Klinische psychologie eigen samenvatting (psychopathology)

Inhoudsopgave:

- hoofdstuk 1: An introduction to psychopathology; concepts, paradigms and stigma

- hoofdstuk 2: classification and assessment in clinical psychology

- hoodfdstuk 3: research methods in clinical psychology

- hoofdstuk 4: treating psychopathology

- hoofdstuk 6: anxiety and stressor-related problems

- hoofdstuk 7:  depression and mood disorders

- hoofdstuk 8: experiencing psychosis: schizophrenia spectrum problems

- hoofdstuk 9: substance use disorders

Chapter 1: An introduction to psychopathology; concepts, paradigms and stigma

Introduction

Psychopathology is the study of deviations from normal or everyday psychological or behavioral functioning. 

Clinical psychology is the branch of psychology that is responsible for understanding and treating psychopathology. 

A brief history of psychopathology

Demonic possession are the historical explanations of psychopathology, often alluded that the individual had been possessed in some way. Some thought this in a way of bad spirits, so demonology.This possession was because of the change in personality. 

Medical model is an explanation of psychopathology in terms of underlying biological or medical causes. It has given rise to a large body of scientific knowledge about psychopathology that is based on medicine, also called psychiatry. Such a medical model is the somatogenic hypothesis; the causes or explanations of psychological problems can be found in physical or biological impairments. For example general paresis. This is a brain disorder occurring as a late consequence of syphilis, characterized by dementia, progressive muscular weakness and paralysis.

Asylums are the hospices that were converted for the confinement of individuals with mental health problems(madhouses). Philippe Panel is considered to be the first to introduce more humane treatments during this time. Later on the Quaker movement came with the moral treatment, this is the approach to the treatment of asylum inmates, which abandoned contemporary medical approaches in favour of understanding, hope, moral responsibility and occupational therapy. It evolved more by the invention of the milieu therapies. These are the first attempts to structure the hospital environment for patients, which attempted to create a therapeutic community on the ward in order to develop productivity, independence, responsibility and feelings of self-respect. A further refinement came with the token economy programmes. It’s a reward system which involves participants receiving tokens engaging in certain behavior, which later in time can be exchanged for a desired item. 

Current models of mental health care espouse compassion, support, understanding and empowerment. 

Defining psychopathology

Abnormal psychology is an alternative definition of psychopathology, this comes with stigmatising relating to not being normal.

The opinion of the persons with mental health problems set groups. For example the service user groups are individuals who are end users of the mental health services provided by government agencies such as NHS. 

Reformist delusions are a belief that an improvement in social conditions can be achieved only through the revision of people’s attitudes. 

Ataque de Nervios is a panic disorder found in Latinos from the Caribbean.

Seizisman is a state of psychological paralysis found in the Haitian community. 

Harmful dysfunction is an assumption that psychopathology is defined by the dysfunction of a normal process that has consequence of being in some way harmful. 

Distressing mental health symptoms are just more extreme versions of normal emotions and behaviors, and are not in any way as qualitatively different from normal behavior as the harmful dysfunction model would imply.
To be diagnosed the symptoms must cause clinically significant distress or impairment in social, academic or occupational functioning. 

So potential ways of defining psychopathology include deviation from the statistical norm, deviation from social norms, exhibiting maladaptive behavior and experiencing distress and impairment. 

Explanatory approaches to psychopathology 

Genetics is the study of heredity(erfelijkheid) and variation of inherited characteristics. The way in which genetics might influence psychopathology can be studies in a variety of ways: 

1. concordance studies= how much genetic material family members have in common, to predict the development of a psychological disorder. 

2. twin studies= comparing monozygotic and dizygotic twins

3. Studying the offspring of monozygotic and dizygotic twins.

The diathesis-stress model suggests that a mental health problem develops because of an interaction between a genetic predisposition and our interactions with the environment. When the heritability number is close to one, the more important the genetic factors are in explaining a symptom.

Molecular genetics is an approach that seeks to identify individual genes that may be involved in transmitting psychopathology symptoms. For example the genetic linkage analysis, which compares the inheritance of characteristics for which gene location is known with the inheritance of psychopathology symptoms. So you can see if for example eye color is at the same gene as a psychological disorder. 

Epigenetics is the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code.

The neuroanatomy of the brain: figure 1.2, blz.22

• corpus callosum= a set of nerve fibres which connects the two mirror-image hemispheres of the brain.

• cerebral cortex= the outer, convoluted(labyrinth) area of the brain.

• occipital lobe= brain area associated with visual perception.

• temporal lobe= the areas of the brain involved with hearing, memory, emotion, language, illusions, tastes and smells.

• parietal lobe= brain region associated with visuo-motor coordination.

• frontal lobe= brain region that controls voluntary movement, verbal expressions, problem solving, will power and planning. 

• limbic system= hippocampus, amygdala, hypothalamus, mammillary body, fornix and thalamus. Involved in emotion and learning.

• hippocampus= a part of the brain which is involved in spacial learning.

• amygdala= the region of the brain responsible for coordinating and initiating responses to fear.

Brain neurotransmitters:

• dopamine= a compound that exists in the body as a neurotransmitter and as a precursor of other substances  including adrenalin.

• serotonin= an important brain neurotransmitter where low levels are associated with depression.

• norepinephrine= a neurotransmitter thought to play a role in anxiety symptoms. 

• gamma-aminobutyric acid (GABA)= a neurotransmitter thought to play a role in anxiety symptoms.

Psychological models:

• Psychoanalytic/psychodynamic→ Sigmund Freud

There were 3 psychological forces that shape an individual’s personality: id(instinctual needs), ego(rational thinking and superego(moral standards). Mental health is maintained when these forces are in a balance. 

