Summary of Psychopathology by Davey - 3rd edition

The type of technique employed by clinicians for clinical classification and assessment often depends on their theoretical orientation to psychopathology. These techniques help in diagnosing, finding the best intervention, and evaluating whether the treatment effectively targeted the symptoms of the client.

How can psychopathology be classified?

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

How were classification systems developed?

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

What are the DSM and the DSM-5?

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

The Four basic objectives of the DSM-5 are:

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

It also provides the following information:

• Essential features of the disorder
• Associated features
• Diagnostic criteria
• Information on differential diagnosis

Diagnosis should be made almost fully on the basis of observable behavioral symptoms, it therefore ignores the nature of the disorder (unless it is certain), and solely focuses on symptoms.

What are problems with the DSM-5?

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

The DSM-5 is no longer categorized in a multi-axis system, but now consists of 20 chapters describing disorder families. Users of the DSM-5 are now encouraged to rate the disorders' severity of symptoms on a continuum. Some other changes are:

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

Some criticisms of the DSM-5 are:

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

What are alternatives to the DSM?

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

Which assessment methods can be used for psychopathology?

What is the clinical interview?

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

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

Limitations are:

• Low reliability for unstructured interview
• Race and sex might influence responses of client
• Poor self-awareness of client
• Interviewer might also be biased
• Client wants to mislead interviewer

What are psychological tests?

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

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

Personality Inventories

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

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

Specific Trait Inventories

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

Projective Tests

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

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

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

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

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

Intelligence Tests

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

Intelligence tests are used in variety of situations by clinicians:

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

There are also limitations of using intelligence tests:

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

What are biologically based assessments?

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

Psychophysiological tests

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

Neuroimaging techniques

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

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

What is meant by reliability and validity of assessment methods?

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

What is the concept of clinical observation?

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

Advantages of clinical observation are:

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

Drawbacks of clinical observation:

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

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

What is cultural bias in assessment?

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

What are examples of cultural bias in assessment?

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

What are causes of cultural bias in assessment?

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

What is case formulation?

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

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

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

Advantages of the case formulation approach include:

• Flexibility in understanding the client's problems, regardless of any previous diagnoses they have received.
• A collaborative form of treatment.
• A basis of theoretical understanding of psychopathology.
• The past history of the client is considered.
• Appropriate treatment can be administered to target specific needs, even in complex cases that do not easily fit standard diagnostic categories.

What is the nature and function of psychopathology treatments?

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

Which theoretical approaches to treatment are there?

What are psychodynamic approaches?

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

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

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

What is behavior therapy?

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

Wolpe (1958) postulated that through the classical conditioning principle of extinction emotional disorders could be cured. Associations between the situation and the threat are in that way 'unlearned'. Popular techniques used for extinction are flooding, counterconditioning and systematic desensitization, which are all termed exposure therapies. Another principle of Wolpe is reciprocal inhibition, in which an anxiety-incompatible response is attached to the cue that induces the emotion. These techniques are utilized for a wide range of disorders. Aversion therapy tries to condition an individual to feel aversion towards a stimulus that they are wrongly attracted to (e.g., addictive behaviour, distressing sexual activities).

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

What are cognitive therapies?

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

The following points are usually part of this therapy:

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

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

What are humanistic therapies?

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

What are family and systemic therapies?

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

What is drug treatment?

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

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

What are different modes of treatment delivery?

What is group therapy?

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

What is counselling?

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

What about digital technologies such as computerised CBT, e-therapy, and virtual reality exposure?

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

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

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

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

• Train many practitioners therapies such as CBT, and these people get known as psychological well-being practitioners (PWPs)
• Improve the access to treatment and reducing its waiting times
• Increase the client choice and satisfaction

The money that is spend on programs like these are thought to be well returned by the money saved because of people gaining more access to therapy, which results in more people returning back to work.

How is treatment evaluated?

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

Which factors affect evaluation of treatment?

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

What is spontaneous remission?

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

What are placebo effects?

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

What about unstructured attention, understanding, and caring?

