Summary of Abnormal Psychology by Nolen-Hoeksema - 7th edition

Abnormal Psychology by Nolen-Hoeksema - 7th edition - Abstract

Introduction of the book Abnormal Psychology

The book Abnormal Psychology was written by Susan Nolen-Hoeksema and last updated in 2014. The update of the book consisted of aligning the book's content with the current criteria of the DSM-V. This edition continues to focus on the importance of doing empirical research, it enlightens biological aspects of different disorders and it emphasizes that we should take cultural differences into account when we look at abnormal psychology.

Susan Nolen-Hoeksema was an American professor at the University of Yale, Michigan and Stanford University in the field of psychology. In her life, she has published several books on the topic of mental health, of which her book on Abnormal Psychology is one. The topics of depression and the gender differences that come with this disorder were of particular interest to her research. She investigated the influence of rumination and mood regulation strategies on one's vulnerability to develop a depressive disorder. Susan Nolen-Hoeksema died in 2013.

Parts of her book on Abnormal Psychology have been included in the custom edition Personality, Clinical and Health Psychology book by Leiden University. This summary will touch upon the origins of abnormality (chapter 1), what current theories are important when we are dealing with abnormality (chapter 2) and our current ideas about how we should assess and diagnose cases of abnormality (chapter 3). Later chapters will touch upon types of abnormality such as anxiety disorders (chapter 5), somatic symptom and dissociative disorders (chapter 6), mood disorders (chapter 7), schizophrenia and related disorders (chapter 8), different types of personality disorders (chapter 9) and eating disorders (chapter 12). The last chapter, chapter 15, will touch upon the themes that the field of health psychology is currently dealing with.

What does abnormality mean? - Chapter 1

The study of abnormal psychology is the study of people who suffer from mental, emotional and often physical pain; which is often called psychopathology. Sometimes these experiences are very different from what an average person would experience; but more often it is the case that people with psychopathological problems experience things that everyone would experience from time to time, but in a much more extreme way.

What is abnormality?

Some behaviors that seem abnormal from our perspective are however considered normal in other cultures or situations. When we are determining whether something is normal, we must therefore look at the context or the circumstances in which the behavior occurs. In addition to the context, there are a number of criteria that must be taken into account when determining whether certain behavior is abnormal.

How does abnormality differ among cultures?

Cultural relativism is a theory that states that there are no universal standards or rules for judging behavior as abnormal. Instead, behavior can only be labeled as abnormal according to the prevailing cultural norms. So there are different definitions of abnormality in different cultures.

Opponents of cultural relativism think it can be dangerous if cultural norms dictate what is normal and abnormal. For example, some societies in history have labeled certain individuals and groups as abnormal in order to justify to exert control on these groups. Think for example of what Hitler did to the Jews. Another example is when you consider the time of slavery: slaves who tried to escape, for example, would be diagnosed with drapetomania; a disease that presumably caused them to want freedom.

Gender also influences whether something is labeled as abnormal. For example, men who show sadness or anxiety, or who choose to stay at home for the children while their wives are at work, are often seen as abnormal. Women who are aggressive or who do not want children, for example, are often subject to the same prejudice. On the other hand, aggression in men and chronic anxiety in women are seen as more 'normal', as this is to be expected on the basis of gender.

In any case, it is clear that culture and gender have a number of influences on the expression of abnormal behavior and the way in which these behaviors are treated. Furthermore, culture and gender can influence the type of treatment that is found acceptable when abnormal behavior occurs.

When is behavior considered to be unusual?

A second standard that is used to judge behaviors as abnormal is the unusualness of the behavior. Behavior that is unusual, is considered abnormal, while typical behaviors are considered normal. This is in a certain sense linked to the cultural relativistic criterion, because the unusual nature of behavior is partly dependent on cultural norms.

This criterion also comes with certain problems. For example, how unusual must a behavior be to be called abnormal? Is behavior considered abnormal if less than 10% of the population exhibits it, or less than 1%? In addition, many rare behaviors can have a positive influence on the individual or society, making it strange to call such behaviors abnormal. People who display such rare but positive behavior are often called eccentric.

When is behavior seen as discomforting (distressing)?

The distress criterion states that behavior can be seen as abnormal when a person feels distress (discomfort) as a result of the behavior. According to this criterion, behavior is therefore not considered abnormal when it only violates cohabitation norms, but does not cause discomfort to the individual. Opponents of this theory state that people are not always aware of the problems that their behavior causes to themselves and others. In addition, it may be that certain behavior causes a lot of discomfort to others, even though it does not harm the individual itself. In such a case, we should actually call the behavior abnormal, even though it does not cause any discomfort to the individual.

How does behavior relate to the psyche?

Some people feel that we should not label behavior as abnormal unless it is part of a mental illness. This implies that a disease process, just like with high blood pressure or diabetes, is the cause of the behavior. However, so far, no biological test has been designed that can diagnose one of the types of abnormality discussed in this book. Many theorists believe that this is because mental health problems are not due to some abnormal genes or disease processes and that we can therefore never develop a simple or definitive test to determine whether someone has a mental disorder. A diagnosis for such a disorder is simply a label for a set of symptoms, so this diagnosis does not refer to an identifiable physical process found in all people who have these symptoms.

What are the four dimensions of abnormality?

Modern assessments of abnormality are not based on one of the previous criteria, but are influenced by a combination of four dimensions, often called the four D's: Dysfunction, Distress, Deviance and Dangerousness .

• Behavior and feelings are dysfunctional if they impair someone's ability to function in daily life. The more dysfunctional the behavior, the greater the chance that it is considered abnormal.

• Behavior and feelings that cause distress in the individual and the people around him / her are also often considered abnormal.

• Strongly deviant behaviors, such as chronic lying and stealing, lead to assessments of abnormality.

• Behavior that is dangerous for the individual; such as self-harm, or for others; such as severe aggression, is also seen as abnormal.

Together, these four D's form the professional definition on the basis of which behaviors are assessed as abnormal or maladaptive. Although these criteria provide much clarity, questions still remain. How much emotional pain or damage does a person have to experience? To what extent should the behavior hinder one's performance? We assume that each of the four D's is on a continuum; so, there is no clear dividing line between what is normal and what is abnormal.

What are the historical perspectives on abnormality?

There are three types of theories that attempt to describe the causes of abnormal behavior. The biological theories perceive abnormal behavior in the same way as physical illnesses caused by problems in physical systems. The supernatural theories perceive abnormal behavior occurs as a result of a divine intervention, curses, demonic possession or sin. The psychosocial theories believe that abnormal behavior occurs as a result of a trauma; such as the death of a loved one, or chronic stress.

Ancient theories

Our understanding of the beliefs about abnormal behavior of prehistoric people is based on deductions from archaeological findings. From the moment that written language emerged, people have been writing about abnormal behavior.

Expelling evil spirits

Historians speculate that even prehistoric man already had a concept of insanity, probably rooted in supernatural beliefs. Someone who acted strangely was said to be possessed by evil spirits. The treatment for this was exorcism; expelling the evil spirit from the body. This was done by making the body unsuitable for the mind to live in, often through extreme measures such as starving or beating the person. Sometimes, possessed people were even killed. Other times, holes would be drilled into their skull, through which the evil spirits could escape.

Ancient China: the balance of Yin and Yang

The ancient Chinese medicine theories were based on the concept of yin and yang. The human body would contain a positive force (yang) and a negative force (yin) that confronted and complemented each other. When the two forces were in perfect balance, the individual would be healthy. If not, illness (including insanity) could occur.

Another theory was that human emotions were controlled by the internal organs. When the breath of life flowed through one of these organs, the individual experienced a certain emotion. The heart was related to experiencing pleasure, the lungs to sadness and the liver to anger. This theory encouraged people to live in an orderly and harmonious way to promote the good movement of the breath of life. Although these explanations are primarily biological, more religious interpretations of abnormal behavior also emerged when Buddhism emerged.

Ancient Egypt, Greece and Rome: Biological theories dominate

Ancient scriptures from Egypt have been found that contain a list of disorders and the treatment that would be used for them. Disorders in women were often attributed to a 'wandering womb'. It was assumed that the uterus could loosen and move through the body, disrupting the other organs. The later Greeks followed the same theory and called it hysteria (from hystera, which means uterus). Today, the term hysteria refers to physiological symptoms that are most probably the result of psychological processes.

Most Greeks and Romans perceived craziness as a disorder of the gods. The sick retreated to temples of the god Aesculapius, where priests would perform healing ceremonies. Greek doctors, however, usually rejected supernatural explanations of abnormal behavior. Hippocrates, for example, stated that abnormal behavior was just like other body diseases. According to him, the body consisted of four basic fluids: blood, mucus, yellow bile and black bile. All diseases, including abnormal behavior, were caused by a poor balance of these four fluids. Hippocrates classified abnormal behavior into four categories: epilepsy, mania, melancholy and brain fever. Treatments were aimed at bringing these four liquids back into balance.

At this time the state took no responsibility for the insane, there were no institutions or institutions to care for them. Basic rights would be withheld from these people, such as the right to marry or the right to decide on their own property.

Medieval perspectives

Although the Middle Ages are often seen as a time when people were obsessed with the supernatural, this was not the case until the late Middle Ages. Before that, many people did believe in the supernatural, but there is also strong evidence that doctors and governments related abnormal behavior to physical causes or trauma and not to witchcraft or demons.

Witchcraft

Some historians argue that people accused of witchcraft were probably mentally ill. They probably suffered from delusions (false beliefs) or hallucinations; signs of some psychological disorder. However, it may also be that they made these confessions because of torturing or in exchange for a postponement of their execution. The theory that 'witches' were actually mentally ill was contradicted by the church at that time.

Psychic epidemics

A psychic epidemic is a phenomenon in which a large number of people exhibit unusual behavior that appears to have a psychological cause. In the Middle Ages, for example, there were dance frenzies in during which people would dance wildly around the house, on the streets, and in the church, while calling out the names of demons, without consideration of the fact that other people were looking at them. These people were often labeled as being possessed by the devil.

Today, these psychic epidemics still happen. In 1991, a great panic at a school in Rhode Island occurred, because many students and teachers thought they were breathing in toxic gases. They were actually starting to show physical symptoms. As a result, great chaos occurred: everyone was evacuated and many people were brought to the emergency room. However, no toxic gasses were found and the final conclusion was that it was an outbreak of mass hysteria caused by the public fear of chemical warfare during the Persian Gulf War.

The distribution of institutions

Around the eleventh or twelfth century, the first facilities in hospitals were created for people who exhibited abnormal behaviors. In these hospitals, the mentally ill were often held against their will and found themselves in very severe, inhumane conditions. The law stated that family members and friends of a mentally ill person were obliged to keep this person in a house, to tie them up or to chain them, to beat him or to take any other action to keep him under control so that he would not hurt anybody or himself. It was not until 1774 that a law was introduced in England that aimed to improve the terrible conditions in which people lived in these institutions. However, a medical theory that was considered to be true at that time stated that the mentally ill could be treated by taking huge amounts of blood from their bodies in order to restore the balance between body and mind.

Moral treatment in the eighteenth and nineteenth century

Fortunately, in the eighteenth and nineteenth century, a much more humane treatment method was developed for people with mental problems. The theory held that people developed problems due to stress of the rapidly changing social situation in that period. The treatment consisted of relaxation in a serene and physically attractive environment. The patients were free to walk around in the asylum and were given clean and sunny rooms and good food. The approach was exceptionally successful, and many people who had been locked up for years got their behavior under control again and were able to live reasonably normal again. Some of them could even leave the asylum.

Unfortunately, the moral treatment movement grew too quickly. As more people were admitted to the new asylums, the practitioners no longer had enough time to give each patient the personal attention they needed. As a result, the earlier major successes were replaced by more modest successes and sometimes even by failures. By the time the twentieth century dawned, many of the old asylums were back: facilities for the mentally ill. Really effective treatments did not arise until well into the twentieth century.

Which perspectives arose at the beginning of the twentieth century?

Despite the poor treatment of the mentally ill at the time, there was considerable progress in scientific research towards these disorders in the early twentieth century. This research laid the foundation for the biological, psychological and social theories of abnormality that we still use today.

The beginning of modern biological perspectives

In 1845, Wilhelm Griesinger published 'The Pathology and Therapy of Psychic Disorders', a paper in which he stated that all psychological disorders could be explained on the basis of brain pathology. In 1883, one of Griesinger's followers, Emil Kraepelin, published a book in which he developed a scheme for classifying symptoms in discrete disorders. This has been the basis for the classification systems that we still use today.

An important discovery was that syphilis appeared to be the cause of some form of insanity. This discovery gave a lot of weight to the idea that biological factors could be the cause of abnormal behavior.

The psychoanalytic perspective

Franz Anton Mesmer developed mesmerism, a method based on animal magnetism. He believed that people had a magnetic fluid in their body that must be well distributed in order to stay healthy. He treated the hysterical disorders by means of a ritual in which the patients sat in the darkness around a container with various chemicals. Then he came in, in a special robe, and while music was playing he touched every patient, with the aim of redistributing their magnetic fluids by his strong magnetic power and presence. Although Mesmer was eventually sentenced as a charlatan, his results continued to lead to discussion. The effects of the treatment are now attributed to the state of trance in which the patients ended up. This was later called hypnosis .

The effect of hypnosis was confirmed by Bernheim and Liebault, led by Charcot, who showed that they could induce symptoms of hysteria by suggesting these symptoms when the patients were under hypnosis. These experiments have contributed a lot to the progress of psychological perspectives on abnormality.

One of Charcot's students was Sigmund Freud. In his work, he became convinced that much of people's mental acitivity takes place outside of consciousness. He collaborated with Breuer on research towards hypnosis and the value of catharsis (a major release of emotions under hypnosis). They found that discussing the problems of the patient is often better under hypnosis because the patient would engage in less censoring. Their research became the basis for psychoanalysis, the study of the subconscious mind.

The roots of behaviorism

While the psychoanalytic theory emerged, the roots of behaviorism were planted in Europe and later on also in America. Ivan Pavlov developed methods and theories for understanding behavior in terms of stimuli and responses, rather than in terms of internal functioning of the subconscious mind. His research into the drooling of dogs when they encountered other stimuli than food is still world famous. From these findings he formulated the theory of classical conditioning . On the basis of this theory, the American John Watson investigated important human behaviors (such as phobias) and explained them entirely based on the theory of conditioning of an individual.

At the same time, Thorndike and Skinner investigated how the consequences of behavior influence the chance that this behavior will be repeated. They stated that behavior that is followed by positive consequences will be repeated more often than behavior that is followed by negative consequences. This became known as operant conditioning .

Behaviorism has had a major impact on psychology and is at the basis of many effective psychological treatments that are used today.

The cognitive revolution

In the 1950s, some argued that the generalizability of behaviorism was limited because the theory did not take into account the internal thought processes that influence the relationship between stimulus and response. It was not until the 1970s that the focus shifted from psychology to studying cognitions; thought processes that influence emotion and behavior. Bandura, for example, stated that the extent to which people think they can influence certain events (self-efficacy beliefs) is crucial for their mental health.

Beck introduced rational emotive therapy. This therapy was controversial, as therapists sometimes really had to challenge their patients to change their irrational thought patterns. The treatment method eventually became very popular and Beck's cognitive therapy has become one of the most used therapies for many disorders.

What has changed in modern mental health care?

Halfway through the 20th century, there were major advances in the medical treatment of some important forms of abnormality. In particular, the discovery of phenothiazines (drugs that can counteract hallucinations and delusions) made it possible for many people who had been in institutions for years to return to normal society. In addition, new forms of psychotherapy have been developed that are very effective in treating a wide range of psychological problems.

Deinstitutionalization

The patients' rights movement arose around 1960. The perspective was that mental patients would be able to recover better when they would be re-integrated into society, with support from treatment within the community. This was called de-institutionalization. This process had a huge effect on the lives of people with serious psychological problems. Many patients experienced a great improvement in their quality of life as a result, and they suddenly had much more freedom.

This can still be seen today. Work in the community is often done by social workers, therapists and doctors. In halfway houses, patients live in a structured environment in which they can get used to life in society, a job and their family and friends. Day treatment centers ensure that people can receive treatment during the day, but can go home and sleep there at night. People with acute problems can go to psychiatric hospitals.

A problem with these developments was that community-based treatment centers could not handle the large numbers of patients who left the asylum. Many ended up in care homes or with family in the house, where they did not receive the right treatment. Another part ended up on the street.

Managed care

Managed care is a collection of methods for coordinating care, ranging from simply keeping an eye on someone to fully checking which care can be given and paid for. The aim is to provide assistance for existing medical problems and to prevent future medical problems. Often, caregivers receive a fixed amount of money per patient per month and then have to determine how they can offer the best care to each patient with that money.

The advantage of this is that finding suitable care no longer has to be done by the patient's family, but that the primary care provider can find the right care and ensure that the patient has access to it. This prevents the patient from missing out on the right treatment. Unfortunately, mental health care is not always (fully) covered by health insurance. In addition, many American states have reduced the mental health care subsidy, which means that poorer people in particular cannot receive the care they actually need

Which theories and treatments of abnormality exist? - Chapter 2

A theory is a set of ideas that provide a framework. On the basis of this framework, questions can be asked about a certain phenomenon and information can be collected and interpreted about this phenomenon. A therapy is a treatment, often based on a theory of a disorder, that deals with the factors that - according to the theory - cause the disorder.

There are different approaches to explaining psychological complaints. When it comes to anxiety complaints, for example, the biological approach states that the symptoms can be caused by a genetic predisposition to anxiety. The psychological approach seeks explanation in one's beliefs, life experience, and relationships. The sociocultural approach looks at the cultural values ​​or social environment of a person. These different approaches are often treated to have an exclusive influence on one's behavior. People are looking for either a biological explanation or a sociocultural explanation. This is also called the nature-nurture debate: is the explanation in someone's nature, or in upbringing (or environment).

Although it is tempting to look for one explanation, nowadays theorists often take the biopsychosocial approach, which recognizes that it is often a combination of biological, psychological and sociocultural factors. Vulnerability to a disorder can also be due to any of these factors and therefore does not always have to be genetic. Vulnerability alone is also not sufficient to develop a disorder, it is only when another trigger occurs (for example stress) that the disorder could really develop.

Treatments have also been developed for each of these approaches. The biological approach mainly prescribes medication, while the psychological and sociocultural approach usually involve psychotherapy. Both types of treatment have proven to be effective and are often used intertwined, in an integrated approach.

What are biological approaches to abnormality?

The famous story of Phineas Gage is about a man, who one day, due to an accident at work, was hit by a thick iron bar that went through his skull and brain. Miraculously, he survived this accident and fully recovered physically. However, his personality had changed completely: from a responsible, kind and intelligent man, he had suddenly changed to a capricious person who had no respect for social interaction norms. His sense of responsibility was completely gone.

Later research showed that Gage had been particularly damaged in the frontal lobe. People who have damage to this part of the brain often have difficulty making rational decisions in social situations and have difficulty processing information about emotions. They can still solve logic and abstract problems, just as Gage could.

Brain dysfunction is only one of three possible biological causes of abnormality. The other two are biochemical imbalance and genetic abnormalities . These three causes can also influence each other. For example, brain dysfunction can be the result of genetic factors and this can in turn cause biochemical imbalance.

Brain dysfunction

The brain can be divided into three main areas: the rear brain, the middle brain and the front brain.

The rear brain contains the medulla (which controls breathing and reflexes), pons (which is important for attention and timing of sleep), reticular formation (that controls arousal and attention to stimuli), and the cerebellum (that deals with coordination of movement) and is crucial for the most basic life functions.

The middle brain contains the superior colliculus and inferior colliculus (that transmits sensory information and controls movement) and substantia nigra (regulates responses to reward).

The forebrain in humans is relatively large and developed compared to other organisms. The outer layer of the cerebrum is called the cerebral cortex, which is involved in many of our most advanced thought processes. The cerebral cortex consists of two hemispheres that are connected to each other by the corpus callosum. Each hemisphere consists of four lobes: the frontal, parietal, occipital and temporal lobes, which each have different functions. Other structures in the forebrain are located just below the cortex and are therefore called subcortical structures. These are the thalamus (which sends incoming information from the senses to the cerebrum), the hypothalamus (that regulates eating, drinking and sexual behavior), the limbic system (which regulates many instinctive behaviors, such as reactions to stress, eating and sexual behavior), the amygdala (which is part of limbic system, and is involved in emotions such as fear) and the hippocampus (that is part of limbic system, plays a role in memory).

Biochemical imbalance

Neurotransmitters are biochemicals that act as messengers. They bring impulses from one neuron (nerve cell) to the next. This happens in the brain and in some other parts of the nervous system. Each neuron has a cell body and a number of short branches, called dendrites. These components receive impulses from nearby neurons. The pulse then moves via a long branch, called the axon, to the synaptic terminal. From there, the impulse stimulates the release of neurotransmitters in the synaptic gap between two neurons. The neurotransmitters bind to special receptors of the next neuron, which in turn initiates an impulse. This is how the impulse from neuron to neuron is transmitted.

Many biochemical theories suggest that specific psychopathologies often have to do with an imbalance of certain neurotransmitters in the synapse. This can be influenced by two factors. The process of reuptake refers that the pre-synaptic neuron takes up the neurotransmitter again, reducing the amount that is present in the synapse. The process of degradation involves the post-synaptic neuron releasing an enzyme into the synapse, which breaks down the neurotransmitter. If one of these processes is not functioning properly, an abnormally high or low concentration of a neurotransmitter in the synapse may result. Psychological symptoms can result from this. It may also be that psychological experiences cause changes in the neurotransmitter system.

There are more than 100 different neurotransmitters. For example:

• Serotonin plays an important role in emotions and impulses, such as aggressive impulses and anxious behavior.
• Dopamine is especially important in our experience of rewards. This neurotransmitter can be influenced by agents such as alcohol, which we see as rewarding.
• Norepinephrine (noradrenaline) only originates in the brainstem and provides a stimulating effect. When we have too little of this, we can feel depressed.
• Gamma-aminiburyric acid (GABA) inhibits the actions of other neurotransmitters and an imbalance of this transmitter is associated with anxiety complaints. GABA is used in many medication that has a calming effect.

The endocrine system

The endocrine system is a system of glands that produce hormones. Hormones also transport information through the body and in this way they have an effect on mood, energy levels, and responses to stress. The pituitary gland is the most important gland and lies just below the hypothalamus. In response to stress, neurons in the hypothalamus secrete corticotropin-release factor (CRF). This factor is transported to the pituitary gland, where it causes the main stress hormone, ACTH, to be excreted. This hormone goes through the blood to the adrenal glands in the rest of the body, where a variety of hormones is released that prepare the body for response to an emergency. This system is called the hypothalamic-pituitary-adrenal axis (HPA axis). When this is disturbed, people have abnormal physiological responses to stress, making them more sensitive to anxiety disorders and depression.

Genetic abnormalities

Behavioral genetics studies the genetics of personality and abnormality and looks at the extent to which behaviors are inherited and through which process genes influence behavior.

Every cell in the body has 46 chromosomes, 23 inherited from the mother and 23 from the father. These are 23 chromosome pairs, one of which determines the gender of an individual. The XX combination makes someone a woman, the XY combination a man. When the structure of these chromosomes changes, this can have serious consequences. This is for example how Down's syndrome arises; in this disease, chromosome 21 does not contain two, but three chromosomes. Each chromosome contains genes, in the form of strands of DNA. These genes provide instructions to the cells to perform certain functions. Errors on the genes are more common than errors in the structure of the entire chromosome.