• Behavioural

Learning theory: classical conditioning from Pavlov(association) and operant conditioning from Skinner(consequences, reward or punishment). 

• Cognitive→ Ellis and Beck

The disorder is the result of an individual's irrational beliefs, developing dysfunctional ways of thinking and processing information in biased ways. Cognitive behaviour therapy(CBT) is an intervention for changing both thoughts and behaviour. 

• Humanistic-existential→ Carl Rogers

To resolve psychological problems through insight, personal development and self-actualisation. 

The client-centred therapy assumes that if individuals are unrestricted by fears and conflicts, they will develop into well-adjusted and happy individuals. The therapist will use empathy and unconditional positive regard. 

Mental health and stigma
It can be divided into two distinct types:

1. social stigma= characterized by prejudicial attitudes and discriminating behavior directed towards individuals with mental health problems, as a result of their psychiatric label.

2. perceived stigma/self-stigma= the internalising by the mental health sufferer of their perceptions of discrimination and perceived stigma, can affect feelings of shame and lead to poorer treatment outcomes.

The media are still a significant source of stigma-relevant misinformation. The ‘Time to Change’ programme tries to lower these stigma by sharing the information.

Chapter 2: classification and assessment in clinical psychology

Classifying psychopathology

Emil Kraepelin was the first person to develop a classification system for psychopathology. He suggested that it could be classified into different and separate pathologies, each of which had a different cause and could be described by a syndrome(a distinct set of symptoms). Later on the WHO added psychological disorders to the International List of Causes of Death(ICD). Despite this development, it wasn’t accepted so the American Psychiatric Association(APA) published its first Diagnostic and Statistical Manual(DSM). It provides the following information: essential features of the disorder, associated features, diagnostic criteria and information on differential diagnosis. 

Comorbidity is the co-occurence of two or more distinct psychological disorders. 

Disorder spectrum is the frequency of comorbidity that suggests that most disorders defined by DSM may indeed not be independent discrete disorders, but may represent symptoms of a disorder spectrum that represents a higher-order categorical class of symptoms.

Hybrid disorders are disorders that contain elements of a number of different disorders. For example the mixed anxiety-depressive disorder.

Attenuated psychosis syndrome is seen as a potential precursor to psychotic episodes. 

Methods of assessment 

The method for an assessment has to be reliable(same result by different clinicians) and valid(it measures what is claims). 

Reliability:

• test-retest= similar results when the same person takes a test with several weeks/months apart. 

• inter-rater= the degree to which two independent clinicians or researchers actually agree when interpreting or scoring a particular test.

• international consistency= to which all items consistently relate to one another.

• Cronbach’s a= statistical test used to assess the internal consistency of a questionnaire or inventory.

Validity:

• concurrent= how correlated scores of one test are with scores from other types of assessment that we know also measure that attribute.

• face= the idea that a particular assessment method may appear to be valid simply because it has questions which intuitively seem relevant to the trait or characteristic being measured.

• predictive= the degree to which assessment method is able to help the clinician predict future behavior and future symptoms.

• construct= independent evidence showing that a measure of a construct is related to other similar measures.

An structured interview is one in which questions to be asked, the sequence and detailed information to be gathered are all predetermined. Such a technique is called the Structured Clinical Interview for DSM-IV-TR(SCID). In which the client's response to one question will determine the next question to be asked. In an unstructured interview questions are not predetermined. It’s the first contact a client will have with a clinician.

Psychological tests have a lot of advantages as methods of assessment:

• they assess the client on one or more specific characteristics or traits.

• they will usually have very rigid response requirements so that the questions can be scored according to a preconceived scoring system. 

• standardisation.

• tested to see if it is valid and reliable.

Most psychological tests are based on the psychometric approach. That is, that there are stable underlying characteristics or traits that exist at different levels in everyone. 

Types of tests:

• The Minnesota Multiphasic Personality Inventory(MMPI) is a personality inventory used by clinical psychologists and psychiatrists. 

• Projective tests consist of a standard fixed set of stimuli that are presented to clients, but which are ambiguous enough for clients to put their own interpretation on what the stimuli represent. Such as the Rorschach inkblot test, the Thematic Apperception test(TAT) and the Sentence Completion test. 

• Intelligence quotient(IQ) tests are used as means of estimating a person's intellectual ability. Such as the Wechsler Adult Intelligence Scale(WAIS).

• Neurological impairment tests such as the Adult Memory and Information Processing Battery(AMIB) and the Halstead Reitan Neuropsychological Test Battery.

• Psychophysiological tests can be used to measure emotional response. Such as electrodermal responding, electromyogram(EMG), electrocardiogram(ECG) and electroencephalogram(EEG). A lie detector depends on these kinds of biological changes, such as sweating. 

• Neuroimaging techniques such as Computerized axial tomography(CAT), Positron emission tomography(PET), magnetic resonance imaging(MRI) and functional magnetic resonance imaging(fMRI).

An ABC chart is an observation method that requires the observer to note what happens before the target behavior occurs(A), what the individual did(B) and what the consequences of the behavior were(C). Observational data has a greater external/ecological validity than other forms of testing. This means that the conditions simulated in the laboratory reflect real-life conditions. The ecological momentary assessment(EMA) is the use of self-observation or self-monitoring. 

The confirmatory bias is a clinical bias whereby individuals with a mental health problem ignore information that does not support their beliefs and interpret ambiguous information as supporting their beliefs.