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

Which methods can be used to examine what treatments are effective?

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

What are randomized controlled trials?

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

Limitations:

• Dropouts are common, especially in no treatment conditions.
• RCTs take a lot of time and are expensive.
• Some participants may like some types of therapy better than others, and in random assignment this is not controlled for.
• Objectivity is hard to obtain in RCTs, and there is often explicit or implicit bias.

What are meta-analyses?

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

What can be concluded about the effectiveness of treatments?

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

Characteristics that can be commonly found in successful therapists include giving good feedback, helping clients gain self-efficacy and autonomy and supporting clients so they can understand their own thoughts and further their relationships. In a large-scale study where clients were asked to rate their satisfaction of the psychotherapy, they reported:

• Significant benefit from the therapy
• There was no difference with psychotherapy plus medication
• The types of therapists were equally effective and
• The longer the treatment was the more they gained from it

What are anxiety disorders?

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

What is comorbidity?

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

• Physiological symptoms are present in panic disorder and in specific phobias
• Cognitive biases play a role in most anxiety disorders
• Dysfunctional perseveration plays a role in various prominent psychopathologies
• In many anxiety disorders certain early experiences are part of the aetiology

What are Specific Phobias and what is their prevalence?

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

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

What is the aetiology of Specific Phobias?

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

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

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

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

With functional neuroimaging techniques, we can look at specific brain regions playing a role in specific phobias. The key structure mediating fear responses to phobic stimuli is the amygdala. It is involved in forming and storing memories associated with emotionally relevant events. It coordinates this with info from subcortical nuclei and higher cortical areas and then relays feedback to the thalamus, which coordinates motor responses. It has also been seen that BII phobia and dental phobia are different in the way that they affect the brain, since it can result in a decrease of parasympathetic response resulting in fainting.

Phobias are acquired in different ways depending on the type of phobia. Not all phobias are acquired through the occurrence of a traumatic event and might be acquired over long-term and gradual experiences that the individual is not always aware of (mostly in animal and height and water phobias). There is evidence that disgust, a food-rejection emotion, plays a role in small animal phobias and blood-injury-injection phobia. The disease-avoidance model states that an individual with high level of disgust sensitivity is more prone to acquiring an animal phobia. Also, there is evidence for a link between specific phobias and panic and panic disorder. Comorbidity rates lie between 40 and 65%, meaning that people with specific phobias also often suffer from panic, especially those with situational phobias. Claustrophobia and height phobia have close links to panic disorder, because sufferers also hold anxiety expectations and focus on bodily sensations. In height phobia ambiguous bodily sensations are experienced as threatening, which is common in panic disorder.

How can Specific Phobias be treated?

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

What is a Social Anxiety Disorder and what is the prevalence?

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

What is the aetiology of Social Anxiety Disorder?

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

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

How can Social Anxiety Disorder be treated?

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

• Exposure therapy, in vivo or with the therapist playing a stranger.
• Social skill training with modelling, behavioral rehearsal, corrective feedback and positive reinforcement.
• Cognitive restructuring, challenging dysfunctional beliefs and reducing self-focused attention.

The best approach is combining pharmacological treatment (MAOIs, SSRIs, benzodiazepines and beta-adrenergic blockers have all been found to be effective) with cognitive-behavioural therapy, with the former providing immediate gains and the latter ensuring long-term effectiveness.

What is panic disorder and agoraphobia and what is the prevalence of these disorders?

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

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

What is the aetiology of Agoraphobia and Panic Disorder?

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

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

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

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

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

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

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

How can a panic disorder be treated?

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

What is a Generalized Anxiety Disorder (GAD)?

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

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

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

What is the aetiology of Generalized Anxiety Disorder (GAD)?

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

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

Individuals with GAD hold the dysfunctional belief that by worrying they can prevent future catastrophes, which motivates them to continue worrying. Another account holds that this chronic worrying takes the function of a distractor from other negative emotions or phobic images that are even more stressful. This can be supported by the evidence that little physiological or emotional arousal is produced by worrying. Another theory focuses on metacognitions, which are overarching processes responsible for our thinking. Metacognitions are responsible for adaptive thoughts of worry in order to anticipate and avoid problems and if they occur, find solutions. However, sufferers from GAD have developed beliefs about worrying which makes it distressing on one hand, but they also find worrying positive as it helps them avoid and solve problems.