When there is an error on a gene, this does not immediately lead to a disorder. Often, several erroneous genes are needed that together contribute to the development of a disorder. This is called a polygenetic process. Diabetes, heart disease and epilepsy, among other things, are the result of such a polygenetic process.

Interactions between genes and environment

There are several ways in which genes and environment can influence each other. In this way genetic factors can determine what kind of environment we choose for ourselves, because we have a certain temperament or talent that is genetically determined. In addition, genes and environment can influence each other because the environment acts as a catalyst (enhancing factor) for a certain genetic tendency. For example, if someone is genetically vulnerable to depression, certain triggers in the environment are still needed to actually develop a depression. Finally, the study of epigenetics shows that environmental conditions can influence the expression of genes. DNA can be chemically modified by various environmental factors, which means that genes are turned 'on' or 'off'. As a result, cells, tissues and organs develop differently.

The study of epigenetics is still very new, but could become very important as knowledge is increasing. For example, it could help explain how identical twins, who therefore have the same DNA, can differ in the way a disorder expresses itself.

Therapy through medication

Most biological treatments for abnormality make use of medication. Medication can alleviate the symptoms by improving the functioning of the neurotransmitters.

• Antipsychotic drugs help to reduce hallucinations and delusions. The first antipsychotics were the phenohiazines, but these had dangerous side effects. Today, atypical antipsychotics are used, which are very effective but have far fewer side effects.
• Antidepressants reduce the symptoms of depression. SSRIs (selective serotonin reuptake inhibitors) are the most commonly used drugs; these affect the serotonin neurotransmitter system. Newer antidepressants, SNRIs (selective serotonin-norepinephrine reuptake inhibitors), act on both serotonin and norepinephrine. These drugs do have side effects, but not very dangerous ones.
• Lithium is a metal that can be found in nature. It is used as a mood stabilizer, especially in bipolar disorder. With this disorder someone suffers alternately from depression and mania (greatly increased mood, feeling of grandiosity, reckless behavior). Also, anti-convulsants can be used in the treatment of mania; which have fewer side effects than lithium.
• Initially, barbiturates were used to treat anxiety; but these turned out to be very addictive and quitting them can have very dangerous effects. Therefore, benzodiazepines are used more often nowadays: They reduce anxiety symptoms without seriously affecting someone's daily functioning. Unfortunately, these drugs are also very addictive, but the withdrawal symptoms are less severe.

Electroconvulsive therapy and newer brain stimulation techniques

Electroconvulsive therapy (ECT) is an alternative to medication. Although originally developed for the treatment of schizophrenia, it was later discovered that this treatment has an effect on depression, but not on schizophrenia. With this therapy, a kind of epileptic seizure is triggered by passing a current through the brain. Nowadays there are alternative techniques that are more focused and have fewer side effects. For example, there is repetitive transcranial magnetic stimulation (rTMS), in which magnetic pulses are aimed at specific brain structures. With deep brain stimulation, the vagus nerve is stimulated by means of electrodes, which in turn stimulates target areas in the brain. It seems that especially these newer techniques are effective. There are also few side effects.

Psychosurgery

Psychosurgery means that brain surgery is performed with the aim of stopping certain symptoms. In the past, a frontal lobotomy was sometimes performed in patients with psychosises. During this procedure, the frontal lobe was separated from the lower brain structures. However, this had serious side effects and psychosurgery is only rarely used today. The biggest problem is that for many disorders we do not know exactly which part of the brain is responsible for this.

Assessing biological approaches

Biological approaches have had a positive effect on the lives of people with disorders. They can now often lead normal lives and it has become clear that they are not guilty of their own behavior, but that they actually have a problem for which there is medical evidence. However, medication does not always work. For some disorders, such as specific phobias, psychotherapy works better than medication. In addition, drugs often come with various side effects, which are sometimes even worse than the disorder itself.

What are psychosocial approaches to abnormality?

Behavioral approaches

Behavioral approaches focus on the influence of rewards and penalties on the emergence of behavior. The most important principles are classical conditioning and operant conditioning. Furthermore, learning can occur through modeling and learning through observation.

Classical conditioning

Ivan Pavlov discovered that the dogs he used in his research did not only salivate when they were fed, but after a while even when he or one of his assistants walked into the room. He had a neutral stimulus (himself) paired with a stimulus that naturally leads to a certain response (eating, leading to drooling) and eventually the neutral stimulus (Pavlov himself) already led to the response. This process is called classical conditioning and here the food is the unconditioned stimulus (US). This stimulus produces the unconditioned response (UR). Pavlov himself served as the conditioned stimulus (CS), and the response that follows is the conditioned response (CR). This phenomenon is used to explain the apparently irrational responses to neutral stimuli.

Operant conditioning

Thorndike discovered that behaviors followed by a reward are strengthened, while behaviors followed by a punishment are weakened. He called this simple observation the law of effect. This observation led to the development of operant conditioning - the formation of behavior by rewarding desired behaviors and punishing unwanted behaviors. Behavior is learned the quickest through a continuous reinforcement schedule, meaning that the behavior must be rewarded or punished every time. However, the behavior can also be maintained through a partial reinforcement schedul, in which the behavior is only rewarded or punished occasionally. Extinction - the elimination of learned behavior - is most difficult when the behavior is learned through a partial reinforcement schedule, because then no continuous reward is needed to reinforce the behavior.

Modeling and learning through observation

In modeling, people learn new behaviors by imitating them from people who are important in their lives, such as their parents. This is especially the case when the model person is seen as authoritarian and similar to the person himself. Learning by observation occurs when a person observes the rewards and punishments that another person receives for his or her behavior.

Behavioral therapies

Behavioral therapies focus on identifying the rewards and punishments that contribute to a person's maladaptive behavior and on changing specific behaviors. We look at the situations in which the behavior occurs the most. There are many different techniques for behavioral change. Systematic desensitization therapy is one of them. During this type of therapy, the patient makes a list of situations that would generate anxiety. Subsequently, the patient is asked by the therapist to imagine these situations step by step in their mind, until he or she can withstand even the most frightening situation without any problems. With in vivo exposure, the patient is asked to actually experience the anxiety-stimulating stimulus directly. This often produces better results than just imagining the situation.

What are cognitive approaches to abnormality?

Cognitive theories state that it is not only rewards and punishments that motivate human behavior. Instead, our cognitions (thoughts and beliefs) would form our behaviors and emotions. When something happens, we tend to make a causal attribution of the event - we wonder 'why' it happened. These attributions determine what meaning we give to events and what we expect from similar events in the future. When an attribution is linked to our own behavior, this has consequences for our emotions and our self-concept: whether we attribute our behavior to ourselves or environmental factors can have very different consequences for how we think about ourselves. In addition to the attributions, we also make global assumptions about ourselves, our relationships and the world. These assumptions can be positive or negative and destructive. If these assumptions are negative, people are more likely to respond to situations in an irrational and negative way.

Cognitive therapies

Cognitive therapies help clients to identify and eliminate negative thoughts and dysfunctional beliefs. In addition, they are taught problem-solving strategies to deal with concrete problems and they learn alternative ways to think about things. Cognitive therapies are often combined with behavioral therapies, in the form of cognitive behavioral therapy (CBT). In the form of assignments, the client must then test alternative thoughts, or try new methods to deal with situations. In addition, new skills can be learned, such as effective communication.

Psychodynamic approaches

The psychodynamic theories of abnormality suggest that all behavior, thoughts and emotions, normal or abnormal, are influenced by unconscious processes. These theories were first developed by Sigmund Freud. He developed the field of psychoanalysis. Psychoanalysis is both a theory of personality and psychopathology, as well as a method to examine the mind, and also a form of treatment of psychopathology. Freud and his colleague Breuer argued that much of human psychopathology is the result of traumatic experiences of their past, which are hidden away in the subconscious mind (by the process of repression).

De Id, Ego and Superego

According to Freud, there are two basic drives that motivate human behavior: the sexual drive (referred to as the libido) and the aggressive drive. These drives want to be released continuously, but can be regulated by three different psychological systems. The ID is the system where the libido originates, and the drives and impulses of this system look for a direct way out in a situation. The ID works on the pleasure principle: it aims to achieve as much pleasure as possible as quickly as possible. It wants to minimize pain. As children get older, part of the id splits and becomes the ego; the system that tries to meet our wishes and needs, but within the rules of society. The superego then develops from the ego. This is the storage space for the rules of conduct that are learned from parents and society. The rules take the form of moral standards and living according to these rules reduces feelings of fear. According to Freud, most interactions between these systems happen completely unconsciously, but some find their way into the pre-consciousness. Only very few actually reach consciousness. Freud also described certain strategies that the ego uses to conceal or change unconscious wishes. When the behavior of a person is controlled by these defense mechanisms, or when the strategies are maladaptive, this can result in pathological behavior.

Psychosexual phases

During development, according to Freud, a child goes through a series of psychosexual phases. In each phase, the sexual drives focus on the stimulation of certain body parts. Parents' responses to the child's attempts to meet certain needs have a major impact on whether a certain phase is properly completed. If this does not happen, a child can become fixed on a certain phase, leaving him with worries and problems of that phase.

The phases of Freud are as follows:

• The oral phase - the first 18 months after birth, during which the child focuses on mouth stimulation. A child who fixes on this phase can develop deep distrust and separation anxiety.

• The anal phase - 18 months to 3 years, during which the child focuses on stimulation of the anus. Children can become fixed when parents are too critical during toilet training, they then become stubborn and stingy.

• The phallic phase - 3 to 6 years, in which the child focuses on the genitals. During this phase the Oedipus complex is created, in which boys are attracted to the mother and hate the father since he is like a rival. They are afraid that the father wants to castrate them, so they put the mother aside and try to become like the father. This leads to a strong superego. Girls are attracted to their father, hoping that he can give them a penis. Because there is no castration fear, they will never develop such a strong superego as boys. Failure to close this phase properly leads to incorrect gender roles or a non-heterosexual orientation and other problems with romantic relationships.

• The latent phase - 6 to 12 years, in this phase the sexual drives are at a low level. The attention is focused on the development of skills and interests.

• The genital phase - from the age of 12 on, sexual orientation reappears when puberty begins.

Later psychodynamic theories

The ego psychology emphasizes the importance of regulating defense mechanisms that ensure a healthy functioning of society. The object relationship perspective integrates aspects of Freud's drive theory with the role that early relationships play in the development of self-concept and personality.

Psychodynamic therapies

The goal of psychodynamic therapies is to help clients recognize their maladaptive coping strategies and the sources of their unconscious conflicts. Freud developed the method of free association for this. It is a therapy in which the client talks about anything that comes to mind. The therapist then looks at the themes that keep on coming back. When a client offers resistance to a certain subject, that is an important indication of the unconscious conflicts, because the most threatening conflicts are suppressed the most by the ego. The therapist must combine all the pieces to form an interpretation of the conflict that occurs. Sometimes the client accepts this as a revelation, but sometimes the client displays resistance. This is then seen as a sign that the therapist has succeeded in identifying an important unconscious problem.

Also transference is important. This means that the client responds to the therapist as if he is an important person from the early development of the client. For example, a client can react extremely angry if the therapist is a few minutes late, because a parent has left him earlier. Again and again treating certain painful memories and releasing emotions (catharsis) ensures that the healing process goes well.

The difference between psychoanalysis and modern psychodynamic therapy is that psychoanalysis often extends over several years, while psychodynamic therapy focuses more on current life events and can usually be finished within 12 sessions.

Interpersonal therapy (IPT) focuses on the pattern of relationships that the client has had with people throughout his life. The therapist offers more structure to the treatment and gives earlier interpretations. This therapy can also be concluded within 12 sessions.

The problem with psychodynamic theories is that the fundamental assumptions are very difficult to test scientifically. The processes that are described are very abstract. The long-term nature of the treatment means that many people cannot afford this. People with acute problems don't benefit either, they need faster results.

Humanistic approaches

Humanistic theories assume that people have an innate tendency to be good and live life to the fullest. The pressure from society to meet certain standards instead of trying to develop the self as fully as possible hinders this tendency. According to Carl Rogers, people strive for self-actualization, the fulfillment of their potential for love, creativity and meaning. According to him, people develop a distorted image of themselves under the pressure of society: They feel like there is a conflict between their real self and the self that they think would please others the most.

Humanistic therapy

The purpose of humanistic therapy is to help people discover their greatest potential through self-exploration. When clients are supported and enabled to grow, they will naturally confront the past as needed for their further development. They are therefore often not strictly directed by the therapist. An example of this therapy is Carl Rogers's client centered therapy (CCT). Reflection is the most important strategy, this is a method whereby the therapist tries to communicate to the client that he understands what the client is going through, but he does not give an interpretation. Humanistic therapy is therefore shifting the focus from what is wrong with people to how we can help people to develop as good as possible. However, it is said that the theories are vague and cannot be scientifically tested.

Family system approaches

Family system theories view the family as a complex interpersonal system, with its own hierarchy and rules that determine the behavior of family members. This system can function well and thus support the growth and well-being of the members of the family, but it can also malfunction and cause psychopathology in one or more members. So if there is a psychological problem, according to this theory, it is often due to a malfunctioning family system. The form that the disorder takes on is also determined by this. In an inflexible family there is a lot of resistance against the outside world and against change within the family. In an enmeshed family, the members are far too involved in each other's lives, so that they no longer have autonomy. In a disengaged family, family members do not pay each other attention and they all function as separate 'units', isolated from each other. In a pathological triangular relationship, the parents try to avoid their mutual conflicts by always involving the children in all their conversations and activities.

Family system therapy therefore assumes that the entire family must be treated, because the problem does not only origin in the person with the disorder. In Behavioral Family Systems Therapy (BFST), cognitive and behavioral techniques are used to teach problem solving and communication skills. These therapies appear to be especially effective in children, because they are much more dependent on the family than adults.

Emotion-oriented approaches

The emotion-oriented approaches focus attention on how people understand and regulate their own emotions. Poor regulation of emotions is seen as to be at the core of many types of psychopathology, including depression, anxiety, substance abuse and most personality disorders. Behavioral and cognitive therapy techniques are combined with mindfulness to help people accept, understand and regulate their emotions. The most well-known emotion- focused therapy is dialectical behavior therapy (DBT). This therapy focuses on problems dealing with negative emotions and controlling impulsive behavior. It was originally used to treat borderline personality disorders, but is now mainly used in people with eating disorders and people with problems with emotion regulation and impulse control. Accepting one's own feelings, thoughts and past and learning to live in the moment are the key to positive change.

What are sociocultural approaches to abnormality?

According to sociocultural approaches, we must look beyond the individual and even the family, to focus on the entire society, to understand psychological problems. For example, socio-economic deprivation is a risk factor for many mental health problems, such as substance abuse, violence, depression and anxiety. Even when there is war, hunger or a natural disaster, these are serious risk factors for, among other things, post-traumatic stress disorder. Social norms that stigmatize certain groups (such as sexual minorities) also cause that members of these groups are more at risk of problems such as anxiety, depression and substance abuse. Society can also influence the types of psychopathology that arise by having implicit or explicit rules for which type of abnormal behavior is acceptable. Some disorders are even unique to a certain culture.

Cross-cultural treatment issues

Usually, people who go into therapy are treated with one of the forms of treatment described in this chapter; and there are few differences among different cultures. However, this can cause problems if, for example, a client comes from a collectivist culture, in which the individual is never seen as separate from certain groups such as family, ethnic group or religion. Also; expression of one's emotions, important in some treatments, is seen as a negative characteristic in some cultures, such as in Japan. In addition, tensions can arise when the client clearly comes from a lower socio-economic class than the therapist. Many studies suggest that people from Latino, Asian and Native American cultures are more at ease with structured and action-oriented therapy, such as behavioral therapy or cognitive behavioral therapy.

When it comes to the treatment of children, cultural standards can be a problem when the rest of the family needs to be involved in the therapy. Parents often expect the therapist to 'heal' the child and find it unacceptable that they themselves have to learn behavioral techniques.

Although it is not self-evident that it is good for the treatment if the therapist and client come from the same culture (they may still have different value systems), the relationship between client and therapist and the client's beliefs about the effectiveness of the treatment are important in how much the client is committed to the therapy. Clients often feel more at ease with a therapist who has the same sex as themselves. Many cultural groups, including within modern, industrialized countries, have their own forms of therapy. Often people from these groups seek help from both a healer from their culture and a therapist who uses one of the treatment methods described in this chapter.

What distinction is made in prevention programs?

Preventing the development of disorders before they begin is called primary prevention. This is possible, for example, by intervening in the characteristics of the neighborhood in which people live. Secondary prevention tries to detect a disorder at an early stage and subsequently to inhibit the development of the disorder, so that it does not arise in its completeness. Tertiary prevention focuses primarily on people who already have a disorder and tries to prevent them from relapse. This form of prevention also tries to minimize the impact that the disorder has on a person's life.

What are common elements in effective treatments?

Successful therapies have a number of components in common. The first is a positive relationship with the therapist. In addition, it is important that the therapist gives a good explanation or interpretation of why the client suffers from the disorder. It is therefore important that the client accepts and believes this interpretation, because then he will be more committed to treatment. The chance of recovery then becomes greater. It is also important that the client confronts painful emotions or memories and thus stops avoiding or denying them.

How can you assess and diagnose abnormality? - Chapter 3

An assessment is the process of collecting symptoms and seeing what the causes may be. A diagnosis is a label for a number of symptoms that often occur together.

There are modern methods for making a diagnosis. Assessment techniques must be valid and reliable. In addition, they must be standardized.

What is meant by validity?

The correctness of a test is referred to as the validity: the test must actually measure what it was designed for. The validity for testing mental disorders is not very large, because there are no good objective methods to determine these.

There are different types of validity:

• Face validity: is good when the test is valid at first sight.

• Content validity: is the extent to which a test measures the important aspects of the phenomenon under investigation and omits the unimportant aspects.

• Competitive validity: is the extent to which the test yields the same result as other similar tests that measure the same construct

• Predictive validity: is the extent to which a test can predict how a person will think, act or feel in the future.

• Construct validity: is the extent to which the test measures what it must measure, rather than something completely different.

What is meant by reliability?

The reliability is the certainty that the result of the measurement remains the same. Possible methods:

• Test-retest reliability: is how reliable the results of the test are over time.

• Alternate form reliability: is when using different forms of the test, when it has to be taken again.

• Internal reliability: is visible by splitting a test into two or more parts, to determine whether the answers of people on one part are comparable to those on the other part.

• Interrater / interjudge reliability: if different people take the test, the outcome of the test must remain the same.

How do you prove reliability and validity?

To prove validity and reliability you can standardize the application and interpretation of a test, so that there is no variation between tests in how this is done.

What information about mental status is there?

A lot of information that is used for an assessment comes from an interview, which often includes research into the mental state of the person.

There are five types of information:

1. Appearance and behavior: does the patient look cared for or not, and how does the patient behave, does he look at you and make eye contact?

2. Thought processes

3. Mood and affect: does the patient seem depressed?

4. Intellectual functioning

5. Is the person well-oriented: does he or she know who and where he or she is; and what the time and date is?

Clinicians increasingly use structured interviews: a series of questions about symptoms.

What do you do with a symptoms questionnaire?

To quickly determine what the symptoms are, a symptom questionnaire can be completed. A frequently used questionnaire is the Beck Depression Inventory (BDI): you have to decide for yourself which description fits best with how you felt last week.

What is a personality inventory?

Personality inventories are questionnaires that look at the typical way of thinking, feeling and behaving of a person. An example is the Minnesota Multiphasic Personality Inventory (MMPI). In this questionnaire, the patient must indicate whether he or she feels that a statement is correct, incorrect or not able to assess it. The questionnaire has been developed empirically, which means that the questions were first asked to healthy test subjects and then to people with psychological problems. The items to which the answers differed between these groups were included in the Inventory. There are also validity scales that check whether a person completes the test fairly. A disadvantage of the MMPI is that this questionnaire was developed in America and may therefore not be representative for participants in the rest of the world. A good, representative sample was not used.

What happens during behavioral observation and self-monitoring?

Clinicians often use behavioral observations to see how patients approach certain situations. They look at specific behavior and what causes that behavior. An advantage is that you look at a person's 'natural' behavior and not at the behavior as reported by the patient themselves. A disadvantage is that people know that they are being observed and therefore tend to behave differently, which is called reactivity. Moreover, this method is not objective. That is why the situation must be standardized.

People can also apply self-monitoring, in which they themselves keep track of how often they perform a certain action per day and in which circumstances this happens. The advantage of self-observation is that people do not change their behavior due to the presence of another person (reactivity).

What does an intelligence test measure?

Intelligence tests measure the intellectual strength of an individual. These tests are used in schools, in the army and for job applications. The WAIS (for adults) and WISC (for children) measure the basic intelligence capacity. However, we still do not know exactly what intelligence means, since there is no good exclusive definition. There is also a bias in the test: the test was developed by and for inhabitants of western countries and this can influence the result when the test is taken by someone from a non-western country.

What does a neurological test do?

A neuropsychological test is used when clinicians suspect a neurological disorder, such as memory problems. An example of this is the Bender Gestalt Test. The therapist assesses the sensorimotor skills of the patient by having him or her draw nine pictures. People with brain damage cannot reproduce these drawings.

Which techniques are used to examine the brain?

Brain imaging is often used to detect brain damage and to search for possible brain tumors. We look at differences in brain structures and the activity that takes place in these structures.

Possible methods are:

• Computerized tomography (CT): X-rays pass through the head of the patient from different angles. The amount of radiation that is absorbed by the brain is measured and from these measurements the computer forms a three-dimensional image of the most important brain structures.

• Positron-emission tomography (PET): This method makes a picture of the activity of the brain. A radioactive isotope is injected that enters the brain through the blood. The more active a certain brain region, the more blood flows there to supply oxygen and provide the brain with energy. Positrons of the isotope collide with electrons and become photons that each go in a different direction. The PET scan can see these photons and thereby see which areas in the brain are most active.

• Single photon emission computed tomography (SPECT): the SPECT has the same effect as a PET scan, but a different substance is injected. This is less expensive, but unfortunately also less accurate.

• Magnetic resonance imaging (MRI): this does not require a radioactive substance, so this method can be used more often with the same person in a short period of time. MRI provides a three-dimensional image of the brain through a magnetic field that causes atoms to be unbalanced for a very short time. The MRI scan records this and measures the time that elapses before the atoms are back to the normal position. Each molecule has a different structure and therefore a different 'reaction time'. The MRI can convert this into images of the brain.

• Psychophysiological tests. Psychophysiological testing is an alternative method for brain-imaging testing. An electroencephalogram (EEG) measures electrical activity around the cerebral cortex. Clinicians compare the results obtained with those of people who have no psychological problems. Measuring heart rhythm is also a psychophysiological test. The tests are used to identify emotional and psychological changes.