Case formulation

A case formulation is the use of clinical information to draw up a psychological explanation of the clients problems and to develop a plan for therapy. It’s based on an individual approach. The case formulation has six components:

1. creating a list of the clients problems.

2. identifying and describing the underlying psychological mechanisms that might be mediating these problems.

3. understanding the way in which the psychological mechanisms generate the clients problem.

4. identifying the kinds of events that may have precipitated the clients problem.

5. identifying how these precipitating events may have caused the current problems.

6. developing a scheme of treatment based on these explanations and predicting any obstacle treatment.

Chapter 3: research methods in clinical psychology

Introduction

Someone who is competent as both a researcher and a practitioner is called a scientist-practitioner/applied scientist. 

Clinical psychology research- what do we want to find out?

The steps of research in psychopathology: description, prediction, control and understanding(explanation). 

Aetiologiy is a term widely used in psychopathology to describe the causes or origins of psychological symptoms. Analogue research is research on healthy, non-clinical populations in order to shed light on the aetiology of psychopathology. 

Clinical audit/evaluation research is the use of research methods to determine whether existing clinical knowledge, skills and resources are effective and are being properly used.

Research designs in clinical psychology

The type of research method you adopt will depend on the nature of the research question, the nature of the population you are studying and whether your research is at an early or advanced stage.

A correlational design is a research design which enables a researcher to determine there is a relationship or association between two or more variables.

A longitudinal study is research that takes measures from the same participants at two or more different times in order to specify the time relationships between variables. This may extend over many years or over a participant's whole lifetime(prospective or cross-sectional).

An epidemiological study is research which takes the form of a large-scale survey used to study the frequency and distribution of disorders within specific populations over a specified period of time(prevalence rates, lifetime prevalence, one-month prevalence and point prevalence). 

An experiment is a design in which the researcher manipulates a particular variable and observes the effect of this manipulation on some outcome, such as the participant's behavior. It’s the most powerful research tool we have. Demand characteristics are the features of an experiment which are the result of participants acting according to what they believe is expected of them. A clinical trial is an experimental research study used to test the effectiveness of treatments for mental health problems.

A mixed design is a research in which uses the non-random assignment of participants to groups in an experiment.  

A case study is an in-depth investigation of an individual participant. In a single-case experiment a single case is studied in which a participant's behaviour is observed and measured both before and after an experimental manipulation. For example an ABA design or an ABAB design, where A is doing nothing and B is the treatment or manipulation.

The grounded theory is an approach to qualitative analysis which involves identifying consistent categories of themes within the data, then building on these to provide more abstract theoretical insight into the phenomenon being studied.

Chapter 4: treating psychopathology

The nature and function of treatments for psychopathology

A palliative effect is the reduction of the severity of symptoms and alleviation of distress. This rarely provides the client with insight into their problems. 

Most psychodynamic approaches assume that unconscious conflicts develop early in life  and part of the therapy is designed to identify life events that may have caused the unconscious conflicts. There are several basic techniques used by psychoanalysts to achieve the goals of get the individual towards a sense of control over behavior, feelings and attitudes:

• free association= a technique used in psychoanalysis where the client is encouraged to verbalize all thoughts, feelings and images that come to mind.

• transference= a technique used in psychoanalysis where the analyst is used as a target for emotional responses: clients behave towards the analyst as they would have behaved towards an important person in their lives. 

• dream analysis= the analysis of dream contents as a means of accessing unconscious beliefs and conflicts.

• interpretation= helping the client to identify important underlying conflicts.

Behaviour therapy are interventions that attempt to change the client’s behaviour, based on conditioning. There are different therapies based on classical conditioning principles:

• extinction= emotional problems can be unlearned, by disrupting the association between the anxiety-provoking cues or situations and the threat or traumatic outcomes.

• flooding= a form of exposure therapy where the patient is repeatedly exposed to highly distressing stimuli, to treat phobias and related disorders.

• counterconditioning= use conditioning techniques to establish a response that is antagonistic to psychopathology. 

• systematic desensitisation= the client overcomes their fears through gradual and systematic exposure, used in the treatment of phobias and anxiety disorders.

• exposure therapy= the client gets confronted and experiences events and stimuli relevant to their trauma and their symptoms. 

• reciprocal inhibition= extinguish the relationship between the anxiety-inducing cue and the threatening consequence, but also by attaching a response to the anxiety-inducing cue which is incompatible with anxiety.

• aversion therapy= attempts to condition an aversion to a stimulus or event to which the individual is inappropriately attracted.

There are also some therapies based on operant  conditioning:

• functional analysis= identifying the consistencies between problematic behaviours and the consequences that may be reinforcing them.

• token economy

• response shaping= a reinforcement procedure that is used to develop new behaviours.

• behavioural self-control= change and control one’s own behaviour. 

Cognitive therapy is a form of psychotherapy based on the belief that psychological problems are the products of faulty ways of thinking about the world:

• rational emotive therapy(RET)= addresses how people construe themselves, their life and the world. Developed by Albert Ellis. 

• Beck’s cognitive therapy= an intervention that depression is maintained by a ‘negative schema’ that leads depressed individuals to hold negative views about themselves, their future and the world(negative triad). 

• cognitive behaviour therapy(CBT)= an intervention for changing both thoughts and behaviour. It’s an umbrella term for many different therapies. 

• mindfulness-based cognitive therapy(MBCT)= third wave. A direct extension of traditional CBT in which treatments emphasize achieving a mental state characterized by present-moment focus and non-judgemental awareness. 

• acceptance and commitment therapy(ACT)= third wave. Adopts some aspects of mindfulness, but has developed more from the Skinnerian approach to understanding behaviour. It teaches to just accept instead of change or manage things. 