Worriers do not tolerate uncertainty; they are perfectionists and feel responsible for negative outcomes. The individual tries to resolve the problems, but this gets hindered through feelings of doubt to successfully solve the problem.

How can a Generalized Anxiety Disorder (GAD) be treated?

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

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

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

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

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

What is obsessive compulsive disorder?

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

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

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

What are other OCD-related disorders?

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

What is the aetiology of obsessive-compulsive disorder?

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

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

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

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

Feelings of 'dirtiness' caused without any physical touch can be provoked by thoughts of specific images or memories, or they can be provoked by emotional experiences like humiliation, betrayal or degradation. These thoughts cause mental contamination and can be a reason why one has to compulsively wash themselves. Individuals with OCD engage in thought suppression if they encounter an intrusive thought. The 'rebound effect' says that suppressing thoughts will make them come back in greater frequency once suppression is stopped. Suppression of intruding thoughts creates a negative emotional state which becomes associated with the intruding thought. Experiencing this negative emotion at some other point in time will then elicit the intrusive thought.

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

How can OCD be treated?

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

What is cognitive behaviour therapy (CBT)?

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

What are pharmacological and Neurosurgical Treatments?

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

What is a Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)?

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

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

At least between 1 and 3% of people experience PTSD at one point in their lifetime, with women being more vulnerable to developing PTSD and culture differences existing between Caucasian disaster victims and Latinos or African Americans.

Acute stress disorder (ASD) is very similar to PTSD but characterized by a shorter duration (3 days to a month). The symptoms exhibited are basically the same of PTSD. There is debate whether or not ASD is a disorder or just a normal way of reacting to some disturbing events. ASD is also seen as a potential precursor for PTSD by some, whether this is true is not yet determined.

What is the aetiology of PTSD?

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

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

• An underdeveloped hippocampus (of which it is known to be critical in relating memories to emotions)
• Failure of areas like the ventromedial frontal cortex in controlling fear centers such as the amygdala
• Heightened startle responses due to genetics, and fear-related hormonal secretion

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

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

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

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

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

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

How can PTSD be treated?

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

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

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

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

What is the nature of psychotic symptoms?

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

What are delusions?

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

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

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

What are hallucinations?

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

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

A study where individuals had to remember words generated by themselves or by the experimenter found that individuals diagnosed with schizophrenia differed from controls in three aspects:

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

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

What is disorganised thinking?

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

What about abnormal motor behaviour?

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

• Catatonic stupor: a significant decrease in a person's reactivity to the environment.
• Catatonic rigidity: a rigid and immobile posture.
• Catatonic negativism: resisting any attempts to be moved.
• Catatonic excitement or stereotypy: excessive, purposeless and unnecessary motor activity consisting of stereotyped movements.

What is meant by negative symptoms?

Some negative symptoms found in schizophrenia spectrum disorders are:

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

How are Schizophrenia Spectrum Disorders diagnosed?

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

What is Delusional Disorder?

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

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

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

What is Brief Psychotic Disorder?

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

What is Schizophrenia?

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

What is Schizoaffective Disorder?

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

What is the prevalence of Schizophrenia Spectrum Disorders?

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

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

What is the course of psychotic symptoms?

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

1. The prodromal stage
2. The active stage
3. The residual stage

What is the prodromal stage?

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

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

What is the active stage?

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

What is the residual stage?

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

What is the aetiology Psychotic Symptoms?

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

What are the biological theories of psychotic symptoms?

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

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

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

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

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

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

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

Two dopamine pathways in the brain especially important in schizophrenia spectrum disorders appear to have different roles when it comes to the role they play in the generation of symptoms.

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

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

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

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

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

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

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

What are the psychological theories of psychotic symptoms?