• Projective testing. A projective test is based on the assumption that when people are confronted with an ambiguous stimulus (such as a strangely shaped ink stain), they want to interpret it based on their current concerns and feelings, their relationships with other people and their inner conflicts or desires. This is used to bring up unconscious things. A well-known test is the Rorschach Inkblot Test, which consists of ten cards with a symmetrical ink dot that has no clear meaning. People have to say what they see in the dot, with this everyone sees something else again. Another test is the Thematic Apperception Test (TAT): you get to see a series of images and then have to tell what kind of story the images tell. Clinicians who work from the psychodynamic perspective in particular use projective tests to investigate underlying conflicts and concerns in patients. Other clinicians doubt the usefulness of the tests because the reliability and validity do not seem to be strong.

What are the challenges during diagnosis?

One of the biggest challenges in diagnosing is when an individual refuses to provide information. Someone can refuse to provide information because that person does not want to be assessed and / or treated. People often have an interest in a particular outcome of the test and therefore provide information that is to their advantage (bias). This arises, for example, when assessments are part of a court case, for example when parents are fighting for the custody of their children. Challenges can arise when children or people from different cultures are evaluated.

How are children evaluated?

A conversation with a sad, stressed child often does not pursue as it should; since you often do not get an answer to your question. Children cannot describe their feelings about certain things in the same way as adults can, and certainly not when it relates to a certain event. Clinicians must therefore rely on others, for example the child's parents. They are often asked about changes in their child's behavior recently. Unfortunately, parents are not always accurate and often they are biased. Sometimes parents take their children to psychologists, while they themselves would actually benefit more from treatment, instead of the child. In addition, parents can also be the cause of the child's problems. Teachers can also provide information about children, they are often the first to detect that a child has problems.

What are the risks if individuals from different cultures are evaluated?

People who have migrated to another country often do not speak the same language as their new countrymen, or do not speak the language well enough. This can cause that someone is under- or over-diagnosed. A translator can help resolve this by being present during the process of assessment, but he or she often already gives an interpretation to the questions and answers and may not be completely literal in his translations. In this way, misunderstandings can arise and the therapist cannot make the correct diagnosis.

There are also cultural prejudices (bias): when people speak the same language but have a different cultural background. Symptoms may be a little more severe. This is because people in other cultures often think differently.

What are diagnoses?

A diagnosis is a label that we give to symptoms that often occur together. A set of symptoms is called a syndrome, which is an observable manifestation of an underlying biological disorder. We must pay attention to behavior that can be a symptom and also to how often that particular behavior is repeated.

Often, symptoms tend to overlap between different syndromes. That is why you have to suffer from multiple different symptoms to be diagnosed with a certain syndrome. A classification system contains all known syndromes and gives clear rules to determine them in the patient. Classifying is therefore referred to as the classification of problems of individuals in certain groups.

Hippocrates was the first to identify syndromes. His syndromes were: mania, melancholy, paranoia and epilepsy.

Nowadays, we have the DSM: Diagnostic and Statistical Manual of Mental Disorders. It contains all syndromes and disorders with the associated symptoms that we need to know to be able to give a correct diagnosis.

What is Diagnostic and Statistical Manual or Mental Disorders?

The DSM has been developed in America. The first DSM came out in 1952, containing all the known mental disorders of the time. The criteria for diagnosing were also given. The criteria were vague descriptions at the time, heavily influenced by Freud's psychoanalytic theory. The reliability of DSM-I and also DSM-II was therefore very low.

DSM-III, DSM-IV, DSM-V

The DSM-IV differs little from the DSM-III, they are both more reliable than the first versions of the DSM. There are specific and concrete criteria for diagnosis: it is often about well-observable and measurable behaviors and feelings. Usually, a person must have at least a certain number of possible symptoms from the mentioned symptoms in order to get a diagnosis. We must also take into consideration for how long the symptoms have been present. The individual's daily life must be adversely affected by the symptoms.

The reliability of the DSM

The reliability of the DSM-III was reasonably good, around 70%. The fact that the reliability was not yet really high was due to various factors, but the main one was that it was mainly observable symptoms and not the underlying factors. The DSM-IV is more reliable because the criteria are tested in a clinical and experimental environment.

Multi-axial system

The DSM-III and the DSM-IV have 5 axes (or dimensions). The first two are the only ones that present the actual disorders, along with the criteria that are required for the diagnosis. The other three are primarily intended to provide information about the physical state of the person, which can influence their mental state.

• Axis 1: Clinical disorders. On this axis, the clinician formulates for which major disorders the patient qualifies, with the exception of mental retardation and personality disorders. It is also noted whether these disorders are chronic or acute.

• Axis 2: Personality disorders and mental retardation. In general, the disorders on this axis are of lifelong occurrence.

• Axis 3: General medical conditions. All medical and physical disorders that a patient has, are recorded on this axis. Although not all of these conditions need to influence the psychological conditions, it is important that the clinician is aware of this, as is the medication that the patient may be taking.

• Axis 4: Psychological problems and problems in the environment. Psychological stressors can influence the mental disorder of a person. On this axis, it also applies that these stressors do not have to have anything to do with the disorder, but that the clinician must at least be aware of them.

• Axis 5: Global assessment of performance. On this axis, the clinician assesses the level at which the patient functions in daily life. This helps to determine the extent to which the disorder affects the patient's life.

An important change in the DSM-V compared to the earlier versions of the DSM is that the DSM-V no longer works with this system of axes. In this way it is brought more in line with the International Classification System of Diseases (ICD). Axis I, II and III have been reduced to a general diagnostic scheme in the DSM-V. Separate notations for important psychosocial and contextual factors (formerly Axis IV) and handicaps (formerly Axis V) are made by the clinician.

Continuous concerns about the DSM (potential areas for improvement)

Consider the continuum: In the DSM-IV there is a clear distinction between normal and abnormal behavior. Many psychologists argue for a diagnostic system that sees disorders as extremes of normal behavior, rather than as qualitatively different from normal functioning.

Distinguishing between mental disorders: It is difficult to distinguish between disorders in the DSM-IV. Many symptoms belong to multiple syndromes and this can cause confusion in the process of diagnosing. It may be good to develop better distinctive criteria. On the other hand, overlap (or comorbidity) between disorders reflects the natural occurrence of problems in mood, behavior and thoughts. The DSM-V focuses more on the underlying dimension of the disorder.

Cultural differences: Different cultures have different ways of conceptualizing mental disorders and some disorders from the DSM-IV do not occur at all in other cultures. In DSM-V, researchers are trying to better chart cultural variation in the expression and characterization of disorders.

What are the dangers of a diagnosis?

There are many benefits when someone has been diagnosed with a certain disorder, but people also experience many disadvantages. Szasz claims that we quickly label people who do not fit within society. Someone with a label is then treated differently, because according to our standards he or she is abnormal.

Rosenhan and 12 colleagues were admitted to different mental hospitals by saying that they heard voices in their heads saying 'hollow', 'empty' and 'thud'. There was actually nothing wrong with them, but they were admittedly diagnosed and treated. After admission, they said they no longer heard voices and, moreover, they wrote down their experiences on a notepad every day. Some other patients realized earlier that the researchers actually had no mental disorder, but the institutions themselves only found out after 19 days on average.

The 'abnormal' label is even more dangerous for children. We will now consider the following example of a study with a group of boys, some of whom had a behavioral problem. The boys had to work together in pairs. Sometimes the boys did get background information about the other, namely that the boy they worked with had a behavioral problem, the other times this did not happen. Afterwards the boys had to say how they found the collaboration. The boys who knew that their partner had a behavioral problem were less friendly and less interactive and did not like the cooperation. These results show that abnormal labeling of a child can have strong effects on the behavior of other children towards this child, even when there is no reason for the child to receive such a label.

What anxiety disorders do we distinguish? - Chapter 5

What is generally known about fear?

Thanks to evolution, people and animals have an automatic response to danger: the fight or flight response. The psychological changes that occur during this reaction are due to the activation of two systems: the autonomic nervous system and the adrenal-cortical system.

The hypothalamus activates the sympathetic part of the autonomic nervous system, which prepares for fighting or fleeing by releasing energy. The hypothalamus also activates the adrenal-cortical system by releasing CRF (corticotrophin-releasing hormone), which releases the adrenocortrophic hormone (ACTH). This hormone causes the cortisol level to rise. Cortisol in the blood and urine is an indicator of stress. We then experience the emotions associated with danger, after which we either confront the danger (fight) or flee for the danger (flight).

People with anxiety disorders follow the same pattern, but with them there is no actual objective danger.

An anxiety disorder is referred to when one is constantly living with anxiety, which is in this way hindering one's daily functioning. The person experiences an unreal nature of fear and suffers from an anxiety disorder.

Anxiety consists of four different types of symptoms.

1. Somatic symptoms; which are physical responses such as sweating and high blood pressure.

2. Emotional symptoms; such as feelings of anxiety and vigilance.

3. Cognitive symptoms; by which we mean unrealistic worries such as the feeling that something bad is going to happen

4. Behavioral symptoms; such as avoidance behavior or escape behavior.

When does someone suffer from a post-traumatic stress disorder and what types of PTSD are there?

Post-traumatic stress disorder (PTSD) and acute stress disorder both occur as a result of an experience of extreme stress. Many people in America suffer from a stress disorder as a result of the September 11 attacks. 7% of people experience a stress disorder during their life due to a traumatic experience.

A diagnosis of PTSD requires at least the following four symptoms:

1. Reliving the traumatic experience: including flashbacks, thoughts.

2. Avoiding of situations, thoughts or memories that are associated with the trauma.

3. Negative changes in thoughts and state of mind that are associated with the event. For example, one may feel guilty about the fact that he or she is still alive when another person may not be. Patients can also feel chronically stressed or emotionally numb.

4. Hyper alertness and chronic arousal: People are always on their guard that another traumatic event might take place.

Many people with PTSD experience symptoms of dissociation, a process during which a person loses connection with parts of his or her identity, memories or consciousness. These people can be diagnosed with the PTSD subtype with prominent dissociative symptoms.

An acute stress disorder (ASD) occurs in the case of traumas that resembles PTSD, yet the symptoms of acute stress disorder only occur for one month. Dissociative symptoms are common in ASD: stiffening, being less aware of the environment, experiencing the world as a dream. People with ASD have an increased risk of developing PTSD.

Another trauma and stress related disorder is adjustment disorder, in which emotional and behavioral symptoms occur only during 3 months after the experience of the trauma. The stressors can also be less severe, while those of PTSD are extreme.

The DSM-IV does not provide a clear definition of a traumatic event, but the DSM-V does: the individual must experience the event himself, see that others experience it, or be a close friend or family of someone experiencing the event, or must be regularly exposed to aversive details of the event. According to the DSM-V, the traumas can be subdivided into events in which someone is exposed to death or a threat of death, serious injuries, or sexual violence. Children often experience other symptoms of PTSD: they express it during play; they tend to role play traumatic situations.

Trauma that can lead to PTSD

The traumas that lead to PTSD are often: natural disasters, war, terrorist attacks, torture and abuse. In the case of a war, about 42% of people on both sides of the conflict get PTSD and in the country where the war is fought about 72% get an anxiety disorder.

Explanations for greater sensitivity to PTSD

Environment and social factors

Strong predictors for PTSD are the severity and duration of the traumatic event and the closeness (proximity) of the individual to that situation. So the longer you experience the event and the more serious it is, the greater the chance of developing PTSD. Also the closer you are to the event, the greater the chance of developing PTSD.

Another predictor is social support. People who receive emotional support recover faster and are less likely to get PTSD.

Psychological factors

People who already have symptoms of stress disorders before a traumatic event occurs also have a higher risk of actually developing PTSD after the traumatic event. The way people deal with trauma is also a predictor of the risk of PTSD. The chance of the disorder is greater if you apply self-destructive and avoidance strategies (drinking, isolating oneself). Some people may feel as if they are in a different body. This is called dissociation and its purpose is to distance oneself from the trauma by looking at it through the eyes of someone else.

Gender and cultural differences

Women are more likely to be diagnosed with PTSD (and all other anxiety disorders in general). Some triggers of PTSD are more often experienced by women than men, especially sexual abuse. Men, on the other hand, often have PTSD due to war situations, for example.

Culture also influences the development of PTSD. In Latin cultures, 'ataque de nervios' (attack of the nerves) is common. People feel warmth, a faster heart rhythm, pin pricks in the body, dizziness, etc. The person then starts to scold, yell or attack others and then falls down, after which he gets a sort of attack or lies still as if he is dead. This often occurs after a recent trauma.

Culture and gender can influence sensitivity: women all around the world are more likely to experience anxiety disorders, but more extremely in one culture than in the other. Gender differences sometimes play a major role: in one culture, men and women are almost the same, in the other, women are very submissive.

Biological factors

Findings by neuroimaging

PET scans and MRI scans show differences between people with PTSD and people without PTSD, especially in brain areas that regulate emotion, memory and the fight / flight response. The amygdala reacts more strongly to emotional stimuli in people with PTSD. The medial prefrontal cortex (modulates the activity of the amygdala) is on the other hand less active. So people with PTSD respond more strongly to emotional stimuli. The hippocampus becomes smaller in people with an anxiety disorder, probably due to too much exposure to neurotransmitters and hormones, such as cortisol, which are released in response to stressors.

Biochemical findings

In a fight or flight response, cortisol is released, which is an indicator of high stress levels. People with PTSD have low cortisol levels as long as they are not reminded of the trauma, but the level increases enormously when they are reminded of the trauma or when they are confronted with other stressors. A lower resting level of cortisol may indicate longer-term activity of the sympathetic nervous system due to stress. In people who are sensitive to PTSD, not all stress receptors work well together (heart rhythm, adrenaline): the brain gets too much epinephrine, norepinephrine and other neurotransmitters.

Childhood trauma causes a change in the biological stress response, and therefore a higher sensitivity to PTSD and other anxiety disorders.

Genes

Sensitivity to PTSD can be inherited. Offspring of people with very serious trauma (such as people who experienced the holocaust) are more sensitive to PTSD than others.

Treatment of PTSD

The goals of treatment are:

1. Exposing patients to what they are afraid of.

2. Tackle twisted cognitions that contribute to their symptoms.

3. Help patients to reduce stress in their lives.

Cognitive behavioral therapy and stress management

Cognitive behavioral therapy is effective for both children and adults. An important element is systematic desensitization. With this method, the client is helped to identify thoughts and situations that cause the anxiety and puts them in order from most anxiety-provoking to least anxiety-provoking. Then the therapist takes the client through this list and uses relaxation techniques to reduce anxiety.

The person must attempt to recall and memorize the event. Because the retrieval of these memories takes place in a safe environment, the patient gets used to the thoughts.

There is another method for people who cannot think back to the event: stress management interventions. Therapists then teach the client skills that ensure that he or she can deal effectively with problems in life.

Biological therapies

Medications: selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines. These are especially effective in treating sleeping problems, nightmares, etc. People who take SSRIs often have no symptoms for five months.

What is a panic disorder?

Panic attacks are short, intense attacks of anxiety, during which the person experiences several symptoms of anxiety. Panic attacks often occur spontaneously, but usually there is something in the environment that triggers the panic attack. The attack usually only occurs in a specific situation. Panic attacks occur every now and then in many people. No fewer than 28% of adult people sometimes have a panic attack, especially during periods of stress. For most people these attacks are annoying, but they do not affect the way people live. However, one speaks of a panic disorder when the attacks occur more often in the same kind of situation and the person becomes concerned as a result and his behavior changes to prevent a panic attack. About 3 to 5 percent of the population develops a panic disorder at some point in his or her life, often between late adolescence and the mid-30s. It is more common in women, and is often chronic.

Some people with this disorder have periods during which they have many attacks, alternating with periods where few attacks occur. Others have the attacks more regularly, such as once a week. During the intervals, a new panic attack is often feared for.

Patients often think that they have a life-threatening illness, or have a heart attack or stroke, even though research has ruled that out. Three to five percent of people develop a panic disorder at some point in their life and this usually develops between late adolescence and the mid-thirties.

What is agoraphobia?

A third to half of all people with panic disorder have agoraphobia (which literally means: fear of the marketplace). They are afraid of being in places that are difficult to leave or where it is difficult for them to get help in the case of a panic attack. They are also afraid of embarrassing themselves. Agoraphobia can also occur in people who do not have panic attacks, but they are less likely to seek help. Agoraphobia can become so bad that the patient no longer dares to leave his or her home.

What theories about panic disorders are there?

Role of genes

10% of people who are directly related to someone with a panic disorder also get the disorder itself. This is in contrast to the 2% chance that you have a panic disorder if you do not have a direct family with such a disorder. The chance of passing on the disorder is greatest from parents to children. From twin studies it appears that 30-40% is passed on by the genes, so the rest is due to environmental factors.

Neurobiological contributors

Panic attacks can easily be triggered by hyperventilation, inhaling carbon dioxide, taking a lot of caffeine or breathing in a paper bag in people who suffer from this more often. These activities trigger a fight or flight response. People without a history of a panic attack feel physical discomfort during these events, but they never get a panic attack because of it.

Differences between people with and without panic disorder can be observed in the limbic system of the brain, which is responsible for the stress response and consists of the amygdala, hypothalamus and hippocampus. People with a panic disorder have a disregulation of the norepinephrine system in the cereleus locus. Poor regulation in the cereleus locus can cause panic attacks to occur, which then causes the limbic system to be stimulated, thereby lowering the threshold for the activation of diffuse and chronic anxiety. The anticipatory anxiety can then again increase the chance of cerebral locus disregulation, and thus increase the chance of a subsequent panic attack.

The hormone progesterone affects serotonin and GABA, causing menstruating women to suffer more from anxiety.

Which psychological models are common?

The cognitive model states that panic stems from the fact that patients pay too much attention to what they feel in their bodies and then misinterpret these feelings. The snowball effect results in catastrophic thinking, resulting in panic reactions. In between panic attacks, a person is hyper vigilant for body reactions and often thinks about his or her health. The notion that physical symptoms are associated with harmful consequences is called anxiety sensitivity. People with a sensivity to anxiety are more aware of their body's reactions that may indicate a panic attack.

The vulnerability stress model combines the biological and cognitive theories into one theory. According to this theory, people with a panic disorder suffer from a hypersensitive fight or flight response. With minor events they already react quite anxiously. This fear alone does not cause a panic attack. Because people are afraid that something is wrong, for example, because they suddenly start to sweat, the fight or flight response becomes even stronger, causing a panic attack.

What treatment methods are common?

The most effective drugs against panic attacks are antidepressants. The frequency of panic attacks is reduced in more than half of people who take antidepressants. The tricyclic antidepressants probably improve the functioning of the norepinephrine system. The disadvantages of these drugs are the side effects and the fact that the drug does not offer a real solution: after one stops taking it, the symptoms reappear.

SSRI's cause an increase in the release of the neurotransmitter serotonin, and this increase appears to have a positive effect on the panic disorder

Benzodiazepines suppress the central nervous system and influence the amounts of serotonin, norepinephrine and GABA. These medicines are effective for many people, but they also have many disadvantages. Benzodiazepines are addictive, cause motor deterioration and cognitive performance, and do not help people get rid of panic attacks in the long run if medication is stopped.

Cognitive behavioral therapy tries to help patients get rid of their panic attacks by showing them that they have irrational thoughts about the panic attacks, and by reducing anxiety reactions. Cognitive behavioral therapy consists of five components. First, a patient is taught how to relax. Thereafter, the therapist helps the patient identify the wrong thoughts. The patient must then learn to control himself while being exposed to symptoms of a panic attack. Then the patient learns that the thoughts he had are wrong. Finally, the therapist applies systematic desensitization to relieve the patient of his fears. This cognitive behavioral therapy works just as well as medication, but is more effective in preventing a relapse.

What distinction is made in phobias?

The DSM-V divides phobias into two categories: specific phobias; which are focused on a specific object, and agoraphobia, a generalized fear of situations in which the person cannot flee or can get help if needed. Agoraphobia has already been described in the part about panic disorders.

Specific phobias are fears that relate to specific objects or situations. Many people are afraid of certain things, but it is only called a phobia when someone starts to organize their life differently to avoid confrontation with these frightening stimuli. There are four different types of specific phobias:

1. Animal type phobias; fears for certain animals such as snakes and spiders;

2. Natural environment type phobias; focus on situations or events in the natural environment, such as floods;

3. Situational type phobias; fears of, for example, elevators or flying;

4. Blood-injection-injury type phobias; being afraid of seeing blood, getting an injection or being injured. The difference with other phobias is that with this phobia the heartbeat and blood pressure do not go up, but rather go down, so that these people faint quickly.

Most people develop their phobia in childhood, which often only the parents understand.

Which psychological theories are related to anxiety?

Freud's theory of phobias is the best-known theory in psychodynamics. This theory states that a phobia arises when an unconscious fear is projected onto a certain object.

As an illustration of this theory, Freud used the story of Little Hans, who was afraid of horses. Freud said this was because Hans moved the tensions of his Oedipus conflict into the fear of horses. This story is not easy to accept, just like the theory in general. The Oedipus complex in general means that boys have a sexual desire for their mother and are jealous or fearful of their father.

The behaviorist theories state that fears are simply caused by classical conditioning, after which the fears persist through operant conditioning. The best known example is that of Little Albert who was frightened of rats. That was done by making a loud noise every time Albert saw a rat with an iron rod. After a while Albert got the same fear response from the rat, without hearing the sound itself. However, if Albert would see the rat very often without hearing the sound, extinction would occur, with his fear response to the rat slowly diminishing.

For people with phobias, the same fear persists for a long time. The behaviorist explanation for this is that operant conditioning has taken place. Because people will avoid or run away from the object they are afraid of, and they unconsciously learn that if they avoid the object, there will be less fear. Because of this 'negative reinforcement' the fear remains equally strong.

According to the safety signal hypothesis, people remember the places where they had a panic attack very well, even if the environment had nothing to do with the panic attack itself. Because people are afraid of having another attack in the same environment again, they will start to avoid being in that place. This avoidance reduces the symptoms which then only reinforces the avoidance behavior. If a man in a cinema gets a panic attack, he may not go to the cinema anymore. If a man then feels safe in his house, staying at home will be associated with not having an attack, and in the future, the man would rather stay at home.

As an extension to the behaviorist theory, it is stated that fears can also arise through learning through observation. If a child sees that her father is afraid of a thunderstorm, the child will also be afraid of it, because he has learned that fear is the appropriate response to that situation.

Another extension to behaviorist theory is that of the Prepared Classical Conditoning. This theory provides an answer to the question why phobias arise in certain objects, but not in others. The similarity between a large proportion of the objects that often arouse fear in humans is that avoiding these objects has always been beneficial to humans in evolutionary history. Although these objects are now much less dangerous than they were before, it is still in humans to quickly become afraid of them.

Biological theories

It seems that phobias are somewhat hereditary. A certain temperament is probably transmitted through the genes. This temperament makes it easier to be conditioned for phobias. For example, children who are very timid and shy have a greater chance of developing a phobia.

Treatment methods for phobias

Behavioral treatments use systematic desensitization, modeling and flooding.

With systematic desensitization, a list is made of the situations or objects that the patient is afraid of, from least scary to most scary stimuli. The patient learns to relax during the confrontation with frightening stimuli. When the patient is no longer afraid of the scariest stimuli, the therapy is proceeding successfully. Often relaxation exercises are also taught, in particular breathing exercises.

There is another method for the blood-injury-injection type phobia, because in this phobia the blood pressure of the person tends to go down instead of up. If someone suffering from this phobia has to relax when he is scared, he will faint even faster. That is why this phobia must be taught precisely to raise blood pressure by contracting muscles.