Humanistic therapies are an attempt to consider the whole person and not just the individual symptoms of psychopathology:

• client-centred therapy= based on empathy and unconditional positive regard. 

• family therapy= involving family members that is helpful as a means of dealing with psychopathology that may result from the relationship dynamics within the family. 

Drug treatments:

• antidepressant drugs= MAOIs, SSRIs(affect the uptake of serotonin) and tricyclic antidepressants(increasing norepinephrine and serotonin) 

• anxiolytic drugs= treat symptoms of anxiety and stress. Benzodiazepines(increasing GABA) and SNRIs(inhibit norepinephrine and serotonin reuptake).

• antipsychotic drugs= chlorpromazine(blocking dopamine receptors) and haloperidol(blocking dopamine receptors).

Recently developed modes of treatment delivery include group therapy, counselling, computerized CBT(CCBT), e-therapy, telepsychiatry and the improving access to psychological therapies(IAPT) programmes. 

Evaluating treatment

The current methodology of choice for assessing the effectiveness of therapies is called randomized controlled trials(RCTs) or meta-analyses.

Factors affecting the evaluation of treatments include spontaneous remission, placebo effects and attentional factors provided by the therapists relationship with the client. 

The Dodo Bird Verdict is an expression from Carroll’s ‘Alice's adventures in wonderland’ implying that all psychotherapies are more effective than no treatment, but produce equivalent benefits.

Chapter 6: anxiety and stressor-related problems

Introduction

An anxiety disorder is a psychological disorder characterized by an excessive or aroused state and feelings of apprehension, uncertainty and fear. 

Specific phobias

An excessive, unreasonable, persistent fear triggered by a specific object or situation. Around 10% will meet this criteria. People with specific phobias acquire a strong set of phobic beliefs that appear to control their fear. These are beliefs about phobic stimuli that maintain the phobic’s fear and avoidance of that stimulus or situation. 

The DSM-5 specifies five subgroups of specific phobias: animal phobias, natural environment phobias, blood-injection-injury phobias, situational phobias and other phobias.

The famous Little Albert study is an example of how phobias can be acquired through classical conditioning. 

Biological preparedness is a theory which argues that we have a built-in predisposition to learn to fear things such as snakes, spiders, heights and water because these have been life-threatening to our ancestors. The non-associative fear acquisition model argues that fear of a set of biologically relevant stimuli develops naturally after very early encounters given normal maturational processes and normal background experiences, and no specific traumatic experiences with these stimuli are necessary to evoke this fear. The disease-avoidance model is the view that some animal phobias are related to attempts to avoid disease or illness that might be transmitted by these animals.

Social anxiety disorder

A severe and persistent fear of social or performance situations. Self-focused attention is a theory of social anxiety disorder arguing that sufferers show a strong tendency to shift their attention inward onto themselves and their own anxiety responses during social performance, especially when they fear they will be negatively evaluated. 

There is evidence for a genetic component to social anxiety disorder, but this may be a predisposition to develop anxiety disorders generally rather than social anxiety disorder specifically. 

Both monoamine-oxidase inhibitors and selective serotonin reuptake inhibitors have been shown to be successful pharmacological treatments for social anxiety disorder, as well as cognitive behaviour therapy. 

Panic disorder and agoraphobia

An anxiety disorder characterized by repeated panic or anxiety attacks. A fear or anxiety of any place where the sufferer does not feel safe or feels trapped, and is accompanied by a strong urge to escape to a safe place. The lifetime prevalence rate for panic disorders is between 1.5 and 3%, although prevalence rates do differ between different cultures.

The biological challenge tests are research in which panic attacks are induced by administering carbon dioxide(CO2) enriched air or by encouraging hyperventilation.The suffocation alarm theories are models of panic disorder in which a combination of increased CO2 intake may activate an oversensitive suffocation alarm system and give rise to the intense terror and anxiety experienced during a panic attack. 

Anxiety sensitivity are fears of anxiety symptoms based on beliefs that such symptoms have harmful consequences. 

A catastrophic misinterpretation of bodily sensations is a feature of panic disorder where there is a cognitive bias towards accepting the more threatening interpretation of an individuals own sensations. Clark’s model of panic disorder:

A reaction to this is safety behaviour, which are activities developed by sufferers as soon as they think they are having a panic attack, developed in the belief that this activity has saved them from a catastrophic outcome. 

Tricyclic antidepressants and benzodiazepines are an effective first-line treatment for panic disorder, but structured exposure therapy or cognitive behaviour therapy(CBT) is as effective, if not superior, to drug treatments over the longer term. 

Generalized anxiety disorder(GAD)

A pervasive condition in which the sufferer experiences continual apprehension and anxiety about future events, and this leads to chronic and pathological worrying about those events.

Information processing biases are biases in interpreting, attending to, storing or recalling information which may give rise to dysfunctional thinking and behaving. The attention bias modification(ABM) are highly anxious individuals who have attentional and interpretational biases towards threats that are known to cause anxiety. ABM is a practical way of reversing these biases and uses experimental procedures that will neutralize them.

A possible treatment is stimulus control treatment, which is an early behavioural intervention for worry in GAD which adopted the principle of stimulus control. Based on the conditioning principle that the environments in which behaviours are enacted come to control their future occurrence and can act to elicit those behaviours. Other treatments are: self-monitoring, relaxation training, cognitive restructuring and behavioural rehearsal. 

