but it is important

to look at the nature of the trauma and whether it is a 'normal' forgetting process or
active suppression.

Can these repressed memories be restored? This is debatable, during the 1980's and
1990's there was a trend that therapists thought many symptoms were due to
childhood abuse, clients were told they were in denial if they could not remember
abuse. This makes it almost inevitable that clients will remember things that never
happened.

Are these recovered memories accurate? There are many cases where there is false
memory syndrome, where erroneous memories are retrieved. Processes that
contribute to this are over-directive psychotherapy or hypnotherapy (the client is
stimulated to believe that abuse has occurred) and weak source-monitoring skills.

What are the biological explanations?

At first glance, it seems logical that neurological disturbances would underlie
dissociative disorders, but this does not seem to be the case. The amnesia is
selective and usually transient. The brain abnormalities should therefore be selective
and transient. A candidate where this appears to be the case is undiagnosed
epilepsy (a disorder of the nervous system characterized by mild, episodic loss of
attention or drowsiness or by severe convulsions with loss of consciousness).
Epileptic seizures seem to be associated with DID, among other things, but this is
unlikely to explain dissociative symptoms. An alternative explanation is that there
are abnormalities in the hippocampus, where various elements of autobiographical
memory converge.

What about role-playing and therapeutic

constructions?
Some theorists argue that the more elaborate symptoms, such as the alter identities
in DID, are a form of role-playing to evoke sympathy and escape responsibility for
their actions. Therapists can also influence this by having the client give names to
the different identities, making these identities therapeutic constructs rather than
real symptoms. There are several arguments for this:

 Alter identities are less commonly seen in children and are common in
adulthood once treatment has begun with a therapist
 Relatives of the individual with DID rarely report seeing evidence of the
alter identities before treatment
  Individuals with DID have strong imaginations and rich imaginations,
which facilitate playing different roles
 There is evidence that in many cases DID is only diagnosed by certain
clinicians and not other clinicians, so these clinicians may have a
therapeutic style where alter identities could easily develop
 Individuals with dissociative disorders are sensitive to suggestion and
hypnosis.

Therapists who view DID as a diagnostic category describe a range of symptoms

that may be indicative of DID. This justifies constant probing during therapy to
confirm a diagnosis, in which therapists can trick clients into believing they have
altered identities. In addition, its prevalence has increased since the 1980s.

However, there are also several (counter)arguments for that DID is not a
construction of the therapeutic process:

 The rise in DID diagnoses may also be a result of reduced scepticism and
a reduction in the misdiagnosis of DID as schizophrenia
 There is little evidence that hypnotherapy contributes to the development
of DID symptoms, because only 1/4 clients are diagnosed with DID after
hypnotherapy
 Core symptoms of DID are seen before the first treatment session, so
DID cannot be completely constructed by therapy
 Clients are often very reluctant to talk about their symptoms, with little
mention at all of past abuse or the existence of multiple personalities.

How can dissociative disorders be treated?

The main focuses in the treatment of dissociative disorders are reducing selective
amnesia and helping the client get used to recovered memories if they are painful or
traumatic and helping clients merge the alter identities into one identity. However,
there are some issues that therapists run into:

 Some dissociative disorders are rare, making therapeutic techniques

relatively underdeveloped and effectiveness unknown
 Some dissociative disorders sometimes resolve spontaneously, where it is
not clear whether the therapeutic methods used are effective or not
 Dealing with recovered memories is often traumatic for the client because
the traumatic events are relived (abreaction), which can lead the client
into an emotional crisis
 Directive therapeutic styles can lead to the recovery of erroneous
memories, which can have negative consequences for the client and the
family
 Integrating alter identities into one identity is a very difficult process,
clients find the identities a nice way to explain their behavior to others
and to absolve the host identity of responsibility
 Dissociative disorders are often comorbid with many other psychiatric
disorders, addressing these issues as well is a requirement in therapy

How can psychodynamic therapy be used?

In the first phase of psychodynamic therapy, a trusting relationship is established
between the therapist and the client. In the second phase, repressed memories or
alter identities are addressed. This second phase is the most challenging because it
can be traumatizing to recall memories and because the client often does not want
to integrate the multiple personalities. If previous phases have been successful, the
client receives training to learn how to deal with the recovered memories or the
integrated personality.

What does hypnotherapy involve?

Hypnotherapy is a form of therapy in which the client is put under hypnosis. This can
help the client bring up repressed memories. Drugs such as amobarbital sodium and
pentobarbital sodium can be used at the same time as hypnotherapy to help you
remember. Age regressing is the re-creation of a client's physical and mental state
prior to experiencing trauma in order to help the client recall certain events from
earlier stages in life.

What is the use of drug treatments?

Since anxiety and depression are common in dissociative disorders, antidepressants,
anxiolytic drugs, and tranquilizers are used in treatment. However, drugs seem to
have little effect on DID. SSRIs and opioid antagonists have been shown to reduce
symptoms in depersonalization disorders.
Ch15: What are neurocognitive disorders?

What are the cognitive impairments in

neurocognitive disorders?
Amnesia is common in neurocognitive disorders. Anterograde amnesia or
anterograde memory dysfunction is amnesia for information acquired after the onset
of the amnesia. The first indications of neurocognitive problems are when the
individual shows signs of a lack of attention, being easily distracted, and being
slower in performing well-learned activities. In addition, it may be difficult to follow a
conversation and more time may be needed to make a decision.

Language impairments are collectively known as aphasia: speech impairments that

result in difficulty producing or understanding speech. This can take several forms:

 An inability to understand speech or repeat speech accurately and

correctly
 Fluent aphasia: the production of incoherent, messy speech
 Non-fluent aphasia: An inability to initiate or respond to speech other
than a few simple words

A distinction can be made between Broca's aphasia and Wernicke's aphasia. Broca's
aphasia is a disturbance in the ability to speak, with difficulty organizing and finding
words and articulation. Wernicke's aphasia is a disturbance in speech comprehension
in which there is difficulty recognizing spoken words and converting thoughts into
words.

Agnosia is the inability to recognize objects, people, sounds, shapes, or smells

without significant memory loss. This can occur with a wide variety of functions.

Apraxia is the inability to perform learned movements despite having the will and
physical ability to perform the movements.

Executive functions are normally associated with the prefrontal cortex, an area of
the brain important for maintaining representations of goals and the means of
achieving them. The Wisconsin card sorting task is a test used to test executive
functioning in which individuals must sort cards for a number of trials with one rule
(e.g., colour) and then another rule (e.g., shape). This requires the ability to shift
and inhibit attention.

Another indication of neurocognitive impairment is impairment in more abstract

mental tasks. For example, individuals cannot perform simple mathematical
calculations.

How does assessment in clinical neuropsychology

take place?
Assessment is important for a number of reasons:
  To determine the nature of impairments and the location of related tissue
damage in the brain
 To obtain information about the onset, type, severity and progression of
symptoms
 To distinguish between neurological impairments that have an organic
basis and psychiatric symptoms that do not
 To identify the focus for rehabilitation programs and to test progress in
these programs

A diagnosis is usually based on neuropsychological testing, nowadays often

supplemented with brain tests such as EEG scans and fMRI. The WAIS-IV is one of
the most widely used tests, this is the fourth edition of the Wechsler adult
intelligence test. This test provides insight into skills such as verbal comprehension,
perceptual organization, working memory and the speed of information processing.

A very short test to perform is the Mini Mental State Examination, which provides
reliable information about the client's level of cognitive and mental functioning in ten
minutes.

How are Neurocognitive Disorders diagnosed?

Diagnosis can be tricky because the impairments found in neurocognitive disorders
are often symptoms of other psychological disorders as well. In addition,
experiencing cognitive limitations in the early stages often leads to the development
of psychological problems, such as depression.

The symptoms of neurological disorders overlap. For example, damage to specific

areas due to closed head injury can cause cognitive impairments that are also found
in more general degenerative disorders. Closed head injury is a concussion or head
trauma, the symptoms include loss of consciousness after the trauma, confusion,
headache, nausea or vomiting, blurred vision, loss of short-term memory and
perseveration.

What diagnostic categories are there in the DSM-5?