Modeling is often used in combination with systematic desensitization. First, the therapist asks the client why he or she is afraid of the object. The therapist then shows how the patient should act, after which the patient must imitate the therapist. This technique works on the basis of the idea of ​​learning through observation.

The idea behind flooding is to let the patient go through the anxiety intensely, until the anxiety goes away (extinction).

Cognitive behavioral therapies often use the methods described above in combination with techniques to identify and change maladaptive thinking. The therapist shows the patient that he engages in maladaptive thinking, while working together to overcome the patient's fear. With social phobias, for example, group therapy is also used. The group works as a factor for desensitization, modeling and flooding in one, and can also help to change the wrong minds of individuals.

Many therapists combine both cognitive and behavioral therapy. This is especially useful with social phobias. People who all have a social phobia are put together to communicate, while the therapist coaches them to relax during the conversation.

Medications are not effective to remedy phobias. Some people do use benzodiazepines to alleviate their fears when they are confronted with the object they are afraid of. Antidepressants are sometimes used in social phobia. The problem with these methods is that people relapse into their fears when the medication is stopped. So medication gives a temporary relief, but the phobia remains.

What is social anxiety disorder?

People with a social anxiety disorder become so scared in social situations, and so scared of being rejected, judged, or humiliated in public, that they are deeply anxious about such events. They worry so much that their lives are focused on avoiding social events. A social anxiety disorder more often causes a serious disturbance in a person's daily life than a specific phobia. People with a social anxiety disorder in a social situation often suffer from shaking and sweating, confusion and dizziness, heart palpitations and sometimes even a complete panic attack. Women are slightly more likely to have this disorder than men. It often arises at a young age, for example during adolescence when many people become aware of themselves. Adolescents also often worry about the opinions that others have about them. More than 90% of people with social anxiety disorder have had humiliating experiences that contributed to their symptoms. It often accompanies mood disorders and other anxiety disorders.

Theories about social anxiety disorder

Social anxiety occurs in families, and twin studies suggest that there is a genetic basis. Genetic factors do not specifically lead to fear of social situations, but rather to a general sensitivity to anxiety disorders.
According to cognitive perspectives, people with a social anxiety disorder have extremely high standards of social performance. They also focus on the negative aspects of social interactions and evaluate their own behavior negatively. They misinterpret potentially threatening social cues. They exhibit 'safety behaviors' to reduce their anxiety. For example, a person may avoid eye contact or social interactions and practice what he or she wants to say in social interactions. After social interaction, the person may worry a lot about their performance and the reactions of other people.

Treatments

SSRIs and SNRIs can be effective in reducing symptoms of social anxiety. However, when people stop taking these drugs, symptoms often come back. Cognitive behavioral therapy is effective in treating social anxiety. The behavioral component means that clients are exposed to social situations for which they are anxious. Relaxation techniques can also be taught to control fear in social situations. Skills for dealing effectively with others can also be learned. Therapists also help clients to recognize and eliminate safety behaviors. The cognitive component includes identifying negative cognitions and changing these cognitions. Cognitive behavioral therapy can also be applied in a group in which the group members form each other's public.

What is a Generalized Anxiety Disorder (GAD)?

It sometimes happens that people are not afraid of a specific object or situation, but have a constant feeling of fear. These people are diagnosed with Generalized Anxiety Disorder (GAD). People with GAD are worried about many things in their lives, such as their health, their children, or being late to an appointment. One concern goes away, but another concern will take its place. Worrying is accompanied by a number of physical symptoms such as tiredness and tension in the muscles. The disorder often starts in childhood and people who suffer from it often stay anxious throughout their lives. GAD is relatively common, around 14% of individuals experience a generalized anxiety disorder once in their life. Almost 90% of people with a GAD also have another mental disorder. This is often another anxiety disorder, but mood disorders and substance abuse are also common. There is also a greater chance of physical diseases caused by GAD, such as cardiovascular diseases.

Theories about GAD

Cognitive theories state that people with GAD are consciously and unconsciously focused on threats. At the conscious level, people with GAD may constantly think things like "I have to make sure that everyone loves me" and "I must always be prepared for danger". At the unconscious level, people may have negative automatic thoughts that are maladaptive. Unconsciously, they are constantly reviewing potential threats. People with GAD always expect bad things to happen, and they are not able to accurately assess the true threat of a situation. Their expectations are often not realistic. It is not yet known why people with GAD are so sensitive to threats. One theory is that people with GAD have been made so sensitive by traumatic experiences, that often occurred very unpredictable as well, that they could not help themselves. A chronic anxiety could arise from these experiences. People with GAD also experience more intense negative emotions that they cannot control.

Within biological theories, GAD is thought to be related to a deficiency of GABA or malfunctioning GABA receptors, because it has been demonstrated that the use of benzodiazepines, for example, shows a recovery from generalized anxiety disorder. Probably the problem originates mainly in the limbic system, which should provide accurate emotional responses. It is not yet clear whether GAD is hereditary.

GAD treatments

Cognitive behavioral therapies appear to be more effective than drug therapies, placebo therapies and other forms of treatment. Cognitive behavioral therapy is effective for a long time, while with drugs the big problem is that the fears return when the medication is stopped. With cognitive behavioral therapies, people learn to use strategies to deal with negative and catastrophic thoughts.

How does separation anxiety disorder develop?

Separation anxiety disorder often develops in childhood. Many children get upset when they are separated from their primary caregiver. As they grow older, however, they learn that their caregiver will return. Some children remain extremely anxious when they are separated from their caregiver, even far into childhood and adolescence. They can be very shy, sensitive and demanding towards their caregivers. They may refuse to go to school because they are afraid of being separated, and may suffer from abdominal pain, headache, nausea and vomiting if they have to leave their caregivers. It is more common with girls than with boys.

Theories of separation anxiety disorder

Children with separation anxiety disorder often have a family history of anxiety and depression. The tendency to develop anxiety is hereditary. The tendency for behavioral inhibition is probably also hereditary. Children who score high on behavioral inhibition are shy, anxious, and easily irritated. They are also quiet and introverted when they go to school. They avoid new situations and prefer to stay with their parents. This characteristic is a risk factor for the development of a separation anxiety disorder in childhood.
Parents of children with separation anxiety tend to be controlling, critical and negative in their communication with their children. This can be a reaction to the child's anxious behavior, but many parents of anxious children are themselves anxious or depressed. Children can learn to be anxious from their parents, or as a reaction to their environment.

Treatments for separation anxiety disorder

Cognitive behavioral therapy is often used to treat separation anxiety disorder. Children are taught new coping strategies and learn to challenge their own cognitions. They can also teach relaxation exercises for when they are separated from their parents. Their fears are challenged. The parents must also be involved in the treatment. Sometimes antidepressants, anti-anxiety medication, stimulants or antihistamines are prescribed. SSRIs are the most effective drugs in reducing anxiety symptoms.

What is OCD?

Obsessions are stubborn, recurring thoughts or images that someone cannot get rid of. These thoughts or images give the person fear and stress.

Compulsive actions (compulsions) are actions that an individual has to perform because they feel that something bad will happen otherwise.

OCD (Obsessive Compulsive Disorder) is an anxiety disorder in which people experience anxiety due to obsessive thoughts and when they cannot perform the compulsive actions. People with OCD sometimes seem psychotic, but they are not. They know exactly what they are doing and realize that it is irrational, but cannot control or control the actions.

OCD usually starts at a young age. For men this is usually between 6 and 15 years, and for women usually between 20 and 29 years. If OCD is not treated, it usually becomes chronic. OCD develops in between one and three percent of people at one point in life. Some of these people are also depressed.

Symptoms

The themes of an obsession are generally the same in different cultures. Especially the obsession with dirt occurs all over the world. This obsession mainly concerns the fear of being infected. Other obsessions that often occur are obsessions about aggressive impulses (for example, being afraid to hurt your own child), sexual thoughts, impulses to do something that goes against the norms of a culture (for example, swearing in the church), and obsessions about doubts (e.g. whether the gas or light is turned off). People with OCD do not carry out these obsessions, but they are very disturbed by the fact that they think these things. If people have a lot of persistent thoughts about something like that, they often start to perform compulsive actions in the hope of making the thoughts and fear of those thoughts disappear.

Sometimes, the compulsive actions can be explained logically from the obsession (if someone is afraid that he has forgotten to turn off the light, he will check that very often). Often, however, the link between obsession and compulsion is the result of magical thinking: people think that it will be okay if they perform a certain action with a certain frequency, and that otherwise something very bad will happen (for example, if they do not switch the light on and off five times). With some compulsions, there is no direct link with the obsession. It is possible that even the patient does not know why he is doing something, except for the reason that he or she feels like it must happen.

Hoarding is a compulsion that is strongly related to OCD, but is listed as a separate disorder in the DSM-V because it has distinct characteristics and distinct biological causes. Hoarding means that people aren't able to throw away their possessions. This applies to basically everything; including waste such as old newspapers. Hoarding differs from OCD because people with this disorder do not experience thoughts about their possessions as unwanted or stressful, but more as part of their natural stream of thoughts. They experience no fear about their behavior.

The hair-pulling disorder is also included in the DSM-V as a separate category. These people repeatedly pull their hair out, leading to hair loss. People with the skin-picking disorder pluck at their skin, causing (permanent) damage to their skin such as inflammation and scars. People with both of these disorders often experience tension prior to the impulse, and pleasure or relief when they give in to the impulse. However, it often happens automatically, without people realizing it. To be diagnosed, the behavior must result in significant stress or limitations.

People with body dysmorphic disorder (BDD) are extremely concerned with a particular part of their body that they think is ugly, but which others see as normal or only slightly abnormal. People spend a lot of time looking in the mirror, trying to hide or change the particular body part. They spend an average of three to eight hours a day on getting ready and checking their appearance. Sometimes they even undergo surgery to have the body part corrected. Women with this disorder are often more concerned with their breasts, legs, hips and weight, while men are more concerned with their physique, genitalia, body hair and thinning hair. The disorder often starts in the teenage years and becomes chronic if it is not treated. The average age at which the disorder develops is sixteen years, and the average number of parts of the body with which one is dissatisfied is four. It often co-occurs with anxiety and depression, personality disorders and substance abuse. OCD also often accompanies body dysmorphic disorder disorder.

OCD statements

In recent years, the biological explanations of OCD are especially popular. A theory states that with people with OCD something is wrong with the circuit that handles their primary impulses. When a certain impulse arises, the information goes from the orbital frontal cortex, via the basal ganglia, to the thalamus where the impulse is conceived to be performed. The impulse is then normally processed. It is thought that in people with OCD this impulse does not stop when the action is done, or that the action will not stop when the impulse is already gone.

There are a number of reasons to assume this theory. With PET scans, it can be seen that in people with OCD the area that was discussed is indeed more active than in other people, without the disorder. People also suffer less often from OCD if they take medicines that improve the effect of serotonin. In the area discussed, there is a serotonin deficiency in people with OCD. Moreover, it seems that OCD is hereditary.

Psychodynamic theories state that a patient's obsessions and compulsions are symbols of unconscious conflicts within that person. These conflicts are so heavily loaded that the patient can only deal with them indirectly by shifting the tension to other thoughts or behavior. The reason that many obsessions and compulsions are about sex and aggression would be because most unconscious conflicts are about these topics. People can be helped by giving them insight into the conflicts that unconsciously occur.

Everyone has negative thoughts that he or she cannot control. Especially when people are under tension, they tend to have these kinds of thoughts and they tend to think very rigidly. According to the cognitive explanation, people with OCD cannot eliminate these negative thoughts. This has several reasons:

1. Because people with OCD are often depressed or anxious and therefore think negatively very quickly, they cannot turn off their thoughts.

2. It is also possible that people with OCD tend to think rigid and moralizing. As a result, they see the thoughts as unacceptable and feel guilty about it.

3. The third reason is that people with OCD have the idea that they should be able to control their thoughts. They can't, which makes them feel bad about it. According to this theory, the compulsions arise from operant conditioning. If people have a certain thought and they try to remove the thought by performing a certain action, then that thought is likely to go away. The patient then associates the departure of the thought with the performance of that action. If that works every time, a compulsion may result from it. For example, if every time you think you want to hit someone on purpose, you will cough very hard, linking the cough to removing the thought.

OCD treatments

It has been discovered that drugs (benzodiazepines and antidepressants), which cause an increase in serotonin, help to reduce OCD. However, these drugs do not work sufficiently. For people who respond to the medication, usually only half of the obsessions and compulsions are taken away. There is also a relapse when the medication is stopped and there are side effects that are sometimes difficult to tolerate.

Medications are often combined with cognitive behavioral therapy. This therapy focuses on exposing patients to the obsessions while they cannot perform those compulsions. By exposing them to the obsessions, the patient gets used to the stimuli, so that less and less arousal is generated. Because the patient cannot perform the compulsions, the habituation (or habit) can be learned.

The therapist can use 'modeling' to teach the patient the desired behavior (or rather: learning not to perform the unwanted behavior). For someone with a fear of stain the therapist can, for example, make his hands dirty and not wash, and have the patient do that too. The therapist can also give the patient some sort of homework. For example, a person with a fear of stain may only clean his house twice a week. This type of therapy works in a small proportion of patients, and when it works, it usually does not work fully.

What types of somatic symptom disorders and dissociative disorders do we distinguish? - Chapter 6

The somatic symptom disorders and the dissociative disorders are discussed below. With somatic symptom disorders people experience physical symptoms without a detectable organic cause. The pain often comes from painful emotions, thoughts or memories. In dissociative disorders, people develop multiple independent personalities, causing them to suffer from memory loss. This is because some personalities do not, as it were, "communicate" with each other.

What is difficult about discovering a somatic symptom disorder?

The problem with somatic symptom disorders is that it is difficult to determine whether the complaints have an organic or psychological cause. Often the symptoms that people have do not correspond to a physiological process associated with these symptoms. If this is the case, it is assumed that psychological factors are of influence. Another possibility is that people do indeed have a physical illness, but that it still has to be discovered or simply cannot be found.

The people who have this disorder really feel the pain. It is not that they can influence or control their symptoms.

Five types of somatic symptom disorders are distinguished:

1. Somatic symptom disorder

2. Illness anxiety disorder (before, this used to be called hypochondria)

3. Conversion disorder

4. Factitious disorder

5. Psychological factors that influence other medical conditions (sometimes called psychosomatic disorder)

What is a somatic symptom disorder and what is Illness Anxiety Disorder?

Someone with somatic symptom disorder has one or more physical symptoms that he or she is concerned about, and he or she spends a lot of time thinking about these symptoms and seeks medical care to treat them. It can be pain symptoms, neurological symptoms, gastrointestinal symptoms; basically all possible symptoms that affect a part of the body. People with somatic symptom disorder have concerns about their health that are excessive given their current physical health. Worries even persist when patients have proof that they are healthy. This worrying interferes with the individual's ability to function. When an individual experiences a certain symptom, he or she will immediately think the worst of it, for example; he or she may think that he has cancer.

Illness anxiety disorder is very similar to somatic symptom disorder. The primary distinction in the DSM-V between these two disorders is that people with somatic symptom disorder actually seek help, while people with illness anxiety disorder are afraid that they will have a serious illness, but they do not always experience severe physical symptoms. When they do experience physical symptoms, these people are very concerned and seek medical help sooner.

People with somatic symptom disorder or illness anxiety disorder often experience periods of anxiety and depression. They can express their stress in physical symptoms or mask the stress with alcohol abuse or antisocial behavior. Their symptoms and health concerns become their identity. When they are anxious or depressed, they report more physical complaints and worries than when they are not anxious or depressed.

Cognitive factors play a major role in somatic symptom disorder and illness anxiety disorder. People with these disorders often have dysfunctional ideas and beliefs about diseases. They assume that serious illnesses are common, and misinterpret physical changes as a sign of a disease. The disorder can also be genetically determined. In addition, children of parents who catalyze their somatic symptoms can adopt the thinking style and health behaviors of their parents. Somatic symptom disorder and illness anxiety disorder can be part of a post-traumatic stress disorder experienced by someone who has survived a severe stressor.

It is difficult to convince people with these disorders that they need psychological treatment. Psychodynamic therapies focus on providing insight into the connections between emotions and physical symptoms by helping people to recall events and memories that may have triggered their physical symptoms. Behavioral therapies seek to discover the reinforcers that individuals receive for their symptoms and health problems, and to eliminate these reinforcements and increase positive rewards for healthy behavior. Cognitive therapies help people to correctly interpret their physical symptoms and to avoid catastrophe. Antidepressants can also reduce somatic symptoms.

What does a conversion disorder entail?

People with a conversion disorder can suddenly stop using certain parts of their body, often after a traumatic experience or event. For example, people suddenly become paralyzed or blind. It also happens that people don't even worry about their loss of function. This is called la belle indifference.

Sigmund Freud examined people with glove anesthesia, where people lose the feeling in a hand, as if a glove has affected the feeling in that hand. He found that people got the feeling back in their hand when they were under hypnosis and had to remember the painful feelings or thoughts. Freud thought that conversion disorders were the result of moving repressed psychic energy to physical symptoms. According to him, the symptoms were symbols of what was oppressed.

People with a conversion disorder are very easy to hypnotize. According to researchers, this may indicate that people with this disorder spontaneously hypnotize themselves in response to extreme stress.

Conversion symptoms were very common during the two world wars. Soldiers became blind or paralyzed spontaneously, almost as to not be forced to go back to the front. The disorder can also occur in children. Usually their symptoms resemble those of someone who is close to them and who has a real illness. This mainly happens with children who have been sexually abused. They can imitate someone's symptoms. For example, if a role model for the child can no longer move his arm, the child can suddenly also no longer move it. Conversion disorder is very rare. Nowadays it is thought that many cases where this diagnosis was made in the past actually had a physical cause. The techniques used to be just not good enough to recognize the real cause. The name 'conversion disorder' assumes that psychological stress, often about a traumatic event, is 'converted' into a physical symptom. Patients and doctors often disagree with this assumption, and in the DSM-V this disorder is labeled as a functional neurological symptom disorder.

Psychoanalytic treatment of this disorder is about gaining insight into the painful emotions that are the cause of the disorder. Behavioral treatments are aimed at reducing the anxiety surrounding the trauma, thereby resolving the disorder. Often people with a conversion disorder are difficult to treat because they do not think there are any psychological problems.

What does a factitious disorder entail?

Someone with a factitious disorder purposely acts as if he or she has a disease to get medical attention. This is also called Munchhausen's syndrome. A factitious disorder is not the same as malingering, where people pretend to have a symptom or disorder to prevent an unwanted situation or to get something, such as payment by insurance. The difference between factitious disorders and malingering is therefore primarily the motivation for it.

Factitious disorder imposed on another (formerly factitious disorder by proxy) means that someone pretends that someone else has an illness, for example with a child, pet or older adult. For example, parents act as if their child has an illness, or they even create an illness with their children, to get attention for themselves.

How does somatization disorder relate to pain disorders?

Someone with somatization disorder usually has a long history of complaints about physical symptoms, while no doctor can tell what exactly is wrong with that person. People with somatization disorder usually have pain in many areas of the body. To be diagnosed with somatization disorder, the person must have pain symptoms in at least four areas of the body, including two gastrointestinal problems, one sexual symptom and one neurological symptom. It is even possible that people lose a function of the body, just like with the conversion disorder. The symptoms of the imagined disease are often vague, dramatic or exaggerated. This exaggeration happens to be treated anyway, even though that treatment is often unnecessary.

The somatization disorder usually occurs in more individuals within one family. It is not clear whether there is a genetic cause. It may well be that children see the somatising parent as a role model. Parents with this disorder also often ignore their children, so that the children learn that they should get attention by feeling sick.

People with a pain disorder only complain about chronic pain. Pain disorder is very similar to somatization disorder, with the difference that the four previously mentioned symptoms do not have to occur with the pain disorder.

People with somatization and pain disorders often suffer from anxiety and depression as well. These disorders are more common in women than in men, and in cultures where it is less accepted to have negative emotions. This may also be because men are more inclined to disguise the symptoms through alcohol abuse or antisocial behavior. A cognitive theory states that people who have this disorder are more sensitive to pain, pay more attention to what they feel in their bodies and that they tend to make a mountain of a molehill. The interpretation of the symptoms is wrong and the pain is often exaggerated to get more attention from family and doctors. Because of this way of thinking, these people express their feelings in an exaggerated way, giving them more attention from doctors and family members. There are also indications that having PTSD influences the development of somatization disorder.

Many people with a somatization disorder have a history of major depression, anxiety disorder, drugs or personality disorder. This disorder is mainly passed on by women within families. Men with a somatization disorder often have problems with alcohol abuse and antisocial behavior. Families with somatization disorder often consists of women with a depression or anxiety disorder and men with a drinking problem.

Parents with a somatization disorder often neglect their children. As a result, they teach their children that they only get attention when they are sick, so the children have an increased chance of getting the disorder themselves.

It is not easy to convince these people that they have a psychological disorder because they actually feel pain. However, if they finally cooperate in treatment, the prospects are good. Psychodynamic theories focus on providing insight into the relationship between emotional causes and the pain they feel. They do this by recalling the experience that caused the pain. Cognitive therapies teach patients to properly assess their physical complaints so that they are less worried about their illness. Behavioral therapy looks at the positive reinforcers that people get from the disorder. This mainly concerns attention. These reinforcers are eliminated and positive reinforcers are created for healthy behavior. Antidepressants also work for people with this disorder, but not as well as therapy.

What is the difference between hypochondria and somatization disorder?

Hypochondria and somatization disorder do not differ so much from each other. The difference between the two is that people with somatization disorder feel pain and that people with hypochondria are only afraid that they have an illness and do not actually have physical symptoms. Once people with hypochondria do feel a physical complaint, they immediately go to the doctor, while people with a somatization disorder wait longer to see how the symptoms develop. People with hypochondria often suffer from chronic depression or anxiety and also often have family members with the same disorders. Their fears about their health usually stem from a general feeling of stress. Cognitive therapy focuses on eliminating the misinterpretation of a physical feeling.

What is body dysmorphic disorder?

People with body dysmorphic disorder feel that they have a body part that is completely deformed. There are about as many women as men with this disorder, but the focus differs from the disorder. Women are often concerned about their breasts, legs, hips and weight. Men are often worried or have a small physique, genitalia and lack of body hair.

People with this disorder spend hours covering their 'deformed' body part and often use plastic surgery to fix their problems. People with this disorder are often withdrawn because they feel ashamed when other people see their malformation. This disorder is a bit like OCD, because it has to be obsessively ensured that the 'bad' body part is fixed.

Psychoanalytical therapy is aimed at providing insight into the background of the concerns about the body part. Cognitive behavioral therapies are aimed at reducing anxiety about a certain part of the body, by changing wrong thoughts about it and through desensitization. It seems that SSRIs can also help treat body dysmorphic disorder, which also indicates that this disorder may be a form of obsessive-compulsive disorder. SSRIs are also used as a treatment for this disorder.

What is the process in a dissociative disorder?