Obsessive compulsive disorder(OCD)

A disorder characterized either by obsessions(thoughts) or by compulsions(ritual). OCD-related diagnostic categories include: body dysmorphic disorder, hoarding disorder, hair-pulling disorder, skin-picking disorder. It has a lifetime prevalence rate of 2.5%

There are some genetic factors and in some brain areas(doubting and checking) there is evidence that it's triggered by OCD’ers. 

Clinical constructs are developed to describe the combination of thoughts, beliefs, cognitive processes and symptoms observed in individual psychopathologies.The ones that are linked to OCD are inflated responsibility(the power to prevent or bring about crucial negative outcomes), thought-action fusion(having a thought about an action is like performing it) and mental contamination(feelings of dirtiness without any physical contact with dirt). 

The mood-as-input hypothesis claims that people use their concurrent mood as information about whether they have successfully completed a task or not. 

Exposure and ritual prevention treatment involves graded exposure to the thoughts that trigger distress, followed by the development of behaviours designed to prevent the individuals compulsive rituals. Cingulotomy is a neurosurgical treatment of OCD involving destroying cells in the cingulum, close to the corpus callosum. 

Trauma and stress-related disorders(PTSD)

A set of persistent anxiety-based symptoms that occurs after experiencing or witnessing an extremely fear-evoking or life-threatening traumatic event. There are four categories of symptoms: intrusive, avoidance responding, negative changes in cognition & mood and increased arousal & reactivity. 

Acute stress disorder(ASD) is a short-term psychological and physical reaction to severe trauma. Symptoms are very similar to those of PTSD, but the duration is much shorter.

Classical conditioning. The emotional processing theory claims that severe traumatic experiences are of such major significance to an individual that they lead to the formation of representations and associations in memory that are quite different to those formed as a result of everyday experience. Mental defeat is a specific frame of mind in which the individual sees themselves as a victim. This is a psychological factor that is important in making an individual vulnerable to PTSD. The dual representation theory is an approach to explaining post-traumatic stress disorder suggesting that it may be a hybrid disorder involving two separate memory systems(SAM and VAM). 

Exposure therapie is the best solution. There is image flooding and eye movement desensitisation and reprocessing(EMDR). This last one is one in which clients are required to focus their attention on a traumatic image or memory while simultaneously visually following the therapist’s finger moving backwards and forwards before their eyes. 

Chapter 7: depression and mood disorders

Introduction

A mood disorder involving emotional, motivational, behavioural, physical and cognitive symptoms. 

A mania is an emotion characterized by boundless, frenzied energy and feelings of euphoria. 

There are two forms of depression: major depression/unipolar depression and bipolar disorder(periods of mania that alternate with periods of depression). 

Major depression

A major depressive episode is defined by the presence of five or more depressive symptoms during the same 2-week period. Estimates of lifetime prevalence rates for major depressive disorder range from 5.2 to 17.1%

Dysthymic disorder is a form of depression in which the sufferer has experienced at least 2 years of depressed mood for more days than not. Premenstrual dysphoric disorder is a condition in which some women experience severe depression symptoms between 5 and 11 days prior to the start of the menstrual cycle. Symptoms then improve significantly within a few days after the onset of menses. Seasonal affective disorder(SAD) is a condition of regularly occurring depressions in winter with a remission the following spring or summer. 

Chronic fatigue syndrome(CFS) is a disorder characterized by depression and mood fluctuations together with physical symptoms such as extreme fatigue, muscle pain, chest pain, headaches and noise and light sensitivity.

Depression has a genetic component. Also a neurochemical factor, namely the levels of the neurotransmitters serotonin, norepinephrine and dopamine. A tricyclic drug blocks the reuptake of both serotonin and norepinephrine. 

The anterior cingulate cortex(ACC) is the frontal part of the cingulate cortex resembling the collar from around the corpus callosum, used for relay of neural signals between the right and left hemispheres of the brain. 

a.orbital prefrontal cortex and the ventromedial prefrontal cortex

b.dorsolateral prefrontal cortex

c.hippocampus and amygdala

d.anterior cingulated cortex

High levels of cortisol may lead to depression by causing enlargement of the adrenal glands and in turn lowering the frequency of serotonin transmitters in the brain.

Biological factors may give rise to many of the symptoms of depression, but psychological processes may in turn trigger these biological factors.

The psychoanalytic account from Freud and Abraham has as first stage the introjection, which means the response to a loss where individuals regress to the oral stage of development, which allows them to integrate the identity of the person they have lost with their own. Symbolic loss is a Freudian concept whereby other kinds of losses within one’s life are viewed as equivalent to losing a loved one. Affectionless control is a type of parenting characterized by high levels of overprotection combined with a lack of warmth and care.

Interpersonal theories argue that depression is maintained by a cycle of reassurance-seeking by depressed individuals that is subsequently rejected by family and friends because of the negative way in which depressed individuals talk about their problems. Beck claims that depressed individuals have developed a broad-ranging negative schema that tends them towards viewing the world and themselves in a negative way. He proposed a negative triad:

This creates a self-fulfilling prophecie.

Learned helplessness is a theory of depression that argues that people become depressed following unavoidable negative life events because these events give rise to a cognitive set that makes individuals learn to become helpless, lethargic and depressed. The battered woman syndrome is the view that a pattern of repeated partner abuse leads battered women to believe that they are powerless to change their situation. Attribution theories of depression suggest that people who are likely to become depressed attribute negative life events to internal, stable and global factors. Hopelessness theory of depression suggests that individuals exhibit an expectation that positive outcomes will not occur, negative outcomes will occur and that the individual has no responses available that will change this state of affairs. Rumination is a tendency to repetitively dwell on the experience of depression or its possible causes. It can increase the risk of depression or increase the risk of relapse.