There are two broader categories of neurocognitive disorders. These are delirium, (a
disturbance of consciousness that develops over a short period of time) and major or
mild neurocognitive impairment, more commonly known in the DSM-IV as dementia
(the development of multiple cognitive impairments, including memory impairment
and at least one other specific impairment). The DSM-5 criteria for delirium are:

 A decreased ability to focus and to direct and maintain attention and

awareness, this develops over a short period of time (hours to a few
days) and fluctuates in severity over that period of time;
 Additional disturbances in cognitive functioning are also seen
 Disturbances are not the result of a previous neurological condition and
do not happen during a coma or other impaired levels of consciousness
 There is no evidence that the disturbance is a direct physiological result
of another medical condition, substance abuse or withdrawal

The DSM-5 defines neurocognitive disorders as conditions in which there is

significant impairment in one or more cognitive domains, such as complex attention,
executive functioning, learning and memory, language, perceptual-motor, or social
cognition. This can be diagnosed as major neurocognitive impairment (substantial
impairment) or mild neurocognitive impairment (moderate impairment). DSM-5
criteria for a major neurocognitive disorder are:

 Significant cognitive impairment in at least one cognitive domain, based

on (1) patient, informant, or physician concerns that there is a
substantial impairment in cognitive function (2) a substantial impairment
in cognitive performance, desirable as documented by standard testing;
 The cognitive impairment interferes with self-reliance in everyday
activities;
 The impairment does not occur in the context of delirium; and
 The disability is not better explained by other mental disorders, such as
depression or schizophrenia

DSM-5 criteria for a mild neurocognitive disorder are:

 Moderate cognitive impairment in at least one cognitive domain, based on

patient, informant, or physician concerns that there is moderate
impairment in cognitive function moderate impairment in cognitive
performance, desirable as documented by standard testing
 The cognitive impairment does not interfere with self-reliance in everyday
activities
 The impairment does not occur in the context of delirium
 The disability is not better explained by other mental disorders, such as
depression or schizophrenia.

What types of major neurocognitive disorder are

there?
There can be several causes for neurocognitive disorders, such as cerebral infection,
traumatic brain injury, cerebrovascular events (CVAs) and degenerative disorders.
One of the viruses that can infect the brain is the human immunodeficiency virus
type 1 (HIV-1). The DSM-5 criteria for a neurocognitive disorder due to HIV infection
are:

 Criteria for major or mild neurocognitive impairment are met

 The patient is infected with HIV
 The disorder is not better explained by non-HIV conditions including
secondary brain diseases
 The disturbance is not due to another medical condition and is not better
explained by another medical condition

Spongiform encephalopathy is a fatal infectious disease that attacks the brain and
central nervous system. This is also known as 'mad cow disease' or variant
Creutzfeldt-Jakob disease. The infectious agent in this disease is said to be a prion:
an abnormal, transmissible agent that can trigger the abnormal folding of normal
cellular proteins in the brain, leading to brain damage. The rapid dementia that
develops appears to be due to prions, or proteins that destroy or replace neurons in
the brain or central nervous system, which is why it is also referred to as prion
disease. The DSM-5 criteria for neurocognitive impairment due to prion disease are:
  Criteria for major or mild neurocognitive impairment are met
 The onset is slow, with rapid progression
 Motor features of the prion disease are evident, such as involuntary
twitching or ataxia
 The disturbance is not due to another medical condition and is not better
explained by another medical condition.

One of the most common neurological disabilities is traumatic brain injury. This can
be due to blunt or penetrating trauma to the head. Indirect damage can also result
from movement of the brain within the skull from the impact of the trauma, causing
damage to the opposite side of the brain. The DSM-5 criteria for a neurocognitive
disorder due to traumatic brain injury are:

 Criteria for major or mild neurocognitive impairment are met;

 Traumatic brain injury is sustained with at least one of the following
features:

1. Unconsciousness,
2. Post-traumatic amnesia,
3. Disorientation and confusion,
4. Neurological signs, such as neuroimaging showing damage
5. The disorder is present immediately after sustaining the traumatic brain
injury.

Brain damage can also result from cardiovascular events (CVA) or stroke: sudden
loss of consciousness due to rupture or occlusion of a blood vessel in the brain
leading to oxygen deprivation. If the blood flow to the brain is obstructed, it is
referred to as an infarction. If a blood vessel ruptures, it is called a haemorrhage.
The most common causes of infarction are embolism and thrombosis. A cerebral
embolism is a blood clot that forms somewhere in the body, then travels to the brain
and damages brain cells, causing a lack of oxygen. Cerebral thrombosis is when a
blood clot forms in a blood vessel that supplies blood to the brain. The clot interrupts
the blood supply and brain cells die from lack of oxygen. A haemorrhage is often the
result of hypertension or high blood pressure and is often caused by an aneurysm:
the localized bulging of a blood vessel due to disease or the weakening of the blood
vessel wall. Depression is an important feature in disability caused by strokes. The
DSM-5 criteria for a vascular neurocognitive disorder are:

 Criteria for major or mild neurocognitive impairment are met;

 The clinical features suggest vascular aetiology, which is marked by one
of the following: (1) the onset of cognitive impairment is temporally
related to at least one cardiovascular event, (2) impairment is noticeable
in complex attention and frontal-executive
 There is evidence of cerebrovascular disease accounting for the
neurological impairments
 The symptoms are not better explained by another brain disease or
disorder.

Degenerative disorders represent the neurocognitive disorders characterized by a

slow, generalized deterioration in cognitive, physical, and emotional functioning due
to changes in the brain. The diagnosis is complex, firstly because the disorder must
be distinguished from the normal process of aging. Second, it is often difficult to
distinguish between different degenerative disorders that affect cognitive and
physical functioning. Third, these disorders are mostly found in the elderly and this
population often has multiple deficits that make diagnosis more complex. Finally, the
manifestation of these disorders depends on factors such as educational level and
the degree of family and social support.

Alzheimer's is the most common form of dementia. It is a slowly progressive

disorder in which there is impairment in short-term memory, with symptoms of
aphasia, apraxia and agnosia, along with limited judgment, decision making and
limited orientation. Risk factors for Alzheimer's include age, gender (more females
than males), genetics (having a first-degree relative with Alzheimer's), family
history of Alzheimer's, past head injury, and low educational attainment. The
aetiology of Alzheimer's lies in the development of beta amyloid plaques and
neurofibrillary tangles. Beta amyloid plaques are abnormal cell development, caused
by abnormal protein synthesis in the brain, they clump together killing healthy
neurons. Neurofibrillary tangles are abnormal collections of twisted nerve cell
threads that cause errors in impulses between nerve cells and can lead to cell death.
In addition, improper production of the brain neurotransmitter acetylcholine
(involved in memory and learning) is thought to be important in Alzheimer's disease.
DSM-5 criteria for a neurocognitive disorder due to Alzheimer's are:

 Criteria for major or mild neurocognitive impairment are met;

 Onset is slow with gradual progression of disability;
 The disturbance is not better explained by a cerebrovascular disorder or
other neurodegenerative diseases or disorders

For major neurocognitive disorder:

Possible Alzheimer's is diagnosed if any of the following are present:

 Evidence of Alzheimer's genetic mutation in the patient's family history or

through genetic testing; and
 The following three are present:

1. Decline in memory and learning and at least one other cognitive ability
2. Steady, gradual decline in cognition
3. No other neurodegenerative or cerebrovascular disease;

For mild neurocognitive impairment:

Probable Alzheimer's is diagnosed if there is evidence of Alzheimer's genetic

mutation in the patient's family history or through genetic testing. Otherwise,
possible Alzheimer's should be diagnosed if the following three things are present:

1. Impairment of memory and learning and at least one other cognitive

ability,
2. Steady, gradual decline in cognition
3. No other neurodegenerative or cerebrovascular diseases.

Fronto-temporal neurocognitive disorder is associated with a loss of neurons in the

frontal and temporal regions of the brain leading to the progressive development of
behavioral and personality changes and language impairments. DSM-5 criteria for a
fronto-temporal neurocognitive disorder are:

 Criteria for major or mild neurocognitive impairment are met

 Onset is slow with gradual progression of disability
  A behavioral or language variant is present. The behavioral variant
involves marked decline in social cognition and at least three of the
following:

1. Lack of inhibition,
2. Sluggishness or lethargy,
3. Compulsive/ritual behavior,
4. Inappropriate things in the stopping mouth or dietary changes. In the
language variant there is a clear decline in language skills;

 Limited learning and memory functions and limited perceptual motor

functions
 The disturbance is not better explained by a cerebrovascular disorder or
other neurodegenerative diseases or disorders, or by the effects of a
substance.