Dissociation is a process whereby parts of a person's memory, identity or consciousness are separated from each other. Many see it as split ideas of consciousness that can be achieved through dreams and hypnosis. According to Hilgard there are two forms of consciousness: an active and a receptive mode. The active mode consists of consciously planning and taking actions. The receptive mode consists of unknowingly processing information, as if there were 'hidden observers'. For most people these two different states of being merge seamlessly into one another, but for people with a dissociative disorder that is a major problem.

Dissociative identity disorder (DID)

Dissociative identity disorder (DID) or multiple personality disorder is a highly controversial disorder. People with this disorder have multiple personalities, sometimes even more than twelve. Each of these personalities has a different character. They regularly take over the body from the 'hostess' or 'host'. Each character has his own behavior, way of talking, gestures and such. Often the different personalities, or alters, have different ages and genders. DID is much more common in women than in men, although there are no gender differences in children. Men with DID are often more aggressive than women with the disorders tend to be.

In this disorder there are different personalities with specific qualities, which are called 'alters'. There are different types of alters:

1. Child alters are alters of young children. This form is the most common type of alter. DID is often caused by childhood trauma. It is possible that this alter is created during the trauma, as a result of which the alter experiences the trauma and thus protects the victim himself. This alter can also act as an older brother or sister who protects the victim from the trauma.

2. Another type of alter is the persecutor personality. This alter tries to destroy the person. It is often the case that these alters throw themselves into dangerous behavior, for example by jumping in front of a truck, after which another alter takes over again, and then has problems. The persecutor personality often has the idea that he can hurt the rest of the alters without harming himself.

3. A third type of alter is the helper alter. This alter has the function to offer advice to other alters, and to do things that other alters are unable to do. Helper alters can sometimes influence the switching of personalities. It often happens that certain personalities know nothing about what happens when the other alters are active. So it may be that someone suddenly finds things in his house that he does not know, or that people greet her who she does not know.

It may be that the host or hostess is not aware of these alters and therefore suffers from some sort of amnesia (memory loss). Sometimes the alters are aware of each other and so information goes from one personality to the other.

People often come to the therapist because of self-damaging behavior caused by the persecutor personality. They have attempted suicide or caused serious damage to their bodies.

Children can also get this disorder. The symptoms in children take on slightly different forms than in adults. Children often have many emotional problems. They often suffer from symptoms that are similar to the symptoms of PTSD. Children with DID often (just like adults) suffer from voices in their heads.

DID was never diagnosed before 1980, and very often after 1980. There can be various reasons for this. This disorder was included in the DSM-III around 1980, as a result of which people were diagnosed with the disorder more often. Furthermore, the criteria for schizophrenia were adjusted in the same version, so that people who might have been called schizophrenic in the past were now diagnosed with multiple personality disorders.

It often happens that before they were diagnosed with DID, people have already received a number of other diagnoses. Sometimes this is because DID often goes together with other disorders, such as depression, anxiety disorders (usually PTSD) and substance abuse. It is also often accompanied by an eating disorder. Most people with DID also have a personality disorder. Some of the earlier diagnoses may also have been incorrect diagnoses of the dissociative symptoms. For example, when people with DID say they hear voices in their heads, they are often diagnosed with schizophrenia. There are a few important changes in the diagnostic criteria for DID in the DSM-V. The DSM-V has added the words 'or an experience of being possessed' to criterion A, in order to make the criteria more applicable to various cultural groups. Many characteristics of DID can be influenced by someone's cultural background. Another change in the DSM-V is that the transition in identity does not have to be observed directly by others, but reporting by the person himself (self-report) is sufficient (criterion A). A final change is that amnesia can also occur with everyday events, and not only with traumatic experiences (criterion B).

Many scientists see DID as a result of coping strategies used in severe trauma, for example physical or sexual abuse. Most people with DID have been sexually abused as children and have shifted this experience to another personality. This can happen because they relive it as an outsider in dreams. The abuse is often done chronically by parents or family. In such a case, personalities are often developed to help process the traumatic experience. These personalities then provide security and safety to the individual. People with DID are easy to hypnotize, which can mean that they hypnotize themselves to dissociate and escape their traumas.

DID is usually more common within certain families. It could be that the ability to dissociate as a defense mechanism is to a certain extent hereditary.

The purpose of treating someone with DID is to ensure that all different personalities are integrated into a single personality. This is done by looking at the different roles of the alters, and by having each alter process the trauma separately. Negotiations are also taking place between the various personalities to bring the person back into one whole. Sometimes antidepressants and other medications are used to help the therapy. Often a treatment with someone with DID is successful, especially if the treatment starts soon after the trauma has started.

Dissociative fugue

Someone with a dissociative fugue can suddenly move to another city and start a new life without remembering that he has ever had another life before that. The person can behave very normally in his new life, and finds it strange that he does not remember anything about his past. Just as suddenly he can return to his old life, where he continues as if he has never left.

Such a fugue can occur once or more often and can take days or even several years. Occasionally a fugue arises from a traumatic experience, but it is more often the case that people experience a fugue when exposed to chronic stress. People are often depressed before the fugue starts. Fugues are more common in people who have previously had some form of amnesia (memory loss). Very little is known about this disorder because it is very rare.

Dissociative amnesia

In the disorders discussed above, people have amnesia (memory loss) for certain parts of their personality or past. People with dissociative amnesia have periods of amnesia, in which they have lost parts of or even their entire identity, but do not assume a new identity. People with this form of amnesia are generally aware that they do not know much anymore. They have a dissociative memory loss.

There is a difference between organic and psychogenic amnesia. Organic amnesia is amnesia caused by brain damage caused by, for example, an illness, the use of drugs or an accident. With an organic cause, anterograde amnesia usually takes place, which means that it is no longer possible to store new information. Psychogenic amnesia has a psychological cause. Anterograde amnesia almost never has a psychological cause. Especially retrograde amnesia (not being able to retrieve old information) occurs in this form. Another difference is usually that people with psychogenic amnesia have forgotten personal information, but still know general information, and that people with organic amnesia often have forgotten both types of information.

Dissociative amnesia is a form of psychogenic, retrograde amnesia. This form of amnesia often occurs after traumatic events. Psychogenic amnesia is often the result of a defense against stress towers or radical memories.

Sometimes people forget a little bit of information, for example what happened before an accident, but they can also forget large amounts of information. Alcohol poisoning can also cause you to lose your memory, although this is often only the case for the things that happened during your alcohol poisoning. People who are addicted to alcohol for a long time can develop a general form of retrograde amnesia, namely Korsakoff's syndrome. Then they cannot remember any personal information.

It is also possible that amnesia occurs because a person was in a very high state of arousal during a certain event, so that the information was not properly coded in the brain.

Another explanation is that memories of an event are sometimes associated with very painful experiences. Because people do not want to evoke the painful experiences, they cannot remember anything about it. A complication in diagnosing amnesia is that amnesia is often cited as a defense in court cases, and it is difficult to determine whether there is real amnesia, or whether the suspect is just trying to get a milder sentence.

A sub-type of dissociative amnesia is a dissociative fugue.

What is a depersonalization disorder/ derealisation disorder?

Depersonalization disorder / derealisation disorder is a condition in which people often feel that they are disconnected from their thoughts and their bodies. It then seems as if they are observing themselves from an outside perspective. People with depersonalization disorder regularly feel that they are not connected to their body mentally or physically. You will only get the diagnosis for this disorder if this experience occurs regularly and if it limits your functioning in daily life. This kind of experience is more common in people, but not everyone gets a diagnosis as long as it does not limit their daily lives and functioning. The disorder is often provoked by periods of insomnia and drug use. Half of the adults indicate that they have had a short episode of depersonalization or derealization, often after a significant stressor.

What is the relationship between mood disorders and suicide? - Chapter 7

Two different mood disorders are discussed below. Bipolar disorder is a disorder with periods of mania and periods of depression. Someone with a unipolar disorder only suffers from depression (and not mania). Furthermore, the subject of suicide will be looked at.

What happens with a unipolar disorder?

The lives of people with depression are totally occupied by their disorder; depression affects human emotions, bodily functions, behaviors and thoughts.

The most important emotional symptoms in someone with a unipolar disorder are being sad and losing all interest in life, which is referred to by the term anhedonia.

In people with depression are also many bodily changes. These concern changes in appetite, sleep and activity. Some people with depression have very little appetite, while others have a lot.

Many depressed people exhibit changes in the way they move in their behavior. For example, they move very slowly with everything they do. This is called psychomotor retardation. Many people feel that they have little energy and are constantly tired. A small proportion of the depressed people feel restless. These people have opposite symptoms: psychomotor agitation, where people feel physically agitated, cannot sit still and walk aimlessly or fiddle.

The cognitive symptoms of depression are all kinds of thoughts about, for example, hopelessness, shame and suicide. In severe cases there are also delusions and hallucinations. Delusions are thoughts that have no true basis in reality. Hallucinations are perceptions that someone has that are not actually there in reality.

Depression can take various forms. Major depressive disorder is a major depression that lasts at least two weeks. The diagnosis requires that someone feels depressed or has a loss of interest in daily activities. In addition, there must be at least four other symptoms of depression. According to the DSM-IV there are two types of unipolar depression: major depression and dysthymic disorder. The difference between these two disorders is that major depression is of shorter duration but very intense. Dysthymic disorder is a chronic form of depression that lasts for at least one year in childhood and two years in adults. This depression can be less serious than a major depressive disorder. A person must have a depressed mood and have lost his interest in life. In addition, there must be at least four other symptoms of depression for at least two weeks, with a disruption of daily life.

There are two types of major depression: in the first type (major depression single event) there is only one single depressive episode, while in the second type (major depression periodically) there are two or more episodes with at least two consecutive months without symptoms between episodes. The DSM-V criteria include the observation that a normal and expected depressive response to a negative event, such as a loss, should not be diagnosed as a major depressive disorder unless other symptoms such as worthlessness, suicidality, and psychomotor retardation are present.

More chronic forms of depression have been reformulated in the DSM-V, and have now been named 'persistent depressive disorder' (formerly dysthymic disorder and chronic major depressive disorder). A persistent depressive disorder has a depressive mood that lasts for at least two years. Children and adolescents must have a depressed or irritated mood for at least one year. In addition, there must be two or more of the following symptoms:

The other variant of depression, a dysthymic disorder, lasts much longer, but is less intense than a major depressive disorder. Some people suffer from double depression. These people have dysthymic disorder, with major depression episodes. When they come out of such an episode, they fall back into dysthymia.

Symptoms of depression:

1. Eating little food or overeating
2. Insomnia or sleeping too much
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration and difficulty in making decisions
6. Feelings of hopelessness

During this two-year period (or one year in adolescents), the depression should never be gone for more than two consecutive months. People with persistent depressive disorder are more likely to have comorbidity of disorders, including anxiety disorders and substance abuse.

More than 70% of people with depression also have a different psychological disorder at some point. The most common disorders in combination with depression are substance abuse, anxiety disorders and eating disorders. Sometimes depression can be a cause or consequence of another disorder.

There are different subtypes of depression.

1. Depression with anxious stress. People with this subtype have both anxiety symptoms and depressive symptoms.

2. Depression with mixed characteristics; People with this subtype meet the criteria for a major depressive disorder, and at least three symptoms of mania, but do not meet all the criteria for a manic episode. Depression with psychotic characteristics; people suffer from delusions and hallucinations during a depressive period.

3. Depression with melancholic features. The physiological symptoms of depression are particularly present.

4. Depression with psychotic characteristics. People also experience illusions and hallucinations.

5. Depression with catatonic characteristics. This type of depression involves strange behaviors that are associated with catatonia. One speaks of catatonia when different types of behavior are totally disturbed. These behaviors can vary from no longer showing any movements to a lot of motor activity.

6. Atypical depression, a depression in which there is a collection of different symptoms;

7. Depression with peripartum onset. This diagnosis is given to women who have a major depressive episode during pregnancy or within four weeks of the birth of the child. Postnatal depression, a depression that develops within 4 weeks of having a child. It can also occur that a mother becomes manic during pregnancy (bipolar disorder with peripartum onset) or after having a child (postnatal bipolar disorder). 30 percent of women who have a child suffer from postpartum blues, which means that they suffer from lability, a lot of crying and tiredness.

8. Winter depression, or seasonal affective disorder (SAD): People with SAD have a history of at least two years in which they were depressed in the winter, for example, and not in the summer. It is also possible that people in those periods become manic. The diagnosis is then bipolar disorder with seasonal onset.

9. Premenstrual mood disorder: a lot of stress before menstruation

Depression is the most common psychological disorder. Of all Americans, 16 percent experience a depressive episode somewhere in their life. Depression is the most common among young adults, after which the risk of depression decreases more and more. Only after the age of 85 can an increase be seen again.

The decrease in the prevalence of depression in older adults, older than 65 years, can be explained by the fact that the diagnosis of these people is more difficult. This may be because older people are less likely to admit that they are depressed because of the norms and values ​​they hold. Depression in the elderly also often coincides with a certain disease, which means that depression is overlooked when making the diagnosis. Depression is also harder to diagnose because older people often deteriorate in cognition. It is then difficult to distinguish between a depressive disorder and the early stages of a cognitive disorder. There is also the possibility that there are indeed fewer depressed elderly people. There are two explanations for this. People who are depressed or have a tendency to become depressed simply become less old. Another explanation is that older adults are developing better coping strategies, which makes them less likely to experience depression.

If a child suffers from depression, it can have a major effect on the rest of his life. Because the self-image is still developing rapidly in a child, a period of depression can change that a lot. Because depression also affects school performance, it can thus affect the child's future. Depression also reduces the chances of the child in other areas, for example due to poorer development of social skills. At puberty there is a large increase in depression among girls, but not among boys. This is probably because boys generally appreciate the changes in their body better than girls do.

Depression can often be a recurring problem. After people have recovered from a depressive episode, people remain prone to relapse. 75% of people who have had a first depressive period experience depression again later in life.

What is bipolar disorder?

Bipolar disorder is a disorder in which the symptoms of depression are alternated with symptoms of mania. The symptoms of depression have already been discussed above, so we will now only discuss the symptoms of mania.

People in a manic episode are elated, but that elation is often mixed with restlessness and irritation.

Symptoms of mania are:

1. A higher self-esteem or feelings of grandiosity
2. Reduction of sleep
3. More talking, or more urge to talk
4. Having the feeling that ideas and thoughts are racing through the mind
5. Being easily distracted
6. Having more targeted activity or psychomotor agitation
7. Performing more activities where there is a good chance of painful consequences.

People with bipolar I disorder have these symptoms which are alternated with periods of severe depression. People with bipolar II disorder also have severe periods of depression, but their manic periods are milder than for people with bipolar I disorder. Bipolar II disorder is therefore also called hypomania: The symptoms of mania are not severe enough to interfere with daily functioning, they tend to contain no hallucinations or illusions, and 'only' last at least four days. As with a dysthymic disorder, a cyclothyme disorder is a bipolar disorder that is less severe but more chronic.

It is difficult to distinguish the excitement associated with mania in adolescents from the symptoms of ADHD or the symptoms of ODD. This is the reason that a new diagnosis has been added to the DSM-V to distinguish children with these outbursts of anger from children with a more 'traditional' bipolar disorder. This new diagnosis is the disruptive mood dysregulation disorder. A child must have at least three outbursts of anger per week for at least 12 months and in at least two different settings of its environment in order to get this diagnosis.

Bipolar disorder is much less common than a unipolar disorder; or depression. Between 1 and 2 percent of people suffer from a bipolar disorder at some point in his or her life. Many people with this disorder have problems in daily life, such as at work or in their family life. Bipolar disorder often co-occurs with other disorders, in particular anxiety disorders and substance abuse.

There are indications that people with bipolar disorder are more creative than people without the disorder. However, this benefit should not be exaggerated in a positive sense, as it does not outweigh the serious disadvantages of the disorder.

What biological theories are there about mood disorders?

There are indications that genetic factors play a role in the development of depression and mania. Research into the family history of people with bipolar disorder shows that first-degree family members (for example, parents, brothers, sisters) have a two to three times greater chance of having that disorder compared to any other person. This may seem like a lot, but if, for example, you have a father with bipolar disorder, you only have a 5 to 10 percent chance of getting the same disorder. For unipolar disorder, the evidence for heredity is less than for bipolar disorder.

What is also interesting is that people with unipolar disorder have no greater chance of developing bipolar disorder than people without unipolar disorder. This indicates that there is a different genetic background for both disorders. Studies in twins have shown that for a bipolar disorder, the concordance (agreement) between identical (monozygous) twins is 60 percent and between non-identical twins (dizygous) is only 13 percent. This is a good indication of the genetic background of depression. The problem is that other investigations showed a much lower level of agreement, so the evidence seems not very strong. A large adoption study showed that biological brothers and sisters of someone with a mood disorder themselves also had mood disorders more often, compared to brothers and sisters of people without a mood disorder. The same also applied to the amount of suicides and suicide attempts.

Many biological theories about mood disorders mainly focus on the dysregulation of neurotransmitters. There are many neurotransmitters that may play a role in mood disorders, but it is mainly monoamines that have to do with mania and depression. The monoamines are norepinephrine, serotonin and, to a slightly lesser extent, dopamine. These neurotransmitters are mainly found in places in the brain that serve to regulate sleep, appetite and emotion. It is thought that a surplus of these neurotransmitters causes mania and too few neurotransmitters cause depression. A shortage of these neurotransmitters can have a number of causes. It may be that too few of the substances are produced, they may also be broken down too quickly, or they may be absorbed too quickly. Too many neurotransmitters have the same causes, but vice versa (too much created, broken down too slowly, or taken up too slowly). A modern version of this monoamine theory states that something is wrong with the amount of or sensitivity of the receptors. In depression, there are too few receptors or they are too sensitive. In bipolar disorder, it seems that the sensitivity and amount of receptors change at the wrong moments. With the help of CT, PET and MRI scans, a number of brain abnormalities have been found in people with a mood disorder. Abnormalities were found in the following four different parts of the brain:

1. Prefrontal cortex. This part regulates attention, short-term memory and solves problems. People with depression have less gray matter on the left and reduced metabolic activity in the prefrontal cortex. The left prefrontal cortex is mainly involved in motivation and goal-oriented behavior, which may explain the motivation problems in depression.

2. Anterior cingulate. In this part of the brain, the body's reaction to stress takes place, as well as emotional expression and social behavior. Different levels of activity are found, which is associated with problems in planning, attention and giving appropriate answers. It also has to do with the symptom of anhedonia that is found in depression.

3. Hippocampus: which is involved in memory and anxiety-related learning. A lower volume of the hippocampus and lower metabolic activity is found in depression. Damage to the hippocampus can be caused by chronic activation of the physical stress reactions.

4. Amygdala: which is responsible for focusing attention on emotional stimuli that are important to the person. In people with depression, this part is larger and more active, which can cause them to focus more on aversive or emotionally exciting information.

The neuronendocrine system regulates the secretion of a large number of hormones that are important for the body. These hormones help the body to respond to environmental stressors and regulate functions such as sleep and pleasure. The hypothalamus, pituitary gland and adrenal cortex are three important parts of the neuronendocrine system, which work together in a feedback-based system. This system is called the HPA axis. Normally, the HPA axis becomes more active when there is a stressor and it then releases hormones such as cortisol. When the stressor has disappeared, the HPA axis returns to an equilibrium state.

In people with depression, there is chronic hyperactivity in the HPA axis, and it is difficult to return to equilibrium. One of the models of depression states that when people are exposed to chronic stress, they get a poorly developed HPA axis, causing them to react too strongly to minor stressors after a while.

There is a discussion about whether the female hormonal cycle plays a role in depression. The main reason why they think that is because women are more likely to suffer from depression when they are in certain periods of their menstrual cycle, after having given birth, or during their menopause. A special name had first been reserved in the DSM for this form of depression, but a discussion is now ongoing as to whether this is necessary.

What are the psychological theories behind depression?

Depression often results from negative events that cause a lot of stress. This can be, for example, after losing a job or after a divorce. The behavioral theory of depression states that stress in a person's life leads to depression, because there are fewer positive reinforcers because of the stress. As a result, the person withdraws, resulting in even fewer positive reinforcers, after which a vicious circle is created. In addition, when people exhibit depressive behavior, they receive attention, which rewards depressive behavior.

Another theory, that of learned helplessness, states that depression usually results from events that people cannot control. Especially if these events often occur in someone's life, people start to think that important things cannot be changed, and they also lose the motivation to change anything. The result is very similar to the symptoms of depression. The learned helplessness model originated from animal research, but it turned out that it could also be applied to humans. People who are depressed often focus on how tired they feel, and for example how hopeless they are. They just think about it, but don't try to change it. This also closely resembles learned helplessness. Some people do not have this tendency and will get rid of their depression sooner.

One of the first cognitive theories was that of Aaron Beck. He stated that depressed people view the world from a negative cognitive triad: they see themselves, the world and the future in a negative way. Depressed people tend to take the wrong steps: for example, they ignore positive events, come to conclusions without sufficient evidence and exaggerate negative things that happen in their life. Often, these negative thoughts occur so automatic that the person is not even aware of them.

The reformulated learned helplessness theory is another important theory. It is an adaptation to the behaviorist theory in the sense that it shows how cognitive factors can influence the feeling of helplessness. The theory focuses on the cause-effect attributions that people make. These attributions are explanations that someone gives for certain things that happen. If someone sees a negative event as something that is stable (it cannot be changed), internally (it was caused by the person himself) and globally ("if it is like this now, then it will also be like that in the future"), then the person will expect that negative events - that he or she cannot control - will often occur in the future. This leads to learned helplessness in many areas of his life. As with the behaviorist theory, proponents of this theory argue that learned helplessness has the same symptoms as depression.

A number of studies have been conducted towards the extent to which people with depression are realistic thinkers. It appears that people with depression can estimate much better than other people how much control they have over certain things. People who are not depressed tend to overestimate their own influence on events, while depressed people are much more realistic. This has led to the idea that it is not the depressed people who think wrong, but the people who are not depressed. This is also called depressive realism.

The ruminative response styles theory focuses more on the way of thinking than on the content of thinking. People who think in this way try not to change the causes of their feelings, and keep worrying about their depression. People with this ruminative coping strategy have a greater chance of depression. Furthermore, depressed people pay more attention to negative thoughts and negative stimuli. In this way they see the world in a more negative light. Depressed people also store memories in a more general way.

Interpersonal theories deal with the relationships between people and what roles people play in certain situations. Disruptions in the roles are seen as the biggest source of depression. One of these theories states that if children do not experience their parents as warm and trustworthy people, they will develop an insecure attachment style. The attachment style a child has lays the foundation for relationships with other people that he or she will have in the future. If someone learns from an early age on that engaging with people goes in a certain, negative way, he gets certain expectations from others, and will act accordingly. These expectations are called contingencies of self-worth. These expectations are wrong, in the same way as in Aaron Beck's theory.

According to interpersonal theories, people who are uncertain in their relationships need constant reassurance seeking. The environment becomes tired of this at some point, with the result that the person feels rejected and continues to slip.

Another theory states that women learn to base their self-image on the relationships they have with others. As a result, they are more likely to become depressed than men.

How does sociology explain depression in people?

The number of people with depression varies from generation to generation. A number of explanations for this have been mentioned at the beginning of the chapter, yet now a statement from sociology will follow. This statement uses the term cohort effect. This is the phenomenon that people from a certain period in history had a different chance on having a certain disorder than people in a different period. These differences are due to the differences in culture between certain periods. Proponents of this theory say that people who were born recently are more likely to suffer from depression because of the rapid changes in culture that began in the 1960s, including the disintegration of the family as the stable basis in society. Another explanation is that nowadays people have higher expectations of themselves than they used to have, which results in the idea that they cannot live up to those expectations, which makes them more prone to depression.