Bipolar disorder

The lifetime risk is 0.4 to 1.6%. There is bipolar disorder I and bipolar disorder II(major depressive episodes alternate with periods of hypomania). Cyclothymic disorder is characterized by at least 2 years of hypomania symptoms that do not meet the criteria for a manic episode and in which the sufferer experiences alternating periods of withdrawal then exuberance, inadequacy and then high self-esteem. 

There is good evidence that a genetic component is included. A common popular treatment of bipolar disorder is a combination of the antipsychotic drug olanzapine and the antidepressant SSRI drug fluoxetine(Prozac). 

Two significant triggers for mania in bipolar disorder include goal attainment and sleep disruption.

The treatment of depression and mood disorders

Stepped-care models are treatments for psychopathology that emphasize that the type of treatment provided for those individuals should be tailored to the severity of their symptoms and their personal and social circumstances.

The three main types of medication for depression are trycyclic drugs, monoamine oxidase(MAO) inhibitors and selective serotonin reuptake inhibitors(SSRIs). 

The traditional treatment for bipolar disorder has been lithium carbonate. Social skills training is a therapy for depression that assumes that depression in part results from an individual's inability to communicate and socialize appropriately and that addressing these skill deficits should help to alleviate many of the symptoms of depression. Behavioural activation therapy for depression attempts to increase clients access to pleasant events and rewards and decrease their experience of aversive events and consequences.  Cognitive therapy for depression attempts to help the depressed individual identify negative beliefs and thoughts, challenge these beliefs as irrational and replace them with positive rational beliefs. Cognitive retraining is an approach to treating depression developed by Aaron and Beck. Reattribution training in the treatment of depression attempts to get clients to interpret their difficulties in more hopeful and constructive ways rather than in the negative, global, stable ways typical of depressed individuals. Mindfulness-based cognitive therapy(MBCT) has been developed to prevent relapse in recovered depressed individuals by making them aware of negative thinking patterns that may be triggered by subsequent bouts of depression. 

Deliberate self-harm

A parasuicidal phenomenon that commonly includes cutting or burning oneself, taking overdoses, hitting oneself, self-strangulation or pulling hair or picking skin. Non-suicidal self-injury is the act of deliberately causing injury to one’s body without conscious suicidal intent. 

It can be performed as a form of self-soothing or as help-seeking. One of the more effective treatments includes problem-solving therapy.

Suicide

Over half of those that succesfully commit suicide are significantly depressed before the fatal atempt. 13.5% of people report suicidal ideation. Women are 3 times more likely to attempt suicide, but the rate for succesful suicide is 4 times higher in men. 

Risk factors include existing psychiatric diagnosis, low self-esteem, experiencing a significant negative life event, poor physical health and physical disability.

Both medication for mood disorders and CBT can be helpful in reducing suicide risks in vulnerable people. 

Chapter 8: experiencing psychosis: schizophrenia spectrum problems

Introduction

Schizophrenia spectrum disorders is the name for seperate psychotic disorders that range across a spectrum depending on severity, duration and complexity of symptoms.

Dementia praecox is an early, general term for a number of diagnostic concepts including paranoia, catatonia and hebephrenia. 

The nature of psychotic symptoms

Positive symptoms tend to reflect an excess or distortion of normal functions. Negative symptoms are characteristic of a diminution or loss of normal functions. They include diminished emotional expression/affective flattening, avolition(inability to carry out normal day-to-day activities), alogia(lack of verbal fluency), anhedonia(inability to react to enjoyable or pleasurable events) and asociality.

Delusions are firmly held but erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. 75% of the people with schizophrenia experience delusions.  The main types are:

• persecutory delusions= the individual believes they are being persecuted, spied upon, or are in danger.

• grandiose delusions= the individual believes they are someone with fame or power or have exceptional abilities, wealth or fame. 

• delusions of control= the individual believes that his or her thoughts, feelings or actions are being controlled by external forces.

• delusions of reference= the individual believes that independent external events are making specific reference to him/her.

• nihilistic delusions= the individual believes that some aspect of either the world or themselves has ceased to exist.

• erotomanic delusions= the individual believes that a person of higher social status falls in love and makes amorous advances towards them. (rare)

Around 70% of people with schizophrenia report auditory hallucinations. A reality-monitoring deficit is where an individual has a problem distinguishing between what actually occurred and what did not occur. A self-monitoring deficit is where an individual cannot distinguish between thoughts and ideas they generated themselves and thoughts and ideas that other people generated.

Disorganized thinking/speech:

• derailment= drift quickly from one topic to another(disorder of speech).

• loose associations= drift quickly from one topic to another(disorganized thinking).

• tangentially= answers to questions may be tangential rather than relevant(disorder of speech).

• clanging= thinking is driven by word sounds(speech pattern in schizophrenia).

• neologisms= made up words, by condensing or combining several words.

• word salads= no link between one phrase and the next(psychotic episode).

• poverty of content= the conversation has very little content(psychosis).

Catatonic motor behaviours are characterized by a decrease in reactivity and maintaining rigid, immobile postures.

The diagnosis of schizophrenia spectrum disorders

A brief psychotic disorder is the sudden onset of at least one of the main psychotic symptoms, with this change from a nonpsychotic state to the appearance of symptoms occurring within 2 weeks and being associated with emotional turmoil or overwhelming confusion. The five central characteristics of schizophrenia are delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour and flattened affect, poverty of speech and apathy. A schizoaffective disorder is characterized by schizophrenia symptoms plus a period reflecting either depression or mania. 