Parkinson's is a progressive neurological condition that affects movements such as

walking, talking and writing. This disease causes psychological problems in 40% to
60% of patients. This disease arises as a result of damage to the basal ganglia,
specifically the substantia nigra. Cells in this area are responsible for producing
dopamine, and dopamine carries messages to areas that coordinate movement.
Depression is common in Parkinson's. The fact that depression is a risk factor for a
variety of neurodegenerative diseases has led to the view that depression is
associated with an allostatic state (biological state of stress) that can accelerate the
disease process and cause nerve cell atrophy. DSM-5 criteria for Parkinson's
neurocognitive disorder are:

 Criteria for major or mild neurocognitive impairment are met

 The disturbance occurs during the existence of Parkinson's disease
 Onset is slow with gradual progression of disability
 The disturbance is not better explained by other medical conditions or
mental disorders

Major or mild neurocognitive impairment probably due to Parkinson's is diagnosed if

both of the following are present and major or mild neurocognitive impairment
possibly due to Parkinson's if any of the following are present:

 No evidence of other neurodegenerative or cerebrovascular diseases,

 The Parkinson's diagnosis precedes the neurological disorder.

Lewy bodies are abnormal protein deposits that interfere with the normal functioning
of the brain. These are found in the brainstem where they deplete the
neurotransmitter dopamine and lead to Parkinson's symptoms. The Lewy bodies are
also found in other parts of the brain. The DSM-5 criteria for a neurocognitive
disorder with Lewy bodies are:

 Criteria for major or mild neurocognitive impairment are met;

 Onset is slow with gradual progression of disability;

Probable major or mild neurocognitive disorder with Lewy bodies is diagnosed when
two core features are present or at least one suggestive feature with other features.
Possible major or mild neurocognitive impairment with Lewy bodies is diagnosed if
one core feature or at least one suggestive feature is present.
Core features are:

 Varying cognition with marked variability in attention and alertness,

 Recurrent, detailed hallucinations,

Suggestive features are:

 REM sleep behaviour disorder

 Adverse reactions to neuroleptics
 The disturbance is not better explained by cerebrovascular disease, other
neurodegenerative diseases or disorders, or by the effects of a substance

Huntington's disease is an inherited, degenerative central nervous system disorder

caused by a dominant gene. The genetic abnormality is found on the fourth
chromosome, resulting in the production of a protein, mutant Huntingtin, which
causes cell death in the basal ganglia. In this disease are affective symptoms,
cognitive impairments, personality disorganization, stubbornness, loss of sanity,
hallucinations, delusions, strange behavior and obsessions. The DSM-5 criteria for
Huntington's neurocognitive disorder are:

 Criteria for major or mild neurocognitive impairment are met

 Onset is slow with gradual progression of disability
 The disruption occurs during the existence of Huntington's disease or
when there is a known risk of Huntington's disease based on family
history or genetic testing
 The disturbance is not better explained by other medical conditions or
mental disorders.

There are drawbacks and benefits to genetic testing for a neurodegenerative

disorder. The benefits are that researchers can better understand the disease and
thus develop better treatments, that people are encouraged to adopt a healthier
lifestyle, that people who are at high risk can use new treatments in the future and
finally that they can help people plan for the future. Disadvantages are that if a
defect comes out of the test it can cause fear, there is a risk of reading too much
into a test, a positive test does not necessarily mean that the disease will develop
and finally that people who test positive can be discriminated against, for example,
with regard to insurance.

What about treatment and rehabilitation for

Neurocognitive Disorders?
Often the neurological damage is such that it is permanent, and the patient has to
learn to live with it. Rehabilitation focuses on helping the patient with exercises that
help improve limited cognitive functions, training in the use of cognitive and
behavioral aids, assistive technology, and basic drug treatment and psychotherapy.

What kind of biological treatments can be used?

The most common form of biological treatments are drug treatments, which help
stabilise or slow degenerative disorders. Other forms are drug treatments to combat
cerebral infections, and electrical brain stimulation for some forms of dementia.
Cholinesterase inhibitors are drugs that prevent acetylcholine from being broken
down by acetylcholinesterase in the synaptic cleft and increase the reuptake of
acetylcholine at the postsynaptic receptors. The most common of these drugs are
donepezil, rivastigmine and galantamine. Only for a fronto-temporal neurocognitive
disorder, the effectiveness of these drugs has not been shown.

The drug mainly used in Parkinson's disease that counteracts the decay of dopamine
is levodopa, an amino acid that is converted into dopamine by the brain. This drug
works mainly for the motor symptoms. Thrombolytic therapy uses drugs that
dissolve or break up blood clots. This is used to reduce disability in CVAs. Medication
is also used in the treatment of disability due to cerebral infections. Bacterial
meningitis is the inflammation of the meninges, the membranes that cover the brain
and spine. These types of infections can be treated with antibiotics. Antiretroviral
drugs have been shown to be effective in HIV-1 associated dementia. These are
drugs that inhibit the replication of retroviruses. In addition, depression is an
important feature in neurological disorders. Addressing depression can be viewed as
directly treating the disorder itself rather than viewed as a side effect. Drugs such as
SSRIs and tricyclic antidepressants have been shown to be effective.

What is deep brain stimulation?

Deep brain stimulation is a form of treatment for Parkinson's that uses a surgically
inserted battery-operated device (a neurostimulator). This device delivers electrical
stimulation to the ventral intermediate nucleus of the thalamus or the subthalamic
nucleus area in the basal ganglia. This ensures the improvement of physical skills.

What is cognitive rehabilitation?

Many of these programs are basic training procedures that provide the client with
structured, extensive training in the area of their disability. Holistic rehabilitation
approaches are treatment approaches for neurological disorders that attempt to
target multiple aspects of the dysfunction.

What is attention process training (ATP)?

Attention process training (ATP) uses different strategies to promote and stimulate
attention skills. Time pressure management (TPM) is not aimed at improving
attention itself, but at providing clients with compensatory skills that help them cope
with their delayed information processing.

How can visual-spatial deficits be treated?

Several programs have been developed for visual impairments. An example is the
computer-assisted program visual scanning, which consists of several tasks to
reduce symptoms of unilateral neglect.

What about apraxia and deficits in coordinated

self-help behaviours?
Gestural training is a form of rehabilitation training that has been shown to be
effective for limb apraxia, teaching the client to recognize gestures and postures
that are appropriate and contextual. For example, a client must demonstrate how to
use a guitar.
Virtual reality environments have been developed to teach patients how to improve
basic skills of daily living. Exercises in this safe and controlled environment lead to
improvements in real-world performance.

How can language and communication deficits be

treated?
Many patients undergo standard forms of speech therapy to stimulate speech
production and comprehension. A specific technique used in aphasia is constraint-
induced movement therapy, which involves practicing verbal responses, requiring
the patient to communicate without gestures or pointing to describe various objects
of varying complexity.

Another specific form that has been shown to be effective for language production
and understanding is known as group communication treatment, which focuses on
increasing conversation initiation and information exchange through any form of
communication.

How can memory deficits be treated?

Memory deficits are mainly treated with compensatory strategies. In addition,
computer-based procedures can help, for example by means of an electronic
agenda. nTeaching memory strategies is also helpful. There is a technique where the
patient is trained to use visual imagery mnemonics to help store and retrieve items
and events. Errorless learning in which individuals with amnesia are prevented from
making mistakes when learning a new skill or information.

How can executive functioning deficits be treated?

Goal management training (GMT) is a procedure in which problem-solving training is
provided to help evaluate a problem, followed by a specification of the major goals
and the division of the problem-solving process into sub-goals or steps. Self-
instructional training (SIT) is a procedure in which individuals learn a set of
instructions to talk themselves through certain problems.

What do holistic rehabilitation methods look like?

It is helpful to take a holistic approach that takes all cognitive, emotional, and
functional limitations into account. These rehabilitation methods show significant
improvement in the overall functioning of patients, and awareness of the limitations
is also developed. This approach is superior to standard neurorehabilitation
programs in improving social integration and patient satisfaction with cognitive
functioning.

What are caregiver support programs?

Many people with neurological disorders live with their families or caregivers, such
as their partners. So, these people need support and training. It is important that
caregivers provide physical and emotional support to patients. In addition, there is
quite a lot on their plate because they often have substantial economic costs due to
the care for a patient. Several recommendations have been made for caregivers that
include tips on taking care of themselves. There are also support groups with carers
who are in the same boat that you can join. In addition, tips have also been drawn
up for caregivers that help to deal better with the patient.
Ch16: What are childhood and adolescent psychological
problems?