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

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

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

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

Paranoid schizophrenia occurs over 50% of the time with cases of schizophrenia, and this sub-type of schizophrenia which is noted by delusions of persecution is therefore of great interest. These thoughts of persecution may be explained by the fact that sufferers are 20 times more likely to have experienced some threatening or confrontational event, therefore they might be more wary of these events. Cognitive biases may also be responsible for paranoid delusions, and the four types are explained below.

Evidence shows that individuals experiencing paranoia delusions show attentional biases towards cues with emotional meaning or cues that are paranoia relevant. Then again, research shows that sufferers of delusions of persecution are slower to recognize angry faces than controls and fixate less on salient features of the face. This might be a defense mechanism the person has developed, where an avoidance strategy makes the person avoid allocating attention to threatening stimuli.

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

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

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

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

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

What are the sociocultural theories of psychotic symptoms?

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

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

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

How can psychosis be treated?

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

What are biologically based treatments of psychotic symptoms?

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

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

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

Second-generation antipsychotic drugs (or atypical drugs) were developed more recently, and were thought to have the following benefits over the first-generation antipsychotics:

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

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

What are psychologically based therapies of psychotic symptoms?

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

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

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

Because symptoms of schizophrenia affect cognitive deficits such as attention, memory and executive functioning, cognitive remediation training (CRT) or cognitive enhancement therapy (CET) are used to improve these cognitive skills, which may speed up progress in other treatments and improvement in social skills.

What are family interventions?

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

What is community care?

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

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

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

What is Anorexia Nervosa?

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

The DSM-5 criteria for anorexia nervosa are:

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

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

1. The restrictive type: in this type, self-starvation is not accompanied by, for example, vomiting.
2. The purging type: in this type, the patient regulates his weight with the help of purging: 'cleansing', for example by vomiting or using laxatives.

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

• Fatigue, cardiac arrhythmias, hypotension, low blood pressure and slow heart rate
• Dry skin and brittle hair
• Kidney problems and gastrointestinal problems
• Development of lanugo over the body
• Absence of menstrual cycles (amenorrhea)
• Hypothermia.

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

What is Bulimia Nervosa?

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

The DSM-5 criteria for bulimia nervosa are:

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

What is Binge Eating Disorder (BED)?

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

The DSM-5 criteria for BED are:

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

What are cultural differences regarding Eating Disorders?

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

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

Which demographic factors play a role?

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

What is the aetiology of Eating Disorders?

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

What are genetic factors?

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

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

What are neurobiological factors?

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

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

What are the sociocultural influences?

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

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

What is peer influence?

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

What is family influence?

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

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

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

What are the experiential factors?

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

What are the psychological and dispositional factors?

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

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

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

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

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

What are the cognitive deficits?

Eating disorders can be conceived as involving either too much or too little control over eating behaviour. This leads to the possibility that cognitive control of eating behaviour may be impaired in some conditions. In the case of BED, many associations have been found between uncontrolled binge eating, and deficits in the cognitive processes that are required to control and regulate behaviour. For example, individuals with BED perform worse on tests of executive functioning, show ineffective inhibitory control of the prefrontal cortex, and demonstrate a negative relation between working memory and body weight. Other cognitive deficits are:

• Deficits in emotional regulation
• Poor top-down regulation and inhibition of food cravings
• Impairments of working memory caused by increased levels of anxiety and depression in obese individuals that worsen executive function performance when control of eating is required.

What are Transdiagnostic Models of Eating Disorders?

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

How can Eating Disorders be treated?

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

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

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

What pharmacological treatments are there?

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

What is family therapy?

One of the most commonly used therapies for eating disorders is family therapy. This comes from the previously discussed family systems theory, which states that a patient is entrapped in a dysfunctional family structure that increases the development of an eating disorder. With therapy, the dysfunctional characteristics can be discussed and treated.

The Maudsley approach is a multi-stage family therapy for eating disorders. The first phase focuses on how the family can help solve the problems they encounter, the second phase helps the family to challenge the symptoms of the eating disorder, and the third phase develops family relationships and activities as recovery takes place found it.