The prevalence of schizophrenia spectrum disorder

The lifetime prevalence rate for diagnosis of schizophrenia is between 0.5 and 0.7% and is similar across different cultures. Estimates for the lifetime prevalence rate for delusional disorder is around 0,2%.

The course of psychotic symptoms

Psychotic symptoms develop through three stages:

• prodromal stage= the slow deterioration from normal functioning to the delusional and dysfunctional thinking characteristic of many forms of schizophrenia, normally taking place over an average of 5 years. Around 70% of those have experienced stressful life events in the previous 3 weeks.

• active stage= the stage when the individual ceases to show prominent signs of positive symptoms.

• residual stage= the individual ceases to show prominent signs of positive symptoms.

The aetiology of psychotic symptoms

Diathesis-stress is the perspective that psychopathology is caused by a combination of genetically inherited biological diathesis(a biological predisposition) and environmental stress. The concordance rate in MZ twins is 44% but falls to 12% in DZ twins.

Genome-wide association studies(GWAS) is a technique which allows researchers to identify rare mutations in genes that might give rise to psychopathology symptoms. 

The dopamine hypothesis is a theory which argues that the symptoms of schizophrenia are related to excess activity of the neurotransmitter dopamine (phenothiazines blocked the dopamine receptor sites). Amphetamine psychosis is a syndrome in which high doses of amphetamines taken for long periods of time produce behavioural symptoms in humans and animals that closely resemble symptoms of psychosis. The mesolimbic pathway is impaired during the positive symptoms of schizophrenia. The mesocortical pathway is impaired during the cognitive processes in schizophrenia. 

The differences in the brain from someone with schizophrenia: enlarged ventricles, reduced grey matter in the prefrontal cortex and structural and functional abnormalities in the temporal cortex(limbic structures, the basal ganglia and the cerebellum). Evidence suggests that schizophrenia may also be associated with birth complications and maternal infections during pregnancy. 

Primary narcissism is a regression to a previous ego state which gives rise to a preoccupation with the self(Freud). A schizophrenogenic mother is a cold, rejecting, distant and dominating mother who causes schizophrenia according to Fromm-Reichmann. 

The orienting response is a physiological reaction to a stimulus consisting of changes in skin conductance, brain activity, heart rate and blood pressure.

Paranoid schizophrenia is a subtype of schizophrenia characterized by the presence of delusions of persecution. 

Biased cognition:

• attentional biases

• attributional biases= negative events are coming from external causes.

• reasoning biases= jumping to conclusion.

• interpretational biases= think about hearing voices.

• theory of mind(TOM)= the ability to understand one’s own and other people’s mental state.

The sociogenetic hypothesis is a theory that individuals in low socio-economic classes experience significantly more life stressors and these stressors are associated with unemployment, poor educational levels, crime and poverty generally. The social-selection theory argues that there are more individuals diagnosed with schizophrenia in low socio-economic groups because after they have developed psychotic symptoms they will drift downwards into unemployment and low-achieving lifestyles.

The double-bind hypothesis advocates that psychotic symptoms are the result of an individual being subjected within the family to contradictory messages from loved ones. Communication deviance(CD) is communication that would be difficult for ordinary listeners to follow and leave them puzzled and unable to share a focus of attention with the speaker. Expressed emotion(EE) is a qualitative measure of the amount of emotion displayed, typically in the family setting, usually by a family member or caretaker.

The treatment of psychosis

Custodial care is a form of hospitalization or restraint for individuals with psychopathologies whose behaviour is thought of as disruptive or harmful. 

Prefrontal lobotomy is a surgical procedure that involves severing the pathways between the frontal lobes and lower brain areas.

Neuroleptics are one of the main classes of drugs used for treatment of psychotic symptoms. First-generation antipsychotic drugs were developed when researchers discovered that antihistamine drugs used to combat allergies also helped to calm patients before surgery. Tardive dyskinesia is a disorder of motor movement developed by taking antipsychotic drugs for any period of time. Second-generation antipsychotic drugs were thought to be an improvement on traditional antipsychotics, however we now know that they can cause significant side effects.

Supported employment is a special programme designed with a built-in support mechanism to help people with physical, mental or developmental disabilities reach and maintain their customized vocational goals and objectives. Cognitive behaviour therapy for psychosis(CBTp) helps to address any abnormal attributional processes and information processing reasoning biases that may give rise to delusional thinking. Reattribution theory is a treatment used in helping individuals with paranoid symptoms to reattribute their paranoid delusions to normal daily events rather than the threatening, confrontational causes they believe underlie them. Personal therapy is designed to help individuals with the skills needed to adapt to day-to-day living after discharge from hospital. 

Cognitive remediation training(CRT) is designed to develop and improve basic cognitive skills and social functioning generally. Cognitive enhancement therapy(CET) is a form of intervention which addresses deficits in both social cognition and neurocognition. Family psychoeducation is designed to educate the family about the nature and symptoms of psychosis and how to cope with the difficulties that arise from living with someone with a diagnosis. Supportive family management is a method in which group discussions are held where families share their experiences and which can help to provide reassurance and a network of social support. Applied family management is an intensive form of family intervention which goes beyond education and support to include active behavioural training elements. Assertive community treatment helps people to recover from psychotic episodes with their medication regimes, offering psychotherapy, assistance in dealing with everyday life and its stressors, guidance, residential supervision and vocational training. Community care here is care that is provided outside a hospital setting.

See figure 8.4 blz.278 The occurrence of violence in schizophrenia.

Experiencing psychosis reviewed

Around 50% of sufferers will rarely fully recover from the effects of their symptoms.