What difficulties are associated with the

identification and diagnosis of childhood and
adolescent psychological problems?
There are some difficulties in psychopathology in childhood and adolescence that are
not present in adults. First, behavioural and psychological problems must be seen in
the context of the child as a developing organism. Bedwetting is normal up to a
certain age, but it is from about 5 years old. Second, children have weak self-
knowledge due to their immaturity. They can sense that something is not right, but
not name it.

The psychological problems in children can be divided into two domains:

externalizing disorders and internalizing disorders. Externalizing disorders are
characterized by outward behaviour problems, such as aggressiveness,
hyperactivity, or impulsiveness. Internalizing disorders are characterized by inward-
looking and withdrawn behaviours and may represent depression, anxiety, and
active attempts at social withdrawal.

It is important to consider what is normal at a given age when determining clinically

relevant behavior in children. Diagnosis often depends on the individual's ability to
communicate problems and their consequences to the counsellor. Children often find
it difficult to communicate feelings and often have weak self-knowledge. Differences
in cultural norms also influence whether behaviors are seen as problematic or not. In
childhood and early adolescence, developments are very fast, which means that
psychological problems can escalate quickly and dramatically. Therefore, problems
should be identified as soon and early as possible to minimize psychological damage.

How is childhood psychopathology a precursor to

adolescence psychopathology?
In many adult psychological disorders, childhood experiences are important in the
aetiology. Developmental psychopathology describes how early childhood
experiences may act as risk factors for later diagnosable psychological disorders. In
addition, it seeks to describe pathways along which these experiences generate
psychological problems in adulthood.

There are several ways in which psychopathology in childhood may be linked to

psychopathology in adulthood. First, a childhood disorder may persist into adulthood
in the same form. Second, psychopathology in childhood may adversely affect
subsequent development and thus indirectly lead to various forms of maladaptive
behavior later in life. Third, psychopathology in childhood may represent a less
cognitive precursor to a related disorder in adulthood. Fourth, a childhood disorder
may leave an individual vulnerable to later life stressors.

⇧
What is the prevalence of childhood and adolescent
psychological disorders?
Estimates are that 10% to 20% of children and adolescents have a diagnosable
psychological disorder. Disorders are more common in men than in women, but this
is reversed in adulthood. Early developmental problems and specific fears (such as
potty-training delays) often resolve themselves as childhood progresses, but other
problems (such as disruptive behaviors) seem more permanent.

Comorbidity is common, about 2% of children have more than one diagnosis. In

addition, psychopathology in childhood is associated with physical health problems
and poor academic performance. Risk factors include having one parent, parental
psychopathology, repeated early parental divorce, harsh or inadequate parenting,
exposure to abuse or neglect, and negative peer influence.

What is Attention Deficit Hyperactivity Disorder

(ADHD)?
Attention deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention
and/or hyperactivity-impulsivity to a greater degree than would be expected based
on age or stage of development. Hyperactivity is a higher level of activity than
normal. Impulsivity is reacting to a situation without thinking about the
consequences.

How Is ADHD Diagnosed?

Most children show both inattention and hyperactivity (combined presentation), but
sometimes one is dominant. Therefore, there are two diagnostic subtypes, namely
ADHD-predominantly inattentive and ADHD-predominantly hyperactivity/impulsivity.
The DSM-5 criteria for ADHD are:

A persistent pattern of inattention and/or hyperactivity and impulsivity, interfering

with normal functioning or development. For inattention, at least six of the following
are present for at least six months: (1) not paying careful attention to details or
carelessly making mistakes, (2) difficulty sustaining attention in activities, (3) not
listening when spoken to becomes, (4) ignores instructions, (5) has difficulty
organizing, (6) dislikes or avoids tasks that require sustained effort, (7) loses things
necessary to complete tasks, (8) is easily distracted , (9) is forgetful in daily
activities. For hyperactivity and impulsivity, at least six of the following have been
present for at least six months: (1) high level of agitation,

 The symptoms were present before age 12

 The symptoms are present in at least two situations
 The symptoms reduce the quality of educational, social, or occupational
skills
 The symptoms do not occur during schizophrenia or any other psychotic
disorder and are not better explained by another mental disorder
 ADHD has a high comorbidity with oppositional defiant disorder and
conduct disorder

What is the prevalence of ADHD?

About 5% of children are diagnosed with ADHD. Half of these carry this diagnosis
into adulthood.

What are the consequences of ADHD?

First, the inattention and hyperactivity can predispose the child to anger outbursts,
frustration, and stubbornness, among other things. This often leads to reduced
learning performance and conflicts with teachers and family. Children with mostly
inattentive symptoms suffer the most in terms of learning performance and children
with mostly hyperactivity symptoms in terms of peer rejection and injuries. In
addition, they generally have difficulty making friends because their behavior is
aggressive and disruptive.

Adults with ADHD have less success and security at work, poorer interpersonal
relationships, poorer academic performance, and poorer overall life satisfaction.

What does the aetiology of ADHD look like?

There are several biological factors in the aetiology of ADHD, including heredity,
brain factors, prenatal factors, and nutrients. The heritability of ADHD is about 76%,
according to twin studies. In addition, several genes have been identified that
contribute to the development of ADHD. Studies show that it is very likely that there
is a gene-environment interaction, with vulnerability to ADHD only manifested by
certain environmental influences.

MRI studies show that there are differences between the brains of individuals with
ADHD and those without ADHD. The brains of children with ADHD are smaller and
develop less quickly. Brain volumes of several specific brain regions are inversely
related to different ADHD symptoms. For example, problems in executive functioning
are related to reduced volume of the frontal lobes. Prenatal factors that interact with
genetic predisposition include maternal smoking and drinking during pregnancy and
birth complications such as low birth weight, respiratory problems and suffocation.

In addition, there are studies that state that hyperactivity is due to biochemical
imbalances from food additives, refined sugars and lead poisoning. There are also
several psychological factors in the aetiology of ADHD, including parent-child
interactions and theory of mind impairments. Children with ADHD are more likely to
have been raised by parents who also have ADHD, which can exacerbate symptoms
caused by the genetic component alone. Psychodynamic theories also point to the
possible role of inconsistent or ineffective parenting. Learning theory suggests that
parental responses to disruptive and impulsive behaviors may be rewarding or
reinforcing for children with ADHD.

Children with ADHD often fail to understand their peers' intentions in social
situations, suggesting problems with theory of mind. There is inconsistency in
finding a relationship between ADHD and poor performance on theory of mind tasks.
There is, however, consistency regarding the relationship between ADHD and limited
performance on tasks that require executive functioning. Therefore, it is argued that
ADHD symptoms are directly linked to impairments in executive rather than social
functioning.

What is Conduct Disorder?

Conduct disorder is a pattern of behavior in which the child shows various behavior
problems, including fighting, lying, running away from home, vandalism and
truancy.

How is conduct disorder diagnosed?

The DSM-5 criteria for conduct disorder are:

A persistent pattern of behavior that violates other people's rights or social norms,
manifested by at least three of the following for at least 12 months:

 Bullying or threatening others

 Starting a fight
 Using of a weapon to inflict serious physical harm
 Physical cruelty to others
 Physical cruelty to animals
 Robbing or other similar offenses
 Forcing others to engage in sexual activity
 Setting fire to destroying or seriously damaging property
 Intentionally destroying another's property
 Breaking into cars or houses
 Lying to get things
 Shoplifting or similar
 Staying out at night despite parental intervention, which starts before the
age of 13
 Running away from home at least twice or once for a longer period of
time, (15) often misses school starting before age 13
 The disruptions cause significant impairment in social, academic, and
occupational functioning
 If the patient is over 18: the condition is not better explained by
antisocial personality disorder

There are two subtypes of conduct disorder, childhood and adolescence-onset

conduct disorder. Childhood-onset conduct disorder is defined by the onset of at
least one characteristic of conduct disorder before age 10. Adolescent-onset conduct
disorder is defined by the onset of conduct disorder symptoms after age 10.