What is Cognitive Behavioural Therapy (CBT)?

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

• Meal planning and stimulus control
• Cognitive restructuring to discuss dysfunctional beliefs about weight and shape
• Developing methods to prevent relapse

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

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

What are Prevention Programs?

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

• Teach vulnerable populations about eating disorders, their symptoms and causes;
• Help individuals to reject media and peer pressure to be thin; and
• Identify risk factors for eating disorders, such as dieting, body dissatisfaction, and so on.

What is the categorical approach to Personality Disorders in DSM-IV-TR and DSM-5?

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

The DSM-IV-TR organized personality disorders into three categories: (1) Odd/Eccentric Personality Disorders, (2) Dramatic/Emotional Personality Disorders, and (3) Fearful/Anxious Personality Disorders.

What problems are there with the categorical approach?

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

What is the DSM-5’s Alternative Model?

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

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

What are personality disorders and how are these diagnosed?

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

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

What are Odd/Eccentric Personality Disorders (Cluster A)?

The eccentric personality disorder cluster contains three subtypes:

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

What is Paranoid Personality Disorder?

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

A general distrust of others insofar as their motives are perceived as malicious, indicated by at least four of the following:

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

What is Schizoid Personality Disorder?

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

A persistent pattern of separation from social relationships and a limited range of emotion expression in relational situations, indicated by at least four of the following:

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

What is a Schizotypal Personality Disorder?

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

An enduring pattern of social and relationship deficits, evidenced by difficulty with and diminished ability to form close relationships, and disturbances and idiosyncrasies in behavior, manifested in at least five of the following:

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

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

What are Dramatic/Emotional Personality Disorders (Cluster B)?

The dramatic/emotional personality disorder cluster contains four subtypes:

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

Many personality disorders are characterized by impulsivity. The DSM-5 describes a number of impulse-based problems separately:

• Intermittent Explosive Disorder: This involves episodes of inability to control aggressive impulses, often resulting in criminal offenses.
• Kleptomania: Inability to control impulses to steal objects.
• Pyromania: There are recurring patterns of arson for pleasure, satisfaction or relaxation.

What is Antisocial Personality Disorder?

An antisocial PD is characterized by impulsive behavior and lack of remorse and is strongly linked to criminal behavior. The terms sociopath and psychopath are also used to describe this disorder. The DSM-5 criteria for this PD are:

A pattern of indifference to and violation of the rights of others manifested in at least three of the following since age 15:

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

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

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

What is Borderline Personality Disorder?

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

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

What is Narcissistic Personality Disorder?

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

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

What is Histrionic Personality Disorder?

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

• Feeling unhappy in situations where he/she is not the centre of attention
• Excessive, sexually suggestive or provocative behavior in interactions with others
• Show rapid swings and superficial expressions of emotions
• Often uses personal appearance to draw attention to self
• Has an excessively impressionistic and devoid of detail manner of speaking
• Is self-dramatic, very theatrical and uses exaggerated emotion expression
• Is easily influenced by others
• Feels relationships as much more intimate than they really are

What are Anxious/Fearful Personality Disorders (Cluster C)?

The anxious personality disorder cluster contains three subtypes:

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

What is an avoidant personality disorder?

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

• Avoiding activities that involve a lot of interpersonal contact because of fear of criticism or rejection
• Not wanting to approach others unless there is assurance of approval and being liked
• Restraint in intimate relationships because of fear of ridicule or embarrassment
• Fixation on disapproval or rejection in social situations
• Inhibition in new relationships due to feelings of inadequacy
• Feeling socially incompetent, unattractive or less than others
• Strongly reluctant to participate in new activities because of possible embarrassment

Some clinicians believe that avoidant PD and social anxiety disorder can be grouped together in a broader social anxiety spectrum.

What is Dependent Personality Disorder?