An important factor that determines depression is social status. This is a possible explanation for the fact that women are more likely to suffer from depression than men (women generally have a lower social status than men). Men also have a different way of coping with stress than women. Men deny that they are stressed and are more likely to drink alcohol, while women are more likely to worry excessively about their feelings and problems. Men are therefore more likely to develop disorders such as alcohol abuse, while women are more likely to experience depression because of their tendency to worry. Social relationships are more important to women than to men. This can give them support when they need it, but it also gives women a greater chance of depression if bad things happen to others or if they have a conflict with another.

There are also cross-cultural differences. Cultures with a lot of poverty, unemployment and discrimination have higher rates of depression.

What is the theory behind bipolar disorder?

Bipolar disorder is strongly linked to genetic factors. Twin studies show that 45-75% of the disorder is caused by genetic factors. Bipolar disorder also has brain abnormalities. There is a difference in the structure of the brain in the amygdala and the prefrontal cortex. Part of the structure of the basal ganglia, the stratium, influences the processing of environmental factors. This does not work normally in people with bipolar disorder. They are often hypersensitive to rewarding environmental factors. Due to an error in the circuit from the prefrontal cortex to the stratium, people with bipolar disorder often have inflexible reactions to rewards. During a manic period they are looking excessively for rewards, while during a depressive period they are insensitive to rewards.

There are also abnormalities in the white matter of the brain, which connects the structures in the brain and transmitters. This is particularly the case in the prefrontal cortex, which means that the prefrontal cortex does not communicate well with other brain regions and cannot properly control other brain regions. This leads to disorganized emotions and extreme behaviors.

People with bipolar disorder are more sensitive to rewards. Disregulation of the dopamine system contributes to bipolar disorder. Higher levels of dopamine are associated with a greater tendency to look for rewards, while low levels are associated with insensitivity to rewards.

A psychosocial factor is stress. Stressful events trigger a new episode. If your body state suddenly changes, for example in the form of different sleep or eating behavior, a relapse can easily take place. Significant changes to the daily routine can also trigger a new episode.

How can mood disorders be treated bilogically?

In general, medication is prescribed to treat a mood disorder. Alternative biological treatments are electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation and deep brain stimulation (DBS). People with a seasonal affective disorder (SAD) often benefit from light therapy.
Changes in the state of mind of people taking medication often occur after a few weeks. This may indicate that these drugs have slow effects on intracellular processes in the neurotransmitter systems and on the actions of genes that regulate neurotransmission, the limbic system and the stress response. Medications work better with severe depression than with mild or moderate depression. Stopping medication in the first six to nine months after the symptoms are over appears to double the risk of relapse in major depression. People with bipolar disorder often take antidepressants continuously to prevent a relapse into depression.

SSRIs (Selective Serotonin Reuptake Inhibitors) are often used to treat depressive symptoms. They are not more effective than other available antidepressants, but they have much fewer serious side effects and are somewhat safer when an overdose is taken. This is because they only work on serotonin and not on other neurotransmitters. In addition, they also have positive effects on a wide range of symptoms that often occur together with depression, such as anxiety, eating disorders and impulsiveness. They also have the advantage that they start working faster and that people take an overdose much less quickly than with other antidepressants. SNRIs (Selective Serotonin-Norepinephrine Reuptake Inhibitors) have been developed to act on serotonin as well as on the norepinephrine levels, making them a little better than SSRIs in preventing relapse into depression. They do have slightly more side effects.

Bupropion works differently from the medication described above. Bupropion works on the norepinephrine and dopamine systems. Bupropion appears to be especially effective in people who suffer from, for example, psychomotor retardation, anhedonia and hypersomnia.

Trycilic antidepressants help fight the symptoms of depression well. They do this by ensuring that serotonin and norepinephrine are not properly re-incorporated into the synapse after they have been released. These drugs are quite effective, 60 to 85 percent of the patients receiving these drugs are helped effectively. The disadvantages of these drugs are the side effects and the fact that someone can get an overdose very quickly, so these drugs are not often prescribed these days out of safety reasons.

Monoamine oxidase inhibitors (MAOIs) are drugs that inhibit the action of the enzyme MAO. MAO is an enzyme that breaks down the monoamine neurotransmitter after it is released. If this enzyme is inhibited, more neurotransmitter is available. MAOIs are actually even worse than the tricyclic drugs if we consider the side effects. The effectiveness is the same, but the side effects are even worse. These drugs can cause damage to the liver, for example, and cannot be used on a diet that contains the amino acid tyramine because it chemically reacts with these molecules.

Far fewer treatments have been developed for bipolar disorder than for depression. Until recently, lithium was the only way to treat manic depression, but nowadays a number of drugs have been added. In addition, people with bipolar disorder often take antidepressants to reduce depressive episodes. They are also often prescribed with atypical antipsychotics.

Lithium is a medicine that reduces the symptoms of mania, but not the depression that follows it. Usually, people also take lithium in between the manic episodes to ensure that no relapse occurs. Lithium probably works by stabilizing the serotonin and dopamine systems. There are a number of problems with the use of lithium. The first problem is that it varies from person to person how much someone needs it. The second problem is that there is only a small difference between an effective dose and a fatal overdose. This means that patients must be guided very well by their practitioner. The side effects of lithium are also very extreme, and sometimes life-threatening.

The use of anticonvulsants, antipsychotics and calcium channel blockers offers some alternatives to lithium. Anticonvulsants are also effective against mania, but it is not yet clear how effective they are. Antipsychotic drugs are discussed in the next chapter, but it appears that they are also effective in treating mania, especially if the mania has psychotic characteristics. Calcium channel blockers also prove to be effective, but they are not sure yet about how they actually work.

Another way to treat depressed people is the use of electroconvulsive therapy (ECT). It was once introduced as a treatment method for schizophrenia. ECT consists of a series of treatments in which a current shock is sent through someone's brain. Usually this only happens on the right side of the brain to prevent memory loss. The patients are anesthetized beforehand and are given muscle relaxants, because the shocks can cause muscles to collapse enormously. The patient may experience problems after the treatment. ECT is used in people who are severely depressed and have not been helped with any other treatment options. How ECT works is not yet clear. It could be that the electric shock ensures that the barrier between the bloodstream and brain (blood-brain-barrier) becomes more permeable, which improves the effect of medicines. It could also be that the synapses release neurotransmitters acutely when a shock passes through the brain. ECT is controversial for various reasons. The fact is that ECT can lead to memory loss. Another problem with ECT is that the chance of relapse after stopping treatment is quite high: 85 percent of the patients treated fall back into depression. The last reason is that the idea of ​​an electric shock through your brain is quite a scary thought.

There are new methods for brain stimulation. The first is repetitive transcranial magnetic stimulation (rTMS). Patients are regularly exposed to high magnetic pulses that are focused on specific parts of the brain. In depression, this is primarily the prefrontal cortex. The big advantage of this is that there is only one side effect; which is a headache. Another method is vagus nerve stimulation (VNS). Part of the brain of the autonomic nervous system (the vagus nerve) transports information from the head, neck, thorax and abdomen to different parts of the brain (including the amygdala and the hypothalamus). With this treatment, the vagus nerve is stimulated by a small electronic device that is implanted under the skin in the left chest wall. The VNS increases the activity in the hypothalamus and amygdala, which has antidepressant effects. The last method is deep brain stimulation. Electrodes are implanted in different parts of the brain, which are then stimulated. They are attached to a pulse generator that is placed under the skin.

Light therapy is often used to remedy winter depression or otherwise seasonal affective disorder (SAD). With light therapy, people are exposed to bright light for several hours a day during the winter. Light therapy is a way to adjust the body's biorhythm. The biorhythm is regulated by various hormones and brain processes, but is also dependent on environmental factors such as light. It is not yet entirely clear how this form of therapy works. It is possible that the biorhythm changes because the production of the hormones is normalized again. It is also possible that the extra light causes increased melatonin production, which in turn causes an increase in dopamine and norepinephrine levels. Another theory says that light therapy influences serotonin levels.

How can mood disorders be treated psychologically?

Behavioral therapy focuses on increasing the number of positive reinforcers and reducing aversive experiences by ensuring that the patient has a better life. This form of therapy usually lasts quite short, around 12 weeks. The first phase of therapy consists of a functional analysis that examines how the patient's circumstances and his symptoms are related. For example, the patient is asked when he or she usually feels the worst. This analysis shows what the therapy should focus on. It also serves to show patients that they themselves can do something about their environment, which will reduce their depression. After the analysis, the therapist and the patient can use a number of strategies to help the patient. This way they can try to change the environment in which the patient feels depressed. What they can also try is to teach the patient new skills, such as social skills. Another strategy is to acquire skills to improve the patient's mood in stressful circumstances.

In cognitive behavioral therapy, the behavioral and cognitive techniques teach the patient to learn certain skills. There are two goals in this therapy: to break through the negative thinking patterns, and to help solve problems in the patient's life so that the patient has fewer reasons to be depressed. Cognitive behavioral therapy, just like behavioral therapy, is often short-lived. With cognitive behavioral therapy it is important that the patient plays an active role.

The first step in this therapy is to identify automatic thoughts. These are, for example, thoughts that the person has of blaming him- or herself for something that happens. The second step is to show the patient that there are other ways to think about these events. The therapist does this by asking all sorts of questions, for example questions like "is this the only way to think about the situation?" The third step in this therapy is to make the patient realize what deeper beliefs underlie his / her depressive thoughts.

With interpersonal therapy, there are four types of problems that are addressed.

• First, there are people who are depressed because they may have lost someone. This may be due to someone's death, but also due to, for example, a divorce or another type of broken relationship.

• The second problem that interpersonal therapy can do something about is a broken or malfunctioning division of roles between people. For example, tension may arise because two married people disagree about who should take care of their children. In therapy, the therapist shows where the problems lie and lets the patients choose which concessions they want to make to solve the problem.

• The third problem is that of role changes. If someone suddenly has to change roles, for example if a working woman suddenly has to take care of her children, this can cause tensions. A therapist can guide someone through this process.

• A final problem that an interpersonal therapist can help someone with is the acquisition of interpersonal skills. The lack of these skills can lead to depression because someone often has less social support.

Interpersonal and social rhythm therapy (ISRT) is a form of therapy that has been specially developed for people with bipolar disorder. ISRT combines interpersonal therapy techniques with behavioral therapy techniques to ensure that patients maintain regular routines of eating, sleeping and activities in their daily lives. It also ensures stability in their personal relationships. Patients learn how stressors in their family and work relationships affect their mood, and they develop better strategies for coping with these stressors.
Family Focused Therapy (FFT) is also designed to reduce interpersonal stress in people with bipolar disorder, especially within the family context. Patients and their families receive education on what constitutes bipolar disorder, and are trained in communication and problem-solving skills. This can be effective, especially for adolescents.

More and more prevention programs are being set up with the aim to prevent depression. This is done because depression can have a devastating effect on people's lives and society in general. The prevention programs focus primarily on groups that are particularly vulnerable to depression, such as adolescents.

In the last decades, people have started comparing which therapy is most effective for various types of disorders. In depression, many types of therapy are all equally effective. Another result of these studies is that there is a large placebo effect. If a person develops a warm bond or relationship with his or her therapist, he will heal faster than if his relationship with the therapist is poor. The therapies are the same in effectiveness, but treatment with medication works faster. However, these treatments have a higher risk of relapse than psychological therapies.

In the case of bipolar disorder, combining medication with psychological treatment can ensure that patients continue to take their medication, making more patients completely better compared to lithium treatment alone. Psychotherapy can help people with bipolar disorder to understand and accept that they need lithium, and it can teach people how to deal with the impact that the disorder has on their lives.

How is suicide defined?

Suicide is the deliberate deprivation of one's own life by causing damage to the body, or by poisoning or suffocation. The definition is easy, but suicide is often difficult to determine, because the termination of life can also be an accident. Suicide attempts sometimes result in death, but they may also not succeed. Suicide ideas or thoughts still have to be implemented, but usually it doesn't come to that point.

What are the rates of suicide?

It is difficult to determine exactly how many people die from suicide, including the stigma associated with suicide. Determining the suicide rate is also difficult because it is difficult to determine what exactly is a suicide and what is not. Although the numbers are probably too low, it appears that very many people die from suicide.

It would be logical that suicide occurs more often in women than in men, because they are also more often depressed. However, that is not the case. It appears that women attempt suicide more often, but that most attempts fail, while men succeed more often in their suicide attempt. This is probably explained by the fact that men use more effective methods than women. Another explanation for this phenomenon is that when men make a suicide attempt, they are more confident of themselves and therefore choose a more effective method. It should also be noted that men use alcohol more often, and that alcohol abuse is a strong predictor of suicide.

The number of suicides among children and adolescents has increased sharply in recent years. It often happens that parents and psychologists do not believe that a child can have suicide thoughts simply because a young child would not understand the concept of suicide. It appears that suicide is still rare in young children, but it certainly happens sometimes. For adolescents, suicide is the third most common cause of death. Adolescents commit suicide more often than children, which may be due to the occurrence of many psychological disorders during the period of adolescence. Another cause may be that adolescents can think better about things like suicide than children. It is also possible that adolescents have more options for committing suicide.

The number of suicides is increasing among the elderly over 85 years of age. The suicide is usually the result of being unable to cope with the loss of the partner or loved ones. Some commit suicide because they are sick.

What is non-suicidal self-harm?

Some people cut, burn, prick or try to damage their bodies in some other way without dying. This is especially common in adolescents. Such behavior is called nonsuicidal self-injury (NSSI). People who engage in NSSI have a greater chance of committing suicide. NSSI would regulate emotions and seeing blood would give people a sense of calmness.

How is suicide explained?

Much is still unknown about suicide because it is too rare to study it properly. Moreover, the surviving relatives often do not know all the information that may be important for an investigation into the motivation of the victim to commit suicide . Finally, most people who commit suicide do not leave a letter. If a note is left behind, there is usually no clear reason why the suicide was committed.

According to Durkheim's sociological theory, three different types of suicide can be distinguished. Egoistic suicide is committed by someone who feels abandoned by others and no longer has any social contacts. Anomic suicide is committed by someone who is disoriented, for example because someone suddenly loses his job after 20 years of service. Altruistic suicide is committed when someone thinks he can help other people with it. The conclusion of this theory is that many suicides can be prevented if society would be more disapproving of the concept of suicide. In such a society, an individual will first try to solve his problems in other ways.

When two or more suicides are linked to each other, this is called a suicidal cluster. This can occur, for example, if someone commits suicide at a school and someone follows him or her in that behavior a few days later. It can also happen that more people commit suicide after a famous person has committed suicide. There are various explanations for this phenomenon. Some scientists call it suicide contagion: People somehow take on the suicidal idea of ​​someone else. It may be that the person who has committed suicide is a role model for those who are left behind, which causes them to have suicidal thoughts as well.

If a celebrity commits suicide, then suicide becomes more acceptable to people who have problems. The media attention is also an extra incentive to commit suicide.

Another explanation is that people enter into relationships with people who have the same problems as them. For example, people who are outcasts tend to interact with each other at school. If someone in such a group commits suicide, it is a negative event in the lives of the other members of that group, and they will be more unbalanced, which will also make them more likely to commit suicide.

Psychological explanations

Freud stated that suicide is an extreme expression of inward-directed anger. This anger is caused when the person is left by someone, but he or she cannot direct his anger to this other person. Therefore, the anger focuses on the part of the ego that represents that other person. This anger can lead to suicidal thoughts. According to this line of thought, people who commit suicide are full of anger and hatred. On the contrary, suicide letters show that people who commit suicide feel guilty for what they do towards others who are left behind. Psychoanalysts say that it is because people cannot express that hatred directly. This is a difficult statement to test.

More than 90 percent of people who commit suicide probably have a psychological disorder. The diagnosis is often only made after the suicide. The psychological past is mapped by psychological autopsy, or by conversations with the relatives and diary reports. Mood disorders, schizophrenia, anxiety disorders and alcohol abuse appear to increase the risk of suicide. The main reason for the suicide is to want to escape unbearable pain.

Cognitive and behavioral psychologists have a few things to say about suicide: People who commit suicide are generally desperate. These people also generally think very rigid (dichotomous). This rigidity ensures that they will not wait until depression decreases. They think suicide is the only solution to their problems.

Biological explanations

Suicide is more common in certain families than in other families. This does not necessarily mean that suicide has a genetic basis, because members of a family may experience the same kinds of stressors. Research into twins has found an indication of the genetic basis of suicide.

A link has been found between suicide and low serotonin levels. This has been demonstrated, for example, by doing autopsies on people who have committed suicide. Low serotonin levels were found to be associated with suicide. This was also the case when people were not depressed, while depression is also caused by low serotonin levels. Little serotonin is likely to cause impulsive and aggressive behavior, which increases the risk of suicide. This is evidenced by the fact that especially people who killed themselves violently had low levels of serotonin.

How can suicidal thoughts be treated or alleviated?

Someone who thinks a lot about suicide needs psychiatric help, and sometimes even hospitalization. To prevent this, there are crisis intervention programs in communities that help people who are prone to become suicidal. They provide care in the short term, but often refer people to specialists for long-term care. There are even suicide hotlines. They try to give people someone they can talk to and who tries to understand their problems. Often the help of the family is also called upon.

Lithium is an effective medicine to reduce the chance of suicide in a suicidal person. SSRIs also reduce the risk of suicide because they stabilize serotonin levels. On the other hand, they increase the risk of suicide among children and adolescents. Antipsychotic drugs are used in psychotic patients to reduce their symptoms. As the symptoms subside, suicidal behaviors often diminish.

Often, the psychotherapies used to treat depression are also used to reduce the risk of suicide. Another therapy is the dialectical behavior therapy: This is a method of therapy that teaches the patient various techniques, such as techniques for dealing with negative emotions and learning to control impulsive behavior.

Many prevention programs, such as suicide hotlines and crisis intervention centers, have been launched to ensure that suicide rates are falling. The problem with this was that they sometimes had an adverse effect: more people committed suicide. The problem with these programs was that they wanted to make suicide less of a taboo in the normal population, but at the same time they made suicide more acceptable to people who had these problems.

In the United States, most suicides are committed with a gun. People generally do not buy a gun to commit suicide, but use a gun that they have had for some time. It could be that people who get an impulse to commit suicide have too much opportunity to do so if they are allowed to possess weapons. If people did not have weapons, there would be a greater chance of a cooling off period in which someone could change their mind or go to a therapist.

What do the schizophrenic spectrum and related psychotic disorders look like? - Chapter 8

A person suffers from a psychosis if he or she has hallucinations and delusions and cannot say for certain whether his observations are real or not. One form of psychosis that often occurs is schizophrenia . People can sometimes think clearly and function well, but they will also have moments during which they can no longer take care of themselves.

Schizophrenia occurs in 1 to 2 percent of people in the United States and in 0.5 to 1 percent of all people around the world. Schizophrenia is more common in men than women and is more common in people of color than in white people. About 90% of people with schizophrenia seek help. The disorder often develops in youth or young adulthood.

What symptoms does schizophrenia have?

Schizophrenia is a very complex disorder. A distinction is made between two categories of symptoms, namely the positive and the negative symptoms. The DSM-V refers to the schizophrenia spectrum in order to indicate that there are five domains of symptoms that define psychotic disorders, and their number, severity, and duration distinguishes different types of psychotic disorders from each other.

Positive symptoms

Positive symptoms, or Type I symptoms, are characterized by the presence of delusions, hallucinations, disorganized speech and thoughts, and disorganized or catatonic behavior. These symptoms can also occur with other disorders, such as bipolar disorder, so that makes the diagnosis for schizophrenia difficult. It is also possible that the symptoms occur in people who actually do not suffer from the disorder. Think of people who hear voices and attribute this to their religion. There are also people who no longer have a grasp of reality because of the symptoms: they often have a delusional disorder.

The rule is that if the positive symptoms only occur during a manic or depressive period, the diagnosis is 'mood disorder with psychotic characteristics'. If the positive symptoms also occur outside of manic or depressive periods, schizophrenia is diagnosed.

Delusions are ideas that the patient thinks are true, while those ideas are very unlikely or even impossible. Many people sometimes have unlikely thoughts, but there are differences between these kinds of thoughts and delusions. When healthy people have unlikely thoughts, they are not completely unbelievable, while delusions are. People with delusions constantly think about it and look for evidence for their ideas, with which they try to convince others. In addition, people with delusions cannot accept that their thoughts are wrong.

There are four types of delusions:

1. A persecutory delusion is a delusion where people think that someone they know is after them to observe and punish them.

2. With a delusion of reference, people think that things in their environment are specifically aimed at them. For example, they think the weather forecast is a secret message to them. They believe that certain things are staged and that everything is a conspiracy.

3. People with grandiose delusions think they are a very special person with special powers.

4. Delusions of thought insertion are delusions where people think that their thoughts are influenced by others.

Many patients experience several of the above mentioned delusions at the same time. The delusions may be very simple, but they can also take on very complex forms.

Many of these types of delusions occur all over the world, but usually the themes of the delusions differ per culture. Americans may think that the CIA is after them, while for example Germans more often think that Satan is after them. A number of scientists believe that thoughts shared by healthy people in that culture should not be considered delusions. However, this statement is not supported in the United States.

Hallucinations are perceptions of a person who are not actually there. The most common hallucination is an auditory hallucination (hearing). For example, with auditory hallucinations, someone can hear music or voices while those sounds are not actually present. People often hear voices that speak against or about the listener and accuse or threaten him.

Another form of hallucination that often occurs is the visual hallucination. Hallucinations of this kind often occur together with auditory hallucinations.

Other forms are the tactile hallucination, in which someone feels something on his body, for example worms on his skin, and the somatic hallucination, in which someone feels something in his body, for example pain that feels like someone has hit him with a laser beam.

People with schizophrenia also often suffer from formal thought disorder, also called unorganized speech and thoughts. This means that schizophrenics are often very confused in their way of thinking and speaking. Schizophrenics often tend to jump from one subject to another in a conversation without any logical connection between them. For them it however seems to be completely logical. This phenomenon is described by the terms loosening of association and derailment. With totally incoherent stories, people also speak of word salad. Sometimes they make new words (neologisms) or make sentences from words that are completely unrelated to content, but whose sounds are related (clangs).

People with schizophrenia often have difficulty with cognitive tasks and have serious concentration problems. Schizophrenic men seem to have more language problems than schizophrenic women. This is probably because language is more distributed across the brain in women than in men. In this way women can compensate better if there is brain damage.

Someone with schizophrenia often behaves very confused. For example, he can suddenly scream or walk back and forth all the time. In schizophrenia, there is a form called catatonic excitement. Hereby a person suddenly behaves very wildly for no apparent reason and is also difficult to silence. This is known as disorganized or catatonic behavior. People often show unexpected behaviors and have difficulty organizing their daily life. They can also often repeat simple tasks.

Negative symptoms

The negative symptoms, or Type II symptoms, are the loss of certain capacities (normal behavior).