There are three considerations in diagnosing conduct disorder. First, individuals are
normally under the age of 18 and are only diagnosed with conduct disorder later in
life if they do not meet the criteria for an antisocial PS. Second, the clinician must
consider the social context in which the behaviors occur. In some environments,
these can have a protective function. Third, there is a related category of disordered
behavior called oppositional defiant disorder (ODD). This diagnosis is made when
children do not meet the full criteria for conduct disorder.

What is the prevalence and course of conduct

disorder?
For boys, the prevalence of conduct disorder is between 4% and 16%, for girls
between 1.2% and 9%. The disorder also manifests itself differently in boys
(aggression, violent behavior) than in girls (lying, running away from home). The
lifetime prevalence is around 9.5%. Symptoms usually appear between mid-
childhood and mid-adolescence and most resolve in adulthood, but some eventually
meet the criteria for antisocial PD.

What is the aetiology of conduct disorder?

There are several biological factors in the development of conduct disorder, namely
genetic, neuropsychological and prenatal factors. Twin studies show that the
hereditary component is between 45% and 67%. These studies also show that the
behaviors such as aggression and violent behavior are hereditary and that
environmental factors probably play an important role.

Neuropsychological impairments in cognitive functioning include impairments in

executive functioning, verbal IQ, and memory. However, the association between
antisocial behavior and weak executive functioning appears to be mainly driven by
relations between weak executive functioning and criminal behavior and
externalizing behavior, rather than by specific conduct disorder. Prenatal factors in
the aetiology of conduct disorder include maternal smoking and drinking during
pregnancy and maternal malnutrition during and after pregnancy.

In addition, there are several psychological factors in the development of conduct

disorder, namely influences from family and peers, cognitive factors and socio-
economic factors. Family and parent-child relationships are important factors
involved. Risk factors for developing ODD and conduct disorder include parental
unemployment, having a parent with an antisocial PD, impaired care for the child,
and abuse or maltreatment during childhood. Family environments that are less
close-knit, have few intellectual/cultural pursuits, have a lot of conflict, and are more
stressful are associated with the development of conduct disorder in the child.

Many children develop antisocial and aggressive behavior because they imitate the
violent activities they see in the media and among their peers. Violent behavior can
thus be facilitated, as it can become the norm if seen regularly. However, children
affected by the media are often already emotionally and psychologically disturbed.

Conduct disorder is associated with the development of deviant moral

consciousness. This may be because they develop highly distorted ways of
interpreting the world. Dodge developed the social information processing model for
antisocial and aggressive behavior, in which he argues that trauma, abuse, neglect,
and insecure attachment can create specific information processing biases. For
example, there is a tendency to interpret cues as malicious, even though there may
be good intentions behind them, this is called the hostile attributional bias. This
often results in an aggressive response. Socio-economic factors that can cause
conduct disorder are poverty, low socio-economic status, unemployment, living in
the city and poor educational achievement.

What is childhood anxiety?

Childhood anxiety manifests itself as withdrawn behavior. Many anxiety disorders
are similar to those seen in adults, but some are specific to children, such as
separation anxiety.

What are the characteristics of anxiety problems?

Separation anxiety is the intense fear of being separated from parents or caregivers.
The prevalence is about 4% for children aged 6-12 months and has a 12-month
prevalence of 1.6% for adolescents. The DSM-5 criteria for separation anxiety are:

Excessive fear of separation from those to whom the individual is attached,

manifested by at least three of the following:

 Disproportionate distress when separation from home or attachment

figures is experienced or anticipated
 Ongoing and unnecessary care about losing attachment figures or
possible things that could happen to them
 Persistent and unnecessary worry about unexpected events that may
cause separation from attachment figures
 Persistent aversion to going out or going far away from home because of
fear of separation
 Persistent and unnecessary fear of being left alone or without the
attachment figures
 Persistent aversion to sleeping alone or sleeping far away from home
 Repeated nightmares about separation
 Complaints about physical symptoms such as headaches or nausea upon
separation from attachment figures or in anticipation thereof.
 The fear is present for at least four weeks in children and six months in
adults
 The disruption causes significant impairment in key areas of functionality
 The disturbance is not better explained by another mental disorder.

OCD in childhood is very similar to OCD in adulthood. The characteristics are

intrusive, repetitive thoughts, obsessions and compulsions. The manifestations of
the disorder are slightly different in children than in adolescents. For example,
obsessions in children include symmetry and contamination, but in adolescents
religious and sexual obsessions. OCD in childhood is comorbid with a variety of
disorders such as tic disorders, Tourette's syndrome, other anxiety disorders and
eating disorders. Tic disorders are uncontrollable physical movements such as facial
and mouth twitching and rapid blinking. Tourette's syndrome is a disorder in which
motor and vocal tics occur frequently during the day for at least a year.

Generalized anxiety disorder in children and adolescents often takes the form of
anticipatory anxiety, with chronic worry about potential problems and threats.
Pathological worry is the persistent worry that is perceived by the individual as
uncontrollable. The number of concerns increases with age.

Specific phobias are common in normal development. However, if a fear persists and
becomes more problematic, it can affect daily life. An example of this is a social
phobia, which starts with a fear of strangers and can grow into a fear of social
situations and strangers.

Tics often begin in childhood and diminish in adolescence. Simple tics are short-
lived, such as blinking, shrugging, sniffing, and grunting. Complex motor tics are of
longer duration and may consist of combinations of simple tics. Tourette's syndrome
and behavioral tics are often comorbid with OCD. Treatments used for OCD can also
be effective for behavioral tics.

What is the aetiology of anxiety problems?

Twin and family studies show that there is a combination of hereditary and
environmental factors. Trauma and stress in childhood are risk factors for a variety
of psychological disorders in adulthood. These experiences cause psychological
stress and anxiety. In addition, illnesses such as asthma and the death of a pet can
cause anxiety and depression. Also, children are very bombarded with information
about possible dangers and threats. If negative information is given by an authority
figure, it can lead to changes in fear beliefs and avoidance. Because children depend
on their parents or caregivers for guidance and emotional support, it is not
surprising that dysfunctional forms of parenting can cause problems in childhood.
Both overprotective and avoidant parenting styles have negative effects and
facilitate anxiety.

What is Childhood and Adolescent Depression?

In childhood, depression manifests as clingy behavior, not wanting to go to school,
and exaggerated fears. In addition, there is a greater degree of somatic problems.
In adolescence, depression manifests as sulking, withdrawal from family activities,
weight disturbances, loss of energy, feelings of worthlessness and guilt, and in
extreme cases suicidal thoughts.

How is depression diagnosed in childhood and adolescence?

The diagnostic criteria are essentially the same as for adults. However, some
symptoms change with age. Certain complaints are more prominent in younger
children than in adolescents. Depression occurs in less than 1% of pre-school
children. Prevalence is between 2% and 3% for school-age children and between 4%
and 8% for adolescents. Depression is comorbid with other anxiety and substance
use disorders. This has negative consequences for learning performance, social
functioning and is associated with an increased risk of suicide, among other things.

What is the aetiology of depression in childhood and adolescence?

There are several risk factors for developing depression:

 Dispositional factors and existing psychological problems

 Stressful experiences
 Weak coping skills
 Weak social support
 Problems in physical health
 Weak learning performance

There appears to be a genetic component to childhood depression, but studies differ

in their findings. Studies suggest that genetic influences are indirect and have their
effect in combination with environmental factors. There is a strong link between
child depression and parental depression, which may indicate heredity on the one
hand, but parental depression may also create negative early experiences that may
precede child depression.

Psychological factors include the parent-child relationship and the development of

dysfunctional cognitions that shape depressive thinking. Depressed parents can
transfer their negative mood to their child through interactions with the child. In
addition, depressed parents may not be able to respond appropriately to their child's
emotional experiences, which may leave the child feeling helpless or unable to learn
how to regulate emotions. Children of depressed mothers have more interpersonal
limitations and a risk of interpersonal dysfunction, which can then exacerbate and
perpetuate depression in the child. Research on cognitive factors has mainly focused
on the role of a pessimistic inferential style, in which negative events are attributed
to stable causes. Children with this style are more likely to have an increase in
depressive symptoms due to negative events than children who do not have this
style. In addition, this style interacts with daily hassles in predicting an increase in
depressive symptoms.

The prototype adolescent most at risk for depression is a 16-year-old female with
early or late puberty. She experiences low self-confidence, negative body image,
feelings of worthlessness, pessimism and self-blame. She is self-conscious and very
dependent on others, but she says she receives little support from family. She
experiences major and mild stressors, such as conflict with parents and poor school
performance, and she has a weak coping style. Other forms of psychopathology are
present, including anxiety disorders, smoking, and past suicidality.