Chapter 9: substance use disorders

Introduction

A drug is a substance that has a physiological effect when ingested or otherwise introduced into the body. Bath salts is the name for an emerging group of drugs containing synthetic chemicals related to cathinone, which is an amphetamine-like stimulant found in the khat plant. 

Defining and diagnosing substance use disorders

Substance abuse is a pattern of drug or substance use that occurs despite knowledge of the negative effects of the drug, but where use has not progressed to full-blown dependency. Substance dependence is a cluster of cognitive, behavioural and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. It’s characterized by tolerance and withdrawal effects. Tolerance means that the need for increased amounts of substance in order to achieve similar effects across time. Withdrawal is where the body requires the drug in order to maintain physical stability, and lack of the drug causes a range of negative and aversive physical consequences. Substance use disorder(SUD) is where an individual has at least one substance disorder diagnosis. Addiction means when a person's normal body state is the drugged state. 

The prevalence and comorbidity of substance use disorders

The lifetime prevalence rate for substance dependence in the US is between 2.6 and 5%. Substance use disorders are highly comorbid with a range of other Axis I and Axis II disorders.

Characteristics of specific substance use disorders

Three specific groups of substances:

• stimulant= increase central nervous system activity and blood pressure/heart rate.

• sedatives= central nervous system depressants which slow the activity of the body, reduce its responsiveness and reduce pain tension and anxiety.

• hallucinogens= psychoactive drugs which affect the users perceptions. They may sharpen the individuals sensory abilities or create sensory illusions or hallucinations. 

Zie figuur 9.3 blz. 290 drug chart

Hazardous drinkers are individuals who have five or more standard drinks(males) or three or more standard drinks(females) on a typical drinking day. Binge drinking is a high intake of alcohol in a single drinking occasion. Alcohol(ethyl) gets absorbed in the bloodstream and then reaches the brain and central nervous system. You get relaxed by influencing the GABA receptors. In the second stage you can get emotional/aggressive. In the last stage the motor coordination gets difficult. This course is known as biphasic, where the initial effects of a drug may act as a stimulant but the later effects act as a depressant. Delirium tremens(DTs) are a severe form of alcohol withdrawal that involves sudden and severe mental or nervous system changes. Fetal alcohol syndrome is heavy drinking in women, during pregnancy it causes negative effects on the baby. Alcohol use disorder is a problematic pattern of alcohol use leading to clinically significant impairment of distress. 

Polydrug abuse is of more than one drug at a time. Many of the so-called positive effects of alcohol are mythical and result from the drinker’s expectation. The lifetime prevalence rate for alcohol use disorder is between 12.5 and 17.8%. 

Nicotine is the addictive agent found in tobacco, it acts as a stimulant by increasing blood pressure and heart rate. It releases dopamine in the brain. Tobacco use disorder is a problematic pattern of tobacco use leading to clinically significant impairment or distress. Passive smoking is breathing in the air that contains other people's smoke. Second-hand smoke is a person's exhaled smoke, inhaled by another person.

Cannabis is a natural drug derived from the hemp plant, cannabis sativa. The main active ingredient is THC. Hashish is the most powerful of the cannabis group of drugs. Marijuna is a derivative of cannabis consisting of dried and crushed cannabis leaves.

Cocaine causes feelings of euphoria by blocking the reuptake of dopamine in the mesolimbic areas of the brain. If it is inhaled by smoking it’s called free-basing. The lifetime prevalence rate for cocaine is between 1 and 3%. Amphetamines have their effects by causing the release of the neurotransmitters norepinephrine and dopamine and simultaneously blocking their reuptake.

Opiates attach to brain receptor sites that normally receive endorphins, encourage the receptors to produce more endorphins that relieve pain, reduce stress and create pleasurable sensations. Some heroin users(controlled drug users/unobtrusive heroin users) seem able to use the drug without affecting their social and occupational functioning.

LSD appears to have its effects by influencing neurons in the brain that normally control emotion and visual information and it does this by affecting levels of the neurotransmitter serotonin. 

MDMA/Ecstasy is known to be a selective neurotoxin that destroys the axons to which serotonin would normally bind.  

The aetiology of substance use disorders

Drugs achieve their pleasurable effects by influencing the dopamine system in the brain, especially the dopaminergic neurons in the ventral tegmental area(VTA) of the midbrain and the nucleus accumbens(NAc). 

Alcohol myopia is the situation where an alcohol-intoxicated individual has less cognitive capacity available to process all ongoing information and so alcohol acts to narrow attention and means that the drinker processes fewer cues less well. 

A gene known as ALDH2 affects the rate at which alcohol is metabolized and will influence the individual's tolerance of alcohol. 

The treatment of substance use disorders

One form of community based service is self-help groups such as Alcoholics Anonymous(AA). Drug-prevention schemes are used with young people to try and prevent first drug use. Residential rehabilitation centres provide a controlled environment for detoxification and longer term support for individuals with substance use disorders. Behavioural therapies adapted to treat substance use disorders include aversion therapy and contingency management therapy. Cognitive behaviour therapy(CBT) is best employed when a sufferer has a psychiatric disorder comorbid with substance use disorder. Motivational-enhancement training(MET) provides communication training, social skills, problem-solving skills, relapse prevention methods and negative mood management. Antabuse(disulfiram) causes alcohol to produce toxins which make the individual feel unwell and has been used for over 60 years as means of controlling alcohol dependency. 

Drug treatments:

• Naltrexone= an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence.

• Naxolone= influences brain neurotransmitter receptor sites and prevent the neuropsychological effects of stimulants, opiates and hallucinogens. 

• Buprenorfine= an opioid drug use in the treatment of opioid addiction.