People with schizophrenia often suffer from affective flattening, showing much fewer or even no emotions. This is sometimes called blunted affect. They often speak monotonously and do not look at others. Affective flattening can be a sign of 'anhedonia'. This is the loss of interest in everything in life. It is also possible that people feel emotions, but cannot express them. Another negative symptom is alogy, a reduction in speech. A person speaks less with others, and gives short and simple answers to questions. It may even be the case that someone doesn't say anything at all for a few weeks. These people probably also have a reduction in thinking.

Avolition is the inability to perform normal daily activities. For example, someone with avolition can stare ahead of him- or herself all day. The person is unorganized, does not care about anything anymore and is unmotivated.

The negative symptoms of schizophrenia are also difficult to diagnose, often even more difficult than the positive symptoms. This is mainly due to the absence of behavior rather than presence. The symptoms also lie on a continuum from normal to abnormal behavior, making it difficult to determine what exactly is abnormal. Another reason is that there are other factors that can cause the negative symptoms, such as the side effects of certain drugs.

People with schizophrenia can also display inappropriate affect instead of flattened affect. They do that when they suddenly start laughing when someone tells something sad. This may be because a schizophrenic person reacts to something other than the sad story. It is also possible that something goes wrong in the brain when processing or expressing emotions. Just as with mood disorders, anhedonia also occurs in schizophrenia. This also has to do with 'affective flattening'. Furthermore, people with schizophrenia have poor social skills.

Which cognitive deficits are caused by schizophrenia?

Schizophrenia can cause defects in cognitive processes such as attention and memory. People are often less able to focus. There is often an error in the working memory, which means that less information is remembered and the information is often manipulated.

It is difficult for people to focus on relevant stimuli and confuse them with their own thoughts. They can no longer find out what is real and what is not.

How is schizophrenia diagnosed?

Schizophrenia has been seen as an official disease since the 1800s. The first name that came up was dementia praecox. This name was given to it because it was thought that the cause of this disorder was an early decline, a precursor of dementia. Later the name "schizophrenia" was given. Schizein means 'shared' and 'phren' means thoughts. So it literally means something like "shared thoughts", or split mind . This name was given because it was thought that the bodily functions were split off from the thoughts. In the beginning of the twentieth century everyone who had a psychosis was given the label schizophrenia, but nowadays the definition is more precise. According to the DSM-V, people are diagnosed with schizophrenia if they show two or more symptoms of schizophrenia for at least 6 months. At least one of these symptoms must be hallucinations, delusions or disorganized speech. Of those 6 months, there must be at least 1 month in which there are more and more extreme symptoms that impede the functioning of the person. This is called the acute phase. The symptoms must interfere with daily functioning. Before people actually enter the 'schizophrenia' phase, they often have prodromal symptoms, and after an episode there are residual symptoms. These symptoms are not as bad as during an episode, but people usually behave strangely and sometimes have mild hallucinations.
In the DSM-IV there were various subtypes for schizophrenia. The DSM-V no longer has these subtypes because there was not enough evidence for the diagnostic stability, validity and usefulness of these subtypes.

What kind of future do people with schizophrenia have in prospect?

Schizophrenia is more chronic than other disorders, 50-80% will be admitted again for schizophrenia after an initial admission. Life expectancy is 10 years shorter than in people without schizophrenia. 10-15% of people with schizophrenia commit suicide.

Contrary to popular belief, people with schizophrenia do not decline further as the disorder progresses. Most people stabilize after 5 to 10 years, and less and less need to be treated as they age. This may be because after a while people have found the right medicine with a dose that works best for them. It may also be that the person's family learns to deal better with the patient, thus preventing the patient from having new episodes. It is also possible that the chance of new episodes becomes smaller as the brain ages. 20-30% of patients heal partially or completely.

It has been found that people who live in developing countries and have schizophrenia have a better prognosis than people in the West. This is probably because people in developing countries have a better social network, which means they have less stress. Stress can lead to new episodes of the disorder.

Women generally have a better course of the disorder than men. Women need to be admitted in the hospital less often, and usually have milder negative symptoms. Women can also adjust better in their social world when they are often not psychotic. The reason that the disorder is usually less severe for women than for men is probably that women lose their social network less. It is also possible that the medicine for schizophrenia influences the regulation of dopamine and that it protects women more than men. In addition, women often have a better history than men: they often have a diploma, are married and have children, and have good social skills. This may also be because women often develop schizophrenia later than men.

What other psychotic disorders are there?

The DSM-V also contains other mental disorders that have similarities with schizophrenia.

A schizoaffective disorder is a mix of schizophrenia and a mood disorder. People often have spontaneous symptoms of schizophrenia and mood changes (manic and depressed). Some people think that the disorder exists because clinicians cannot decide which disorder it is: schizophrenia or a mood disorder.

With Schizophreniform disorder, people have the symptoms of schizophrenia, no schizoaffective disorder or mood disorder and the symptoms are not caused by medication, drugs or alcohol. They only need these symptoms for 1 to 6 months to get the diagnosis. The majority (approximately 2/3) of people with a schizophreniform disorder are eventually diagnosed with schizophrenia or schizoaffective disorder.

Brief psychotic disorder: sudden symptoms of schizophrenia that last only 1 day to 1 month. The symptoms often come from a stressful situation such as an accident. Some women also have it after the birth of their child.

Delusional disorder: these people have delusions for at least a month, which relate to things that can happen in life (being chased). They have no trouble functioning. It is more common in women than in men.

People with schizotypal personality disorders have a lifelong pattern of significant disruptions in their self-concept, the way they interact with others, and their thinking and behavior. They do not have a clear and independent image of themselves and may have difficulty setting realistic or clear goals. Their emotional expression can be limited or odd. They think and behave in strange ways, even though they still have a grip on reality. Sometimes they develop schizophrenia.

Are there genetic connections underlying people with schizophrenia?

Schizophrenia has been investigated through family studies, twin studies and adoption studies. It appears that genes influence the onset of schizophrenia. This conclusion can be drawn, for example, from the discovery from a family study that the greater the genetic similarity between two people, the greater the chance that if one has schizophrenia, the other will get it. However, the fact that a child of two schizophrenic parents has a high chance of becoming schizophrenic can also say something about the environment in which the child grows up. Therefore, adoption studies were conducted, which showed that children of a schizophrenic mother who grew up in a different family were much more likely to have schizophrenia than adopted children without schizophrenic parents. This is a strong argument for the role of genes in the development of schizophrenia.

From twin studies showed that genetic factors may play a greater role in severe schizophrenia than in milder forms of schizophrenia. It appears that genes play a role in this disorder, but it is still unclear which genes play a role in its development.

One of the biggest difficulties is that schizophrenia is not a single, but a group of disorders together, making it difficult to find specific genes involved. It may even be that the different types of schizophrenia all have different genetic backgrounds. It could also be that some forms of schizophrenia are not genetically transmitted. The last problem is that if someone has a genetic predisposition to schizophrenia, it does not have to be that they also get schizophrenia.

There are deviations in the brains found in people with schizophrenia. Very often they appear to have enlarged ventricles. Ventricles are the spaces in the brain that are filled with fluid. If these are larger, there is less room for the brain's actual volume. The enlarged ventricles indicates the death of the brain tissue. People with enlarged ventricles are often less social, emotional and show less 'good' behavior. They also often have more severe symptoms and respond less well to medication.

The most consistent finding is that people with schizophrenia have a large reduction of gray matter in the cortex, especially in the medial, temporal, superior temporal, and frontal areas. There is also abnormal activity in the prefrontal cortex and in the temporal cortex. Certain parts of the brain are often smaller in people with schizophrenia. The prefrontal cortex in particular has shown that it is often smaller and exhibits less activity in people with schizophrenia. The prefrontal cortex is important for language, expressing emotions, plans and social interactions. It is connected to both the limbic system, which is involved in emotions and cognitions, and the basal ganglia, which are involved in motor skills. The prefrontal cortex is developed especially in adolescence, which is probably the reason why adolescents in particular develop schizophrenia.

Research has shown that in people who show more negative symptoms of schizophrenia (such as poor motivation or poor social skills), the prefrontal cortex is indeed often less active. However, this is found less for people who mainly show positive symptoms (hallucinations or delusions).

People with schizophrenia also appear to have abnormalities in both the structure and activity of the hippocampus. The hippocampus plays an important role in long-term memory.

People with schizophrenia also have reductions and abnormalities in the white matter, especially in areas associated with the working memory. These abnormalities are already present before people develop the disorder, making it likely that these are the early signs of the disorder. The abnormalities in the white matter cause problems with the cooperation of different brain regions.

Various causes are possible for the abnormalities in people with schizophrenia. Serious birth problems are more common in people with schizophrenia, for example. Especially if the child does not receive oxygen during delivery (perinatal hypoxia), this may increase the risk of schizophrenia. It has also been found that if mothers became infected with the influenza virus during their pregnancy, the child was later more likely to develop schizophrenia in its life.

It is thought that schizophrenia can also be caused by problems with the neurotransmitter dopamine. The original theory explains that there is too much dopamine in the brain, especially in the frontal lobe and in the limbic system. There are a number of indications for that. Medications that reduce the effect of dopamine (phenothiazines) also seem to reduce the symptoms of schizophrenia. Medications that improve the action of dopamine (amphetamines) also further stimulate the psychotic symptoms. Autopsy and PET scans show that schizophrenics have more dopamine receptors and higher dopamine levels than other people.

These days, this theory is found too simple. Many people do not respond to drugs that lower dopamine. People who are helped by these drugs only show a reduction in positive symptoms, not negative ones. These criticisms have replaced the old theory with a newer one. The new theory suggests that there is a dopamine surplus in the mesolimbic system, which causes the positive symptoms. Atypical antipsychotics can help reduce symptoms by binding to D4 (dopamine) receptors in the mesolimbic system and thereby blocking the action of dopamine.

In addition to the surplus in the mesolimbic system, there is just a dopamine deficiency in the prefrontal cortex. This deficiency causes the negative symptoms of schizophrenia. This is a good explanation for the fact that the old medicines remedy the positive but not the negative symptoms.

Another theory states that the positive symptoms stem from a dopamine surplus in the limbic system, but that the negative symptoms are due to abnormalities in the brain structure of the prefrontal cortex.

Finally, research shows that the neurotransmitters serotonin, glutamate and GABA probably also play a role in schizophrenia.

What psychosocial perspectives are there on schizophrenia?

Despite the fact that people now think that schizophrenia is to a large extent biologically determined, there have always been psychological theories about it.

People with schizophrenia live more often than other people in stressful circumstances, for example in impoverished neighborhoods. Research suggests an explanation by social selection. This means that people who are schizophrenic end up in lower social classes because, for example, they have difficulty finding a job. Other studies show that schizophrenics were born relatively more often in a large city than in a village. This is probably not due to the stress of a large city, but because people from a city are more susceptible to viruses, which means that a pregnant woman is infected with a virus more quickly. This gives the child a greater chance of schizophrenia. Stressful circumstances are therefore not the cause of schizophrenia, but they can start a new psychotic episode.

The environmental factor that has been studied the most is the family. An early theory about the influence of family is about the so-called double binds. These are ties that a child has with a parent (especially the mother) whereby the child always receives information that is in conflict with each other (according to Freud). For example, a child may be stroked by the mother, while she also scolds to the child. When children often receive such mixed messages, they learn that they cannot trust their own feelings and perceptions, so that they get a disturbed picture of themselves and the world. This can contribute to schizophrenia.

This theory is not supported by research, but research into communication patterns has discovered striking things in families with a member who is schizophrenic. In such families, communication is often unclear and vague and there are often misunderstandings. It could be that children who are already susceptible to schizophrenia from their genes are even more likely to develop this disorder.

A lot of research has been done within families on what is called expressed emotion. Families that score high on this scale are very involved with the schizophrenic family member, and they show that they are sacrificing themselves, while at the same time being very critical and hostile towards the schizophrenic person. Schizophrenics with a family that scores high on expressed emotion are more likely to fall back into psychosis than schizophrenics with a family that has a low level of expressed emotion.

Critics of this theory say that the hostile attitude may actually be a cause of the patient's condition. Because although people are usually forgiving of the positive symptoms, they are often not forgiving of the negative symptoms, because they often feel that the patient can do something about it. Another explanation is that people who have a high expressed emotion are themselves susceptible to a psychological disorder. It could therefore be that people in such families have a greater genetic burden for a disorder, which means they also relapse faster.

The behaviorists and cognitive psychologists have not had much to say about schizophrenia. Some behaviorists have tried to explain schizophrenia using operant conditioning. According to them, schizophrenic people have not learned to deal with their social environment, so they pay too much attention to irrelevant stimuli. This theory has never been tested well, but behavioral techniques that teach schizophrenic people social skills do have an effect. Few cognitive psychologists have dealt with schizophrenia. It is believed that schizophrenia has a biological basis. Cognitive psychologists suggest that delusions are developed to give meaning to the strange sensations that someone has.

People with schizophrenia often have fundamental difficulties with attention, inhibiting and adhering to rules of communication that cause them to 'preserve' their limited cognitive aids. They often use certain schemes, sometimes called prejudices, to easily understand information.

Positive symptoms are often due to hypersensitivity. Negative symptoms come from the expectation that social interactions are hostile. A therapist helps the patient identify situations and deal well with stressful situations.

What is the correct treatment for schizophrenia?

Scientists have tried many things to "cure" schizophrenics. Examples of this are locking up the patient, brain surgery, injecting insulin to cause a coma and ECT. These things all proved ineffective.

The drug chlorpromazine (a phenothiazine) was the first drug that actually worked in treating schizophrenia. It works by blocking dopamine receptors, so it reduces the effects of dopamine. Another type of antipsychotic are neuroleptics. These drugs do not work for everyone, since about 25 percent of patients do not respond to them. The drugs work well to reduce the positive symptoms but much less in treating the negative symptoms.

There is usually a major relapse when the medication is stopped. It is also very dangerous to continue taking this medicine for a long time, as there are very serious side effects such as akinesia (slow motor skills, slow speech), akathesis (not being able to sit still) and tardive dyskinesia (involuntary movements of the tongue, of the jaw or of the face). Tardive dyskinesia occurs in 20 percent of people who use chlorpromazine for a long time, and often does not go away. To limit the side effects, people are often put on a maintenance dose. This is a dose that is just enough to cope with the positive symptoms, but still has as few side effects as possible.

Other side effects include dry mouth, poor vision and weight gain. Some people even get symptoms of Parkinson's disease, such as stiffness and shaking.

These days there are also atypical antipsychotics. These drugs seem to be more effective than the older ones. Clozapine is an example. This drug works on the dopamine receptor D3. Many people who did not respond to the old medicines do respond to this medicine, and it seems that this drug also reduces the negative symptoms.

Tardive dyskinesia does not occur with the use of this drug, but there are other side effects such as dizziness, palpitations, and agranulocytosis. This is a very dangerous condition that occurs in 1 to 2 percent of people who use this medicine. There is then a shortage of granulocytes and this can be fatal.

Another effective drug is rispiridone. This drug also affects serotonin receptors and is as effective as clozapine, but works faster.

Psychological interventions are mainly used in combination with drug therapies. They are primarily aimed at teaching people social skills and getting them out of their isolation. Most experts believe that a broad intervention is needed that resolves behavioral, cognitive and social problems in a way that is tailored to the patient.

Cognitive interventions try to change the patients' views on their illness, so that they are more likely to seek help and become more involved with society. They also learn to understand the disorder through cognitive interventions

Behavioral techniques are used to teach people techniques to continue in daily life. This is often done by operant conditioning, with positive and negative reinforcers.

Social interventions are aimed at helping people out of their isolation.

Because people with schizophrenia benefit greatly from a caring and supportive family, it is important that the patient's family learns how to cope with the disorder. Therapies that are successful in this area combine providing information about the disorder with training family members to properly cope with the impact that the disorder has on them. This family therapy, combined with medication, is more effective than therapy with medication alone. These interventions must take into account the cultural values within a family.

Sometimes people no longer have a family who can take care of them. Assertive community treatment programs provide services for those with schizophrenia. The people who do this work have a medical background, they are social workers and psychologists who visit people with schizophrenia on a weekly basis. They ensure that the chance of a relapse is smaller and the chance of a hospitalization smaller. The patients are prepared for daily life, looking for a job, etc.

Schizophrenia is seen and treated differently in other cultures than in Western culture. There are four ways in which that happens:

1. According to the structural model, there are connections between, for example, the body, emotions, society and culture. According to this model, healing is the process of restoring the connections between these elements.

2. According to the social support model, the symptoms of schizophrenia are the result of poor relationships between people. People try to cure someone by solving those problems.

3. The persuasive model tries to heal people through rituals.

4. The clinical model is about the belief that the patient has in the healer, which heals the patient.

What personality disorders do we distinguish? - Chapter 9

Personality is the collection of characteristics that the person has or exhibits and that distinguishes him or her from others. It is the way we behave, think, believe and feel. These characteristics make us unique. A personality trait is a complex pattern of behavior, thoughts and emotions that remains constant over a longer period of time, and in different situations.

The big five theory states that there are five different factors of personality traits. Everyone's personality has each factor to a certain extent, and how strongly that is the case for each factor determines our personality.

The big five:

1. Negative emotionality

2. Extraversion

3. Openness for new experiences

4. Compliance

5. Accuracy

What is a personality disorder?

A personality disorder is a long-term pattern of inappropriate behaviors, thoughts, and feelings. Personality disorders usually begin in adolescence, or in early adulthood, and last a large part of life. To diagnose a personality disorder in someone under the age of eighteen, the personality pattern must be present for at least one year.

In the DSM-IV personality disorders are on the second axis. This means that people see these disorders differently than acute disorders. The disorders on the second axis are chronic and invasive. The DSM-V has rejected this distinction between disorders on Axis-I and Axis-II. Personality disorders are therefore no longer on the second axis in the DSM-V. The DSM-V has divided ten personality disorders into three clusters, based on their similarities. The DSM-V does admit that this system is limited, has not been properly validated and does not explain the fact that people often have multiple personality disorders from different clusters. The three clusters of the DSM-V are as follows:

1. Cluster A contains odd or eccentric behaviors and thinking. In this cluster are the paranoid personality disorder, the schizoid personality disorder and the schizotypal personality disorder. These personality disorders have characteristics of schizophrenia, but the patients do not "live outside of reality".

2. Cluster B consists of dramatic, erratic and emotional behavior and interpersonal relationships. This cluster includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder. People with one of these disorders are manipulative, fleeting, carefree in social relationships and susceptible to impulsive behavior.

3. Cluster C has the description of anxious and fearful emotions and chronic self-doubt. It contains dependent personality disorder, avoidant personality disorder and obsessive-compulsive personality disorder. These people have low self-esteem and difficulty with social relationships.

How do people behave with an 'odd-eccentric' personality disorder?

People with an odd-eccentric personality disorder (from cluster A) behave in a way that is strongly reminiscent of schizophrenia. Many scientists therefore believe that this disorder is a weakened version of schizophrenia, or that people with this disorder have a very high chance of developing schizophrenia. Some scientists believe that this disorder should fall under schizophrenia rather than personality disorders, precisely because it appears to be a milder version of schizophrenia.

Paranoid personality disorder

People with a paranoid personality disorder are very suspicious of others. The most important characteristic of this disorder is a pervasive and unjustified mistrust of others. They believe that other people want to exploit them and are constantly worried about the loyalty and reliability of others. They are very sensitive to evidence that confirms their views, but ignore the evidence that goes against their views. Some paranoid people withdraw to protect themselves, but others become very aggressive towards the outside world. Between 0.7 and 5.1 percent of people are diagnosed with paranoid personality disorder in their lives. Studies show that this disorder is more common in people with a family member with schizophrenia. Twin studies show that the genetic contribution of this disorder is approximately 50%.

Cognitive psychologists think that this disorder stems from the idea that other people are hostile, combined with poor self-confidence.

People with a paranoid personality disorder often only go to the therapist when they are in crisis. They also seek help for symptoms of depression or anxiety. It is almost uncommon for people to seek help because of the paranoia itself. In therapy, cognitive psychologists try to reduce the patient's anxiety and hostility. Psychoanalysts try to give the patient insight into their condition, but this has to be done in a very careful way. The therapist must be calm and respectful and explain everything easily in order to gain the trust of a patient. He can never directly point out to a patient that it is paranoid, the therapist must do that by asking questions. In this way he lets the patient see for himself that these things are interpreted in a certain, negative way.

Cognitive therapy focuses on giving these people the feeling that they can do things themselves in difficult situations. They also learn to reduce the fear of others.

Schizoid personality disorder

People with schizoid personality disorder have no desire whatsoever to enter into relationships with other people. They see these relationships as useless, and do not express any kind of emotion when talking to someone else. Other people see someone with a schizoid personality disorder as aloof, withdrawn, slow, uninterested and humorless. Schizoid people can generally function in society, in places where little social interaction is needed. This fairly rare disorder is mainly found in men.

Twin studies suggest that some personality traits responsible for a schizoid personality disorder are hereditary.

Cognitive psychologists describe schizoid individuals as people who cannot express emotions. These people are not interested in life and other people. Treatments for schizoid individuals are to make patients feel more emotions and to teach them social skills. Sometimes group therapy is also given.

Schizotypal personality disorder

Schizotypal personality disorder is quite similar to schizoid personality. These disorders have the same symptoms, with the difference that people with schizotypal personality disorders also suffer from strange thinking. The symptoms of a schizotypal personality disorder are very similar to the symptoms of schizophrenia, but then they are less severe.

There are four categories for the characteristics of this personality disorder:

1. Paranoia or suspicion: they see others as deceptive and hostile.

2. Ideas of reference: they believe that random events are related to them.

3. Strange beliefs and magical thinking: for example, they may believe that others can read their mind

4. Illusions: a kind of hallucinations

People with this disorder often switch topics spontaneously, and speak far too extensively. When others say something, they can show socially unwanted emotions or even have no emotional response at all.

The behavior of these people is often strange.

Neuropsychological research has shown that people with this disorder have a smaller working memory. As a result, they are less able to keep their attention on cognitive tasks and have less memory. The biological background is broadly the same as in people with schizophrenia. Another similarity with schizophrenia is that schizotypic people show the same abnormalities in attention. Schizotypal personality disorders are often treated with the same drugs as schizophrenia.

Psychotherapy is sometimes used as therapeutic treatment. The point is that people should get good social skills. Cognitive therapy attempts to adjust the mindset of schizotypic people.

How do people behave with a 'Dramatic-emotional' personality disorder?

People with cluster B disorders have in common that they often exhibit dramatic or impulsive behavior. They often do not pay attention to the safety of themselves or others.

Borderline personality disorder

The characteristics of a borderline personality disorder are instability of mood, self-image and interpersonal relationships. For example, someone can suddenly become very insecure or anxious. People with borderline can think of someone as their idol one moment and hate the same person the next. These people are almost always paranoid about being abandoned and when they are abandoned they react to it in an extreme way.

People often describe a feeling of emptiness that they want to fill with keeping new acquaintances close by. They "stick" to people. This disorder is more common in women than in men.

Borderline personality disorder is a very complex disorder. As a result, many people with borderline have many similarities in symptoms with other personality disorders. People with borderline also generally have a different mental disorder, for example a depression, an anxiety disorder, substance abuse or a somatization disorder. They often exhibit impulsive and self-damaging behavior.