What drug treatments are there?

SSRIs were first used to treat depression, but this has been shown to increase the
risk of suicide. However, new studies call for this to be reconsidered, as the benefits
would outweigh the risks. Fluoxetine is used in the treatment of anxiety disorders.
However, there are several reasons why drug treatment in children should be
treated with caution:

 Complete resolution of symptoms is rarely achieved, especially in the

treatment of depression with SSRIs
 SSRIs have unpleasant side effects, such as nausea, headache and
insomnia
 Safety and effectiveness have not been proven, as studies vary widely in
methodology
 Doubts about the safety of various antidepressant drugs in children exist
in both the US and the UK, to the extent that official warnings have been
issued against their use.

With regard to ADHD, more is known about drug treatments. Ritalin

(methylphenidate) is the most commonly used form of stimulant medication to treat
hyperactive children. The exact effect is not known, but it probably acts on the
neurotransmitters noradrenaline and dopamine in areas of the brain that regulate
attention and behavior. Disadvantages of Ritalin are that the long-term effects are
not known that there are various side effects (such as sleeping problems and
memory loss), and that it is an amphetamine, which means that it can also be
abused.

How can Behaviour Therapy be used?

A commonly used classical conditioning method to treat nocturnal enuresis is the
bell-and-battery technique. A sensor is placed in the underwear of the child and if it
detects urine, an alarm will sound. As a result, the child learns to associate a full
bladder with waking up.
Specific behavioral therapy techniques such as systematic desensitization can also
be used to treat anxiety problems. Selective reinforcement techniques are used to
improve learning performance in children with ADHD and conduct disorder. Desired
behaviour is rewarded, and disruptive behaviour is ignored. Time-out (TO) is a
means of reducing disruptive behavior (aggression, breaking things, not listening)
by taking the child out of the situation and, for example, having him/her sit in a
specific TO chair for a period of 5 to 15 minutes.

Behavior management techniques are treatment methods that can be used in a

variety of settings and can even be taught to parents as a tool to monitor and
respond appropriately to their children at home.

What family interventions are there?

Systematic family therapy is based on the view that childhood problems stem from
inappropriate family structure and organization. The therapist focuses on the
boundaries between parents and children and how they communicate. Parent
management training seeks to teach parents how to adjust their responses to their
children so that acceptable behavior, not antisocial behavior, is rewarded. This is
used in families with children with conduct disorder. Functional family therapy (FFT)
combines elements of systematic family therapy and CBT. The treatment focuses on
strengthening family relationships by opening up communication between parents
and children.

These forms of therapy are used for conduct disorder, ADHD, depression, anxiety
and eating disorders and are more useful than no treatment or alternative
treatments.

How can Cognitive Behaviour Therapy (CBT) be

used?
CBT is mainly used to treat depression in adolescents. The individual is then made
aware of pessimistic and negative thoughts, depressive beliefs and erroneous
attributions. The individual is then taught to replace these with more realistic and
constructive cognitions. CBT has been successful in treating anxiety disorders such
as OCD, generalized anxiety disorder, specific phobias, social phobia and separation
anxiety. Family interventions can be successful by teaching parents how to apply
basic CBT procedures to their child's anxiety.

What is Play Therapy?

Play therapy includes a variety of play-based therapeutic and assessment techniques
that can be used with younger children who are less able to communicate and
express their emotions. It also allows children to develop a positive relationship with
the therapist, learn to communicate, express feelings, modify behavior, and develop
problem-solving skills. This form of therapy appears to be effective and also has
positive effects on behavior in general, social adjustment and personality.
Ch17: What about neurodevelopmental disability and
diversity?

How are Neurodevelopmental Disabilities and

Diversities categorized and labelled?
Neurodevelopmental disorders are apparent in early development and affect
intellectual, social and motor development. Three categories will be discussed:
specific learning problems, intellectual disabilities and autistic spectrum disorders.

Learning disabilities is an umbrella term for the three main categories as mentioned
above. In the DSM-IV-TR, the term mental retardation was used to refer to an IQ of
70 or less.

What are Specific Learning Disorders?

The DSM-5 divides specific learning problems into two broad categories, namely
specific learning disorders, and communication disorders.

A specific learning problem is a diagnostic category that includes disorders such as

dyslexia and communication disorders. There is high comorbidity between specific
learning disabilities and bipolar disorder, ADHD and autism. The DSM-5 criteria for a
specific learning disability are: Deficits in learning and using academic skills,
reflected in at least one of the following for at least six months:

 Inaccurate or slow reading with difficulty

 Difficulty understanding what words read mean
 Spelling problems
 Difficulty with expression through writing
 Difficulty understanding numbers
 Difficulty with mathematical reasoning
 The academic skills affected are substantially below what would be
expected based on the patient's age
 The difficulties are not better explained by intellectual impairment, visual
impairment, hearing impairment, or other mental or neurological
impairment

What is Dyslexia?
Dyslexia is a complex pattern of learning disabilities associated with difficulty with
word recognition in reading, weak spelling, and difficulty with written expression.
Reading involves word distortions, substitutions, and omissions, and reading is often
slow with difficulty understanding what has been read. Dyslexia is more common in
boys, this may be because boys tend to be more disruptive than girls in learning
environments, because girls compensate by liking reading more than boys, and
because girls have more effective coping strategies to deal with the reading
difficulties.

What is Dyscalculia?
Dyscalculia is a specific learning disability characterized by substantially below
standard arithmetic ability based on chronological age, intelligence, and level of
education. Skills that may be limited in dyscalculia include:

 Understanding or naming arithmetic terms

 Decoding problems in arithmetic terms
 Recognizing and reading numerical symbols or arithmetic characters
 Copying numbers or symbols correctly
 remembering to perform certain arithmetic operations
 Following sequences of arithmetic steps in the correct order.

What are Communication Disorders?

Communication Disorders include impairments in language, speech, and
communication. The DSM-5 diagnostic categories of language disorder, speech
sound disorder, and childhood-onset fluency disorder (also known as stuttering) are
discussed.

What is Language Disorder?

A language disorder is a disability in which there are problems in vocabulary
comprehension and production. The DSM-5 criteria for this are:

Persistent difficulties in acquiring and using language (spoken and written), due to
difficulty in comprehension and transmission where the following are present:

 Reduced vocabulary
 Limited sentence structure
 Difficulty with dialogue
 The skills are substantially below what would be expected based on the
patient's age
 Symptoms start in early development
 The problems are not better explained by visual and hearing problems,
motor dysfunction, or other mental or neurological disorders.

What is speech sound disorder?

A speech sound disorder is a persistent difficulty with speech sound production,
which interferes with speech intelligibility or prevents verbal communication of
messages. The DSM-5 criteria for this are:

 Persistent problems with speech sound production causing difficulty

understanding speech or preventing verbal communication;
 The problems create limitations in effective communication, interference
with social participation, academic or occupational performance;
 Symptoms start in early development; and
 The problems are not better explained by congenital or acquired
conditions, such as cerebral palsy, deafness, or other medical conditions.

What is childhood-onset fluency disorder (stuttering)?

Childhood-onset fluency disorder or stuttering is a disturbance in the normal fluency
and temporal pattern of speech that is inappropriate for age. The prevalence is
about 0.7%, specifically in children the prevalence is 1.4% and in adolescents 0.5%.
The DSM-5 criteria for stuttering are:

Persistent disturbance in the normal fluency and temporal pattern of speech,

inappropriate for the patient's age and language skills, where at least one of the
following is present:

 Sound and syllable repetitions,

 Sound lengthening of vowels and consonants,
 Hyphenated words,
 Filled or unfilled pauses in speech,
 Word substitution to avoid difficult words,
 Pronunciation of words with excessive bodily tension,
 Repetitions of words that consist of one syllable exist;
 The disturbance creates fear of speaking or limitations in effective
communication;
 Symptoms start in early development
 The problems are not better explained by speech-motor or sensory
impairments or other medical conditions.

What is the aetiology of Specific Learning

Disabilities?
Risk factors for developing dyslexia are failure to recognize rhyme at age 4, not
being able to name everyday objects at age 5, difficulty learning syntactic rules at
age 2-3. Family studies and twin studies show that there is a hereditary component
to dyslexia. There is evidence that certain genes play a role in brain development
and thereby cause brain development abnormalities associated with dyslexia. The
phonological theory of dyslexia states that reading difficulties are primarily caused
by difficulty distinguishing between speech elements (phonemes) and associating
these sounds with the letters in a written word.