75% of people with borderline attempt suicide, 10% succeed. The risk of suicide is greatest in the first two years after the diagnosis has been made.

It is not clear whether there is a genetic background for borderline. People with borderline are usually impulsive and have low serotonin levels. People with borderline personality disorder are thought to have an error in emotion regulation. This would then be a physiological error. As a result, people develop extreme emotions that cause impulsive behavior. These emotions are often criticized by others, but that does not help regulation. This often makes the problem worse.

People with this disorder need help from others in difficult situations, but often do not dare to ask for help. In difficult situations, they often have more stress than other people.

Psychoanalysts think that people with borderline personality disorder have an underdeveloped image of themselves and others. When parents demand dependence on the child, a child becomes very receptive to what others think about him and will not develop a good self-image. If these people think they are being rejected by others, they reject themselves by doing self-harm. People with borderline tend to see people as very good or very bad, so in extremes. This is called splitting.

A therapy has been developed, dialectical behavior therapy, in which cognitive behavioral therapy and interpersonal and psychodynamic techniques are used. The focus is on helping to develop a more realistic and positive self-image and skills to solve problems and regulate emotions and correct black-and-white thinking. People are presented with a potential stressful situation and learn to find a solution. This makes them less impulsive in such a stressful situation, because they know what they can do. The therapy appears to be effective.

With psychodynamic treatments, it is about making patients realize that their disorder depends on the way they were raised. Transference-focused therapy uses the relationship between the patient and the therapist to help the patient gain a more realistic and better understanding of himself and his or her interpersonal relationships. Mentalization-based therapy is based on the theory that people with borderline personality disorder have problems understanding the mental states of themselves and others due to traumatic childhood experiences and poor attachment with their caregiver. Cognitive therapies focus on giving their clients a better self-image. These therapies also try to eliminate splitting. Medication is aimed at reducing anxiety and depressive symptoms. Antipsychotic drugs are also used in people who are psychotic. The results can be called doubtful.

Histrionic personality disorder

The characteristics of the histrionic personality disorder resemble those of borderline, only people with this disorder want to be the center of attention. They do this by, for example, being very dramatic or enticing. They also like to show the positive qualities of their body. Often in the family of these people there is someone with a different mental disorder.

The diagnosis is most common among women who no longer have a partner.

People with this disorder greatly exaggerate problems, and on average they have more doctor visits per year than an average other person. If they seek psychological help, it is usually not for their personality disorder, but for anxiety or depression.

Psychoanalysts provide insight into the problems and cognitive psychologists try to change the assumptions of patients. They are taught to express their emotions in a socially desirable way.

Narcissistic personality disorder

The narcissistic personality disorder is very similar to the histrionic personality disorder, only people with the last disorder look at others for confirmation, while narcissists only look at themselves. They see dependence as something bad and dangerous and they see themselves as great and powerful. These people can often become very successful in Western society. However, if the disorder is very serious, they can get into trouble because they make the wrong choices.

People with this disorder behave in a dramatic way, seek attention from others and show few emotions. They see others as weak and themselves as important. They think they are better than the rest of the world.

In relationships, they expect things from other people which they can usually not provide. They ignore the wishes of others themselves. Often these people are arrogant and want power.

Sigmund Freud thought that narcissism was a phase that every child must go through. According to him, the problem with narcissistic personalities is that they have got stuck in that phase. That may be because they found the phase too fine or too annoying. Other theorists said that narcissism comes from loneliness because of being rejected. Supporters of social learning theory think that parents of narcissistic people overestimate the child. The child cannot live up to expectations, but still feels superior to others. People with narcissistic personality disorders often have a history of physical abuse and neglect, and often had a parent who was abused or who had a mental health problem.

People with this disorder generally do not seek help. If they seek help, it is usually for another disorder. They see problems as weakness and as problems for others. These people are very difficult to deal with because they have a hard time coping with the criticism they are dealing with. Cognitive therapy lets them form a realistic picture of what they can actually do. They also learn to be more sensitive with others.

How do people with an 'anxious-fearful' personality disorder behave?

Cluster C disorders are characterized by the fact that people who suffer from them all have chronic anxiety and show behavior to avoid the things they fear.

Avoiding personality disorder

People with a preventive personality disorder are very scared of being criticized. That's why they avoid people as much as possible. People with this disorder feel that they cannot do anything. The difference between this disorder and a social phobia is that people with a social phobia are usually afraid of specific situations, while people with an avoiding personality disorder are afraid of and avoid other people in general. The difference with a schizoid personality disorder is that schizoid people do not see themselves as incompetent.

It could be that people inherit a temperament from their parents, giving them a greater chance of having this disorder. If parents often respond to their children with frustration and anger, children can become very sensitive to criticism, especially if they already have a biological background for this. Often people don't dare to believe positive feedback, because they are afraid that the other person is only telling them to be nice.

Treatments for this disorder are usually aimed at learning social skills, and changing negative thoughts about the patient himself and about others. Sometimes SSRIs are used to reduce social anxiety.

Dependent personality disorder

People with a dependent personality disorder are also anxious in interpersonal relationships, but this fear is caused by being afraid of being abandoned. The fear comes from the need to be cared for by others and a desire to be loved. These people always want someone around them who can take care of them. They are afraid of bumping into others and want to please someone at all costs, whatever the requirement may be.

It is difficult for these people to make decisions for themselves, they only do things to please another.

This disorder is more common in certain families than in others, but it is not clear whether it is due to genes or the environment.

Children who are afraid of a chronic illness or to be abandoned by their parents can develop this disorder. The cognitive theory states that negative thoughts, in which people get rid of themselves, are the reason for this disorder.

Unlike other personality disorders, people with this disorder often do seek help. Psychodynamic therapy shows the patient what his experiences with caregivers were that led to their dependent behavior.

Cognitive behavioral therapy makes people more assertive and reduces anxiety. It makes patients realize that they are not as dependent on others as they think. Techniques are also taught to relax in an anxious situation and they learn to make decisions for themselves.

Obsessive-compulsive personality disorder

People with obsessive-compulsive personality disorder are very rigid and dogmatic, and cannot express their emotions. They have an extreme amount of self-control, attention to detail and often lack spontaneity. They often work a lot and do not take time for fun activities. Others see these people as stubborn, stingy, possessive and moralistic.

People with this disorder are very focused on efficiency, but because of their perfectionism they often don't get much done. They often think that they should not make mistakes.

This disorder is more common in men. People with this disorder have a greater chance of a depression, an eating disorder or an anxiety disorder.

The difference with obsessive compulsive disorder is that the personality disorder is more general, while OCD is more specific. Strangely enough, within families there is no connection found between having both disorders.

People often seek therapy because they are in crisis. This crisis must first be overcome before the actual therapy can be started. Here they learn to reduce obsessive behavior and to change or mess up their daily schedules. The patient learns to relax and must write down his automatic, negative thoughts in order to gain insight into this.

What is an alternative to personality disorders as they are described in the DSM-V?

The definition of personality disorder and the criteria used to diagnose personality disorders have not changed in the DSM-V compared to the DSM-IV-TR. The DSM-V, however, uses a dimensional, or continuum, perspective. However, this perspective is not used in clinical practice. The categorical approach to personality disorders has received much criticism. The most important limitation is that the personality disorders have a lot of overlap in their diagnostic criteria. There has been little agreement between clinicians. Research has shown that individuals with personality disorders differ over time in how severe the symptoms are and what symptoms they show. The alternative DSM-V model characterizes personality disorders in terms of personality defects and pathological personality traits.

1. The first step in diagnosing a personality disorder is to determine the level of sense of identity or relationships with others on a scale.
2. The second step is to determine whether the individual has pathological personality traits. These can, according to the theory, occur in five different dimensions: negative affectivity, detachment, antagonism, disinhibition, and psychoticism.
3. The third step is to determine whether the individual meets the criteria of one of the following six disorders:
   • antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypic.

If an individual does not meet the criteria for one of these disorders, but does have significant problems with self-esteem and relationships with pathological personality traits, the personality disorder-trait specified diagnosis is given. The clinician then specifies which pathological personality traits the person has. The DSM-V approach is therefore a hybrid model: it combines a dimensional model with a categorical approach.

What eating disorders do we distinguish? - Chapter 12

Most individuals meet the criteria for two or more eating disorders at different times. Also, many people do not meet the criteria for an eating disorder, but do show behaviors and concerns that fit with an eating disorder. They are diagnosed with other specified feeding or eating disorder.

What is anorexia nervosa?

People with anorexia nervosa are starving themselves, while they are already far below a healthy weight. They do this by eating little or no food for a long time. Although they are already very thin, they still insist that they have to lose even more weight. People with anorexia refuse to maintain a healthy, normal weight. They have an intense fear of gaining weight or becoming fat. They have a disturbed idea about their body and think that they are bigger than they really are and therefore have to lose weight.

The self-esteem of these people is completely dependent on their body weight and control over their eating behavior; people with anorexia nervosa tend to feel good when they lose weight but feel guilty or even worthless if they fail. Due to the loss of weight, people with anorexia nervosa are often chronically tired. Despite this fatigue, they continue to set up heavy training programs to lose weight.

Anorexia nervosa usually starts between 15 and 19 years. Of all cases with anorexia nervosa, 90 to 95 percent are women. The weight reduction stops the menstrual cycle in girls and women with anorexia, this is called amenorrhea. In the DSM-V, the criterion for amenorrhea has been removed from the diagnostic criteria, because many girls with anorexia nervosa do however still have menstrual activity. Anorexia is a physically dangerous disorder. Severe complications such as a very low heart rate or kidney damage can result; 5 to 8 percent of people with anorexia will die as a result.

There are two types of anorexia nervosa. People with the restricting type of anorexia nervosa refuse to eat, or eat very small amounts, to prevent them gaining weight. Some eat nothing for days. People with the restricting type of anorexia nervosa often have a sense of distrust of others and tend to deny their problems.

The other type is the binge / purge type of anorexia nervosa. These people have binges (binges) that are interspersed with actions to prevent weight gain (purge). This often happens due to intentional vomiting or the use of laxatives. People with the binge / purge type of anorexia nervosa often have varying moods, problems with controlling their impulses, problems with alcohol and auto-mutilation.

The binge / purge type of anorexia nervosa is very similar to bulimia. The difference is that people with the binge / purge type of anorexia nervosa do not have a healthy weight, while people with bulimia nervosa are generally healthy or even slightly overweight.

Just like in the DSM-IV, people with anorexia nervosa must have a significantly low body weight. The DSM-V suggests that a BMI of 18.5 is the lower limit of a healthy body weight. Anorexia nervosa is mild if the BMI is greater than or equal to 17, on average if the BMI is 16 to 16.99, and severe if the BMI is 15 to 15.99. The severity is determined not only on the basis of BMI, but also on the basis of clinical symptoms, the degree of functional impairment, or the need for supervision. The prevalence of anorexia nervosa has been higher since working with the DSM-V, because two criteria that were still in the DSM-IV have been removed. The first criterion was that someone had to be at least 15% below normal body weight, and that women should have amenorrhea. Not all girls met this requirement, so the prevalence was lower.

Ten to fifteen years after diagnosis, about 70% of former patients are no longer diagnosed with anorexia nervosa, but many of them continue to have eating problems or other psychopathology, such as depression. People with the binge / purge type often have more comorbid mental disorders than people with the restricting type. In particular, impulsive, suicidal and self-damaging behavior occurs.

What is bulimia nervosa?

The important characteristics of bulimia nervosa are uncontrolled binge eating, followed by actions to prevent weight gain. The definition of binging, uncontrolled binge eating, is described in the DSM-IV as consuming in a short time (such as 1 to 2 hours) an unusual amount of food in a certain situation and being unable to control it. They then eat more than a normal person can eat in such a situation and in that time frame. Binge eating can vary in size per person. Most people with these binge eating are not actually hungry at all. At such a moment they lose control of their eating behavior.

As with anorexia patients, the self-esteem of a bulimia patient is highly dependent on their figure and body weight. However, they have no disturbances in their body image. After binge eating they want to make sure they don't gain weight. Vomiting is often associated with bulimia. Excessive exercise or fasting can also be used by patients to keep their weight in check. In the DSM-V, the criteria for bulimia nervosa are somewhat more relaxed compared to criteria as stated in the former DSM-IV. The minimum number of times per week in which binge / purge behavior must be shown has been reduced from 2 times to once per week. This will increase the prevalence of the disorder. Bulimia nervosa is more common in Western cultures than in non-Western cultures. It often occurs in adolescence. Bulimia can also cause serious medical complications and result in death. One of the most serious complications is an electrolyte imbalance, due to the loss of fluid after excessive and chronic vomiting. Suicide is also 7.5 times more common in people with bulimia nervosa. Bulimia nervosa is often chronic.

What is a binge eating disorder?

People with Binge-eating disorder resemble people with bulimia nervosa in their behaviors, but they however do not perform the actions to compensate binge eating and prevent them from gaining weight, such as vomiting, fasting or excessive exercise. These people are often far overweight, disgusted with their bodies and ashamed of their behavior. They can often eat all day long, with no planned eating moments for breakfast or lunch. There are also people who eat a lot at certain planned times. They usually do this as a result of stress, depression or anxiety. People with this disorder often have obesity and a history of following diet programs. Most people with this disorder have obese family members. This eating disorder is also more common among women. People with a binge eating disorder often also have a depression or an anxiety disorder. In addition, they are more likely to experience alcohol abuse and personality disorders. This disorder also appears to be chronic.

What other 'specified feeding' or 'eating disorders' are there?

Some people have an eating problem where the behavioral pattern is very similar to anorexia or bulimia nervosa, but do not fully meet the criteria for any of these disorders. This eating disorder is called the partial-syndrome eating disorder. People with this syndrome, for example, suffer from binge eating only a few times a month. They do not have a normal weight, but are also not that far below a normal weight. They derive their self-esteem from their weight. The symptoms are therefore the same as those of anorexia or bulimia, but they are not serious enough to be diagnosed with this eating disorder. People with this syndrome often have psychological problems such as an anxiety disorder, substance abuse, depression and sometimes suicidal tendencies. They have a lower self-image, poorer health and a lower appreciation for life than healthy people.

The DSM-V has added a new diagnostic category, called other specified feeding or eating disorder. This includes manifestations of eating disorders that cause clinically significant stress or deficiencies, but that do not meet the diagnostic criteria for one of the eating disorders discussed. The partial-sydrome eating disorder just discussed falls under this new category. In the DSM-IV this category was called 'eating disorders not otherwise specified' (EDNOS). EDNOS is often just as severe and persistent as bulimia nervosa or anorexia nervosa. The DSM-V category other specified feeding or eating disorder includes disorders such as atypical anorexia nervosa, where all criteria for anorexia nervosa are met, except for underweight. Another example is bulimia nervosa of low frequency and / or limited duration. All criteria for bulimia nervosa are met, except that binge eating and compensation behavior occur less than once a week or for less than three months. A final example is the night eating syndrome, a newly adopted disorder in the DSM-V. People with this disorder eat excessive amounts of food after dinner and at night. They often suffer from insomnia and believe they have to eat to fall asleep. People with this disorder are often overweight and often have depression.

What is obesity?

Obesity is defined as a BMI of 30 or more (weight / height * 2). It is not an official eating disorder listed in the DSM-V, but it still forms a risk to a person's health due to a higher risk of heart disease, stroke, diabetes and cancer. The higher your BMI, the greater the chance of dying earlier. You could say that we live in a rather poisoning society, where you can find mostly food with a lot of calories that is cheap. We work out very little and often do not get the required exercise. Not everyone who comes into such an environment gets overweight or obese. Genes also influence how your metabolism works and how much fat you store.

Many people diet to avoid being overweight. Many do not keep up with the entire diet and are disappointed with the results, because more is promised than is being achieved by them. There are even medicines to lose weight, although they do have side effects. It is best to eat fewer calories and exercise more. Surgery is also possible, such as a stomach reduction. It is difficult to get lose weight, but even harder to keep it off.

Which cultural and historical trends underlie an eating disorder?

It is said that eating disorders are culture-related because they occur mainly in the West, where being thin is the ideal image. There is also a historical trend for eating disorders. The number of cases of anorexia and bulimia increased between 1930 and 1970 and remained virtually unchanged thereafter. In Curaçao, where many black people live, there is less of an eating disorder. This while white people do occur in Curaçao.

What theories explain eating disorders?

It is very likely that the development of an eating disorder is caused by the sum of biological, cultural-social and psychological factors.

There is evidence that the predisposition for both anorexia and bulimia nervosa is hereditary: 33-84% is in the genes. A lot of biological research is done on the hypothalamus, because the hypothalamus plays a major role in regulating eating behavior. The hypothalamus receives messages about food intake and nutritional values ​​and ensures that people stop eating when they are satisfied. These messages are delivered by neurotransmitters and hormones. The abnormal eating behavior can be caused by the fact that these substances are out of balance or are not properly regulated, or by problems in the structure of the hypothalamus.

People with anorexia nervosa have a malfunctioning hypothalamus, and abnormal levels of the serotonin and dopamine neurotransmitters. The question is whether this is the cause or consequence of the behavior of anorexia patients.

Many people with bulimia show abnormalities in the serotonin neurotransmitter. A serotonin deficiency appears to make the body hungry for carbohydrates.

Unfortunately, why people with anorexia or bulimia have such a bad self-image cannot be explained biologically.

Cultural-social norms with regard to beauty ideals play an important role in eating disorders. In the last 45 years, the ideal image of women has become increasingly thinner. This thinness ideal, promoted mainly by advertisements, influences self-image and causes the feeling of not complying with the norm. Role models such as actresses and models are almost always skinny. Anorexia and bulimia occur more often in women than in men, probably because thinness is more appreciated by women than by men. There are also more diets in women's magazines. The social pressure to be thin and beautiful is further emphasized in TV shows that do makeovers. All these things can trigger the development of an eating disorder. Of course there is also social pressure in your area, namely from family and friends.

These disorders are much less common in less developed countries. Certain groups within a culture, such as athletes, also have an increased chance of developing unhealthy eating behavior, especially if their body weight is perceived as an important factor in mutual competitions. Women who practice a sport where you have to be thin, such as gymnastics, often struggle with their body during puberty. For their sport a girl's body is desired and not the curves of a woman. They try to prevent the emergence of the female forms through diets.

Eating disorders are also more common among athletes, especially those who do sports where weight is an important factor in competition. Think of dancing, horse riding, wrestling and bodybuilding.

Eating disorders can sometimes be a way to deal with painful emotions. Thin people then develop anorexia or bulimia nervosa, while overweight people develop binge eating problems to deal with their problems (binge eating disorder).

Having depressive symptoms has proven to be a predictive factor in the development of an eating disorder. A distinction is made between two types of abnormal eating patterns in which binge eating is central to the regulation of emotions: the dieting subtype and the depressive subtype. People with the dieting subtype are very concerned about their figure and their body weight. They break or do exercises to prevent them from gaining weight. People with the depressed subtype of eating patterns are also concerned about their figure and weight, but suffer from depressive feelings and low self-esteem; they often eat in order to feel nothing. They have greater social and psychological problems.

For people with an eating disorder, appearance is very important. They think that achieving the ideal, slender figure brings social and psychological benefits. Eating disorders often occur in people who are dissatisfied with their bodies, who are often perfectionist and have low self-esteem. Other research has shown that people with eating disorders are more interested in the opinion of others, want to conform more to the wishes of others and are rigid in their opinion about themselves and others (something is either good or bad). Many are obsessed with their eating behavior and plan their days around these behaviors.

Girls with eating disorders were often very good and listened carefully to what the parents were saying. Often, they used to be very good at everything they did, want to achieve a lot, are dutiful and are often accommodating daughters who want to be perfect. The parents often have high expectations of the child and the child may not express negative feelings. In these families the family members are very dependent on each other and it is difficult to develop their own identity. They do not learn to identify their own feelings and wishes and therefore do not learn how to deal with negative emotions. If even physical sensations, such as hunger, are not recognized, this can lead to anorexia nervosa.

In adolescence, girls in particular develop an eating disorder due to parents' fear of separation and fear of independence. This is especially the case with families that are too involved, where girls are given little freedom, in particular. Control over food gives them the feeling of regaining control of their lives.

How are people with eating disorders treated?

Treatments for anorexia nervosa

People with anorexia nervosa often do not want psychotherapy. They want to keep control over their behaviors and have difficulty coping with a therapist's attempt to change behaviors. They also want to keep their weight and body as it is right now, and they often do not want to be a healthy weight. Winning patient trust is therefore very important in the treatment of patients with anorexia nervosa. Most anorexia patients are first forced into a hospital because their weight has reached an extreme low level. If therapy is to be given there, trust is even more difficult because the patient has to come against her will. Psychotherapy helps, but it is a lengthy process. The patient must first reach a healthy weight and then their self-image must rise. Unfortunately, many people with this disorder fall back into old habits after the therapy has been completed.

In individual therapy, the emphasis is placed on learning to recognize one's own feelings and trusting them. Only then can you respond to hunger feelings in the right way. This therapy is usually cognitive behavioral therapy, in which the patient is confronted with the overvaluation of being thin. The patient must also naturally reach a healthy weight. In behavioral therapy , patients are rewarded when they gain body weight. Because taking food often evokes anxiety and tension, they also learn relaxation exercises that they can use while eating. Another common method is family therapy. Hereby the anorexia patient and the family are treated as a unit. Sometimes parents must first be made aware of the severity of the eating disorder, because they have consciously or unknowingly stimulated eating behavior. The therapist will map the interaction problems within the family and show the role of anorectic behavior within the family. Parents are often overprotective, controlling, have too high expectations and children are not allowed to express their feelings. The therapy lasts six months to a year, with ten to twenty sessions. Psychotherapy is usually a very lenghty process. It usually takes years for the anorexia patient to heal. It often happens that people fall back into their old habits or develop bulimia nervosa.

Therapy for bulimia nervosa and binge eating disorder

Cognitive behavioral therapy appears to be the most effective for the treatment of bulimia nervosa. Cognitive behavioral therapy is based on the assumption that figure and body weight concerns are the central characteristics of the disorder. Maladaptive cognitions are mapped and the patient is confronted with this. In addition, healthy eating patterns are taught using behavioral therapeutic methods. The patient must eat three healthy meals a day. In addition, 'prohibited food' such as bread must be reintroduced into the diet. With interpersonal therapy, the therapist tries to solve interpersonal problems related to the eating problem of the patient with bulimia. Supportive-expressive therapy has the same purpose as interpersonal therapy, but with this therapy the therapist treats the patient in a non-directive manner. The patient must talk about the problems related to their eating disorder.

Giving solely behavioral therapy is also an option for treatment. In this therapy, the eating pattern is adjusted, with food that is healthier and prevents binge eating.

For bulimia nervosa, cognitive behavioral therapy works best because it addresses both the patients maladaptive thoughts and behaviors. This is also the best approach for binge eating disorder.

Because depression is often associated with eating disorders, antidepressants are also prescribed to patients. By tricyclic antidepressants bulimia nervosa patients sometimes gain more control over their eating and vomitting behavior. Patients, however, fall back into their old behavior when medication is stopped. Research into the effects of SSRI's also shows a decrease in bingeing and vomiting, but no change in other behaviors. Antidepressants are not effective in anorexia patients and SSRI's can only help anorexia patients when they have reached a normal weight again.