Difficulty associating written letters with corresponding sounds is associated with

impairments in brain function, particularly in the temporoparietal regions. In
addition, abnormalities are found in the number and organization of neurons in the
posterior language areas. fMRI studies show reduced activation in several areas of
the left hemisphere, which could be a cause of impaired reading in children with
dyslexia. Individuals with dyslexia appear to compensate for their impairment by
using other brain areas that help identify words and associate them with sounds.

Dyscalculia appears to be the result of several impairments in basic number

processing, which can take three forms:

1. Impairment in memory and retrieval of arithmetic facts

2. Underdeveloped strategies for solving arithmetic problems
3. Impaired visual-spatial skills, resulting in errors in number alignment or
decimal point placement

There also seems to be a familial component and abnormalities in brain functioning

are partly genetically transmitted. Brain abnormalities have been found in areas
responsible for processing numbers and arithmetic calculations.
Many communication disorders are caused by organic problems related to abnormal
development of the physical apparatus to make and articulate sounds. In addition,
there is growing evidence that familial and genetic components contribute to the
development of communication disorders. One brain circuit that plays a role is the
basal ganglia-thalamo-cortical motor circuit, if this is damaged it will affect the
ability of the basal ganglia to produce timing cues for the initiation of the next motor
segment in speech. Stuttering is often also a result of brain damage in the basal
ganglia. In addition, the production of sounds could be influenced by emotional
factors, such as fear.

What about treatment and support for Specific

Learning Problems?
There is controversy whether specific learning difficulties should be treated in an
educational setting or in a clinical setting. Problems are often noticed in the context
of a child's educational development, but on the other hand, clinical problems are
often associated with them, such as anxiety, depression and disruptive behavior.
However, many problems can be treated by school psychologists or speech
therapists.

For younger children at risk, appropriate reading instruction can help them become
fluent readers. However, older children require more, such as adapted learning
materials and extra time. Altered auditory feedback (AAF) is a treatment for
stuttering that provides delayed auditory feedback or a frequency change in the
voice as they speak. It's not clear how exactly it works, but it reduces stuttering.
Prolonged speech is another technique in which a stutterer is taught a set of new
speech patterns, resulting in changes in the wording and articulation of speech and
breathing patterns.

What is Intellectual Disability?

An intellectual disability is a modern term to replace mental retardation to describe
severe and generalized learning disabilities. The DSM-5 criteria for intellectual
disability are:

 Impairments in intellectual functions, confirmed by clinical assessment

and standard intelligence tests
 Impairments in adjusted functioning resulting in an inability to meet
developmental and sociocultural standards of personal independence and
social responsibility
 The symptoms start in the developmental period

The DSM-5 also provides the option to classify intellectual disability into mild,
moderate, severe, and profound.

What are alternative approaches to defining Intellectual

Disability?
Rather than focusing on the negatives of intellectual disability, a view has recently
emerged that seeks to highlight factors that can facilitate better intellectual and
adaptive functioning. Each individual has different manifestations of the disability,
which is why the term 'intellectual disability' is more of a social construct than a
diagnostic category.

In addition, a more individualized assessment of an individual's skills is promoted,

where limitations should be described in such a way that appropriate support can be
developed. This focuses on the specific needs of a person, instead of putting them in
a box. As a result, in 2001 the rights of individuals with intellectual disabilities were
extended in the United Kingdom, allowing them to attend mainstream schools.
These schools must draw up so-called accessibility strategies to facilitate this.

What is the prevalence of Intellectual Disability?

Prevalence estimates are highly dependent on how intellectual disability is defined.
The DSM-5 estimates the prevalence at around 1% and the prevalence for severe
intellectual disability at approximately 6 in 1000.

What is the aetiology of intellectual disability?

Causes of intellectual disabilities in individual cases are often difficult to isolate and
identify. In addition, the same cause may have different manifestations in different
individuals. Differential diagnoses are also problematic, often it is unclear whether
an individual has a specific learning disability, more general intellectual disabilities,
an autism spectrum disorder or psychological or emotional problems.

What biological causes are there?

There are three categories into which biological causes of intellectual disability can
be divided:

1. Chromosomal disorders
2. Metabolic causes
3. Perinatal causes

Down syndrome is a disorder caused by the presence of an extra chromosome 21

and characterized by intellectual disability and distinctive physical features. The IQ is
usually between 33 and 55. Individuals with Down syndrome often have a thick
tongue which makes it difficult to pronounce words easily, they also often have heart
problems, and they grow old quickly. The disorder can be detected prenatally in
high-risk parents using amniocentesis, a procedure that analyses the amniotic fluid.
Fragile X syndrome is another chromosomal abnormality that causes intellectual
disability, where the X chromosome shows physical weakness and may be bent or
broken. Individuals with this disorder have language impairments and behavioral
problems.

Metabolic disorders occur when the body's ability to produce and break down
chemicals is limited. A recessive gene is a gene that must be present on both
chromosomes of a pair in order to be expressed. Two metabolic disorders underlying
recessive genes are phenylketonuria and Tay-Sachs disease. Phenylketonuria (PKU)
is caused by a deficiency in the liver enzyme phenylalanine-4-hydroxylase, which is
necessary for effective metabolism of the amino acid phenylalanine. It prevents
effective myelination of neurons, causing intellectual disability and hyperactivity. In
Tay-Sachs disease, the enzyme hexosaminidase A is absent in the brain and central
nervous system, which can cause neurons to die. The disorder is degenerative,
children of 5 months show a violent startle reaction and weak motor development.
Few live longer than 4 years.
Perinatal risk factors include factors that negatively affect the foetus in the womb.
Disorders acquired during prenatal development are called congenital disorders. The
mother's diet as well as infections and drug use by the mother can cause intellectual
disabilities in the child. Maternal malnutrition is the lack of minerals and vitamins
during pregnancy, which can lead to intellectual disabilities in the child. If there is
too little iodine in the mother's diet during pregnancy, it can lead to cretinism, which
results in slow development, intellectual disability and short stature in the child. In
addition, infections in the mother can cause intellectual disabilities in the child. If the
mother gets rubella in the first ten weeks of pregnancy, the child has an almost 90%
chance of developing congenital rubella syndrome if it survives, which is
characterized by various congenital malformations, heart disease, deafness and
intellectual disabilities. Maternal HIV infection is the incidence of the mother having
HIV during pregnancy, leading to the likelihood that the infection will be passed on
to the child. Drug use by the mother leads to intellectual disabilities. The use of
medicines, alcohol, smoking and cocaine can all lead to limitations in the child. A
final example of a perinatal cause of intellectual disability is anoxia, where there is a
significant period without oxygen immediately after birth, this damages the brain.
The main consequence of this is cerebral palsy, which is characterized by motor
symptoms affecting the strength and coordination of movements.

What causes arise from one's childhood?

If a child is born healthy, it can still develop intellectual disabilities. There are
several possible causes:

 Accidents and injuries: This can damage the brain to such an extent that
intellectual disabilities arise. An example of abuse is shaken baby
syndrome, where brain trauma is caused by the baby being violently
shaken, which can lead to intellectual disabilities
 Exposure to toxins: An example is exposure to lead, which causes
neurological damage by accumulating in the tissue and interfering with
brain and central nervous system metabolism
 Poverty and social deprivation: These two are linked to risk factors for
the development of intellectual disabilities, such as malnutrition,
exposure to toxins, maternal drug and alcohol use, and childhood
physical abuse. A cycle of deprivation, poverty and intellectual disability
arises when young adolescents in poor environments have children of
their own. They are called teenage mothers and often have a below
average IQ themselves
 Poor environments provide less stimulation for a child, for example in
terms of educational stimulation and one-on-one parent-child
experiences. This reduced stimulation could affect early brain
development, causing limitations in brain function

There are several sad facts about teenage mothers:

 Teenage mothers are less likely to complete their education and are more
likely to raise their children alone in poverty.
 Infant mortality is 60% higher in teenage mothers who are born to older
mothers.
 Teenage mothers smoke more during pregnancy and breastfeed less
often, both of which have negative consequences for the child.
 Teenage mothers are three times more likely to suffer from depression
than older mothers and have a higher risk of poor mental health.
Children of teenage mothers are often at increased risk of poverty, have lower levels
of education, poor housing and health, and have lower levels of economic activity in
adulthood. Teenage pregnancy is more common in disadvantaged areas, so the
negative impacts of teenage pregnancy are disproportionately concentrated among
those who are already disadvantaged.

What interventions exist for intellectual

disabilities?
First, there are interventions that focus on preventing intellectual disability by
educating parents about risk factors. Secondly, training is given to teach skills that
help in everyday life. Third, there are approaches based on the principle of inclusion:
self-help strategies, social skills, life skills and self-reliance are taught in order to
function more effectively.

What do prevention strategies look like?

Preventing Intellectual Disabilities focuses on the parents, educating them about
what to watch out for during pregnancy and providing information about the risk
factors described earlier. In addition, genetic analysis can also provide information in
advance about possible problems in the child, so that parents can prepare for this
and be well informed. Teenagers can be given advice on contraception, among other
things.

Which training courses are there?

A variety of training courses are available for individuals with intellectual disabilities.
Examples are training for self-help and adaptive skills, language and communication
skills, basic skills and training that learns to regulate behavior.

Applied behavior analysis is the application of the principles of learning theory

(mainly operant conditioning) to the assessment and treatment of individuals
suffering from psychopathology. Basic techniques used include operant
reinforcement, response shaping, errorless learning, imitation, chaining, and self-
instruction training.

What inclusion strategies are there?

Inclusion is only a thing of the past few years. In the UK, the government's strategy
for individuals with special educational needs (SEN) includes improving support for
these children and their families and providing them with an integrated education
and care plan. These strategies lead to improvements in:

 Coping with daily life and self-confidence,

 The frequency of maladaptive behaviors, and
 Self-care and social skills.

Improvements can also be seen in quality of life as individuals gain opportunities to

pursue social, educational and occupational goals.

People with intellectual disabilities are less likely to get a job. There are special
sheltered workshops that provide individuals with intellectual disabilities with work
tailored to their needs and skills.
⇧

What is Autistic Spectrum Disorder (ASD)?

Autism spectrum disorder is an umbrella term that refers to all disorders that display
autistic symptoms of varying degrees of severity and disability.

What are the characteristics of Autistic Spectrum Disorder?

Deficits in social interactions is one of the most commonly reported and enduring
features of the disorder. There are limitations in the use of nonverbal behavior and
there is an inability to regulate social interaction and communication. Striking is the
inability to understand the intentions and emotions of others. There is a delay in the
development of spoken language and in those learning to speak there is an inability
to maintain a conversation. Some show echolalia, which is a direct imitation of the
words or sounds just heard. Pronoun reversal also occurs, where the individual
refers to himself as 'he', 'she' or 'you'. A common feature of autism spectrum
disorders is that individuals display restricted, repetitive, and stereotyped patterns
of behavior and interests. They can bond strongly with objects and often make
stereotypical movements, such as rocking.

What intellectual deficits are there?

About 80% of those with autism spectrum disorders show symptoms of intellectual
disability. However, they often excel in one specific task or area. This is also known
as savant syndrome: the phenomenon of extraordinary ability in a specific skill in
individuals with multiple cognitive impairments. This is strongly linked to autism
spectrum disorders and is commonly found in Asperger's. Asperger's is characterized
by impairments in social interaction and the development of restricted, repetitive
patterns of behaviour, interests and activities. This diagnostic category is no longer
used in the DSM-5.

How can Autistic Spectrum Disorder be diagnosed?

The DSM-5 criteria for an autism spectrum disorder are:

Persistent impairments in social activities, characterized by:

 Impairments in social situations, such as abnormal social approach or

inability to initiate or respond to social situations,
 Impairments in nonverbal communication, such as abnormalities in eye
contact or poor integrated verbal and nonverbal communication,
 An inability to develop, maintain, or understand relationships

Restricted and repetitive patterns of behavior, interests, or activities, characterized

by at least two of the following:

 Repetitive movements or use of objects or speech,

 Inflexibility and strong adherence to routine,
 Abnormal, intense, fixed interests,
 Hyper- or hypo responsiveness to sensory input or unusual interest in
sensory aspects of the environment;
 Symptoms start in early development;
 The symptoms cause significant limitations in important areas of life
  The symptoms are not better explained by intellectual disability or a
delay in general development.

Difficult to diagnose is that behavior patterns can change with age, symptoms can
manifest with varying degrees of intellectual disability, and autism spectrum
disorders are often comorbid with other problems, such as ADHD and epilepsy.

What is the prevalence of Autistic Spectrum Disorder?

The latest studies estimate the prevalence at around 1%. About 80% are boys.

What is the aetiology of Autism Spectrum Disorder?

There is strong evidence for the presence of a genetic component in autism
spectrum disorders. This is shown by family and twin studies. Molecular genetics
studies show abnormalities in specific genes.

One source of the cognitive and behavioral problems is abnormalities in brain

neurotransmitters that regulate and facilitate normal adaptive brain functioning. For
example, older studies show low levels of serotonin and dopamine. However, it is
important that more research is done on this first.

Several birth complications and prenatal factors have been identified as risk factors
for developing autism spectrum disorders, including maternal infections and infant
drug exposure during pregnancy, bleeding after the first trimester of pregnancy, and
impaired immune function during pregnancy. pregnancy. However, these risk factors
have only been found in case reports and thus are unlikely to be primary causative
agents of the disorder.

fMRI and EEG studies show that autism is associated with abnormal brain
development. Abnormalities have been found in the frontal lobes, limbic system,
cerebellum, and basal ganglia, among others. Also, individuals with autism spectrum
disorders have larger brain volume and weaker neural connectivity. The lack of
theory of mind is associated with reduced activation of the prefrontal cortex and
amygdala. The abnormalities are defined by a period of abnormal overgrowth in
early childhood followed by abnormally slow growth, which occurs at a point in
development when brain circuitry formation is at its most vulnerable.

What cognitive factors are there?

First, individuals with autism spectrum disorders show impairments on tasks that
test executive functioning, suggesting difficulty in problem solving, planning,
initiating, organizing, monitoring, and inhibiting complex behaviors, among others.
However, individuals may also be limited in the basic cognitive skills required to
accomplish tasks that test executive functioning. Second, individuals with autism
spectrum disorders are said to lack theory of mind. A traditional way to test this is
by using the Sally-Anne false belief task, which is a procedure that requires
resourcefulness. Third, researchers argue that limitations in theory of mind can
explain social and communication problems. Individuals with autism spectrum
disorders are said to have superior skills in systemizing, analysing and constructing
systems for understanding the world. This could explain the specific interests,
repetitive behaviors and resistance to change. This will systematize distinguishes
autism from other forms of psychopathology that also contain theory of mind
impairments. This empathizing-systematizing theory also helps to explain the
inability to 'generalize' in autism spectrum disorders.

What support and interventions are available for

individuals with Autism Spectrum Disorder?
First, individuals with autism spectrum disorders do not like change, but this is what
interventions aim to do. Second, individuals respond poorly to communication and
therefore the treatment program should begin at a basic level of communication,
such as learning to make eye contact. Third, children often show interest in only a
narrow range of events and objects, making it difficult to find effective reinforcers.
Fourth, there is strong selective attention, which makes it difficult to generalize what
has been learned to other situations than in which it was learned. Finally, individuals
may be treated with suspicion and restraint due to weak communication and social
skills.

What drug treatments are there?

Antipsychotics are most commonly used in the treatment of autism, including
haloperidol and risperidone. These mainly help control the behavioral problems. The
opioid receptor antagonist naltrexone has also been shown to be useful in controlling
hyperactivity and self-injurious behavior.

What behavioral training exists?

Most autism training programs will attempt to help the individual develop basic self-
help, social and communication skills. Modeling demonstrates desired behavior
before asking them to imitate the behavior. This technique is mainly helpful in
teaching sign language communication. Parent-implemented early intervention
involves parents in treatment by having them act as trainers to teach their children
basic self-help and communication skills. This improves communication in the child,
increases knowledge about autism, strengthens the mother's communication style
and parent-child interaction and reduces depression in the mother.

What inclusion strategies are there?

After the individual has acquired skills, they still need support for major life changes,
such as finding, and keeping a job. Supported employment provides support for both
the employer and the employee with autism. This type of support therefore ensures
better social integration and improves employee satisfaction and self-confidence.