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

• Inability to make everyday decisions without unnecessarily high levels of advice and validation from others;
• Needing others to take on most of the responsibilities of daily life;
• Difficulty expressing disagreement with someone for fear of losing support;
• Difficulty doing or initiating things yourself;
• Feeling uncomfortable or scared when left alone because of a fear of not being able to take care of themselves;
• Urgently seeking a new supportive relationship when the previous one ends;
• Being unrealistically obsessed with fear of being left alone to fend for oneself.

What is Obsessive Compulsive Personality Disorder?

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

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

What is the prevalence of personality disorders?

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

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

What is the aetiology of personality disorders?

What psychodynamic approaches are there?

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

How are cluster A disorders related to schizophrenia?

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

What is the aetiology of Odd/Eccentric Personality Disorders (Cluster A)?

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

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

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

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

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

What is the aetiology of Dramatic/Emotional Personality Disorders (Cluster B)?

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

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

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

Psychodynamic theories state that individuals with narcissistic PD have childhood experiences with cold, dismissive parents who rarely expressed praise for their child. Therefore, clients try to look for confirmation.

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

What is the aetiology of Anxious/Fearful Personality Disorders (Cluster C)?

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

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

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

How can personality disorders be treated?

There are several factors that make treating personality disorders difficult:

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

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

What drug treatments can be used?

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

What are psychodynamic and insight approaches?

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

What is Dialectical Behavioral Therapy?

Dialectical Behavioral Therapy is a client-centred therapy that seeks to provide clients with an understanding of their dysfunctional ways of thinking about the world that is particularly successful in borderline personality disorders. There are four phases:

1. Identifying dangerous and impulsive behaviors and helping the client deal with these behaviors
2. Helping the client to moderate extreme emotions
3. Improving the client's self-confidence and coaching the client in dealing with relationships
4. Promoting positive emotions

How can cognitive behaviour therapy be used?

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

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

What is schema-focused cognitive therapy?

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

What is Dissociative Amnesia?

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

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

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

The prevalence of dissociative amnesia is about 1.8%.

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

What is Dissociative Identity Disorder?

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

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

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

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

What is Depersonalization Disorder?

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

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

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

What is the relationship Between Dissociative Disorders and PTSD?

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

What are the risk factors for dissociative disorders?

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

What is the psychodynamic perspective?

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

What is the role of fantasy and dissociative experiences?

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

What are the cognitive approaches?

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

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

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

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

Can memories of childhood trauma or abuse be suppressed? Yes, but it is important to look at the nature of the trauma and whether it is a 'normal' forgetting process or active suppression.

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

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

What are the biological explanations?

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

What about role-playing and therapeutic constructions?

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

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

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

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

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

How can dissociative disorders be treated?

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

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

How can psychodynamic therapy be used?

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

What does hypnotherapy involve?

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

What is the use of drug treatments?

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

What difficulties are associated with the identification and diagnosis of childhood and adolescent psychological problems?

There are some difficulties in psychopathology in childhood and adolescence that are not present in adults. First, behavioural and psychological problems must be seen in the context of the child as a developing organism. Bedwetting is normal up to a certain age, but it is from about 5 years old. Second, children have weak self-knowledge due to their immaturity. They can sense that something is not right, but not name it.

The psychological problems in children can be divided into two domains: externalizing disorders and internalizing disorders. Externalizing disorders are characterized by outward behaviour problems, such as aggressiveness, hyperactivity, or impulsiveness. Internalizing disorders are characterized by inward-looking and withdrawn behaviours and may represent depression, anxiety, and active attempts at social withdrawal.

It is important to consider what is normal at a given age when determining clinically relevant behavior in children. Diagnosis often depends on the individual's ability to communicate problems and their consequences to the counsellor. Children often find it difficult to communicate feelings and often have weak self-knowledge. Differences in cultural norms also influence whether behaviors are seen as problematic or not. In childhood and early adolescence, developments are very fast, which means that psychological problems can escalate quickly and dramatically. Therefore, problems should be identified as soon and early as possible to minimize psychological damage.

How is childhood psychopathology a precursor to adolescence psychopathology?

In many adult psychological disorders, childhood experiences are important in the aetiology. Developmental psychopathology describes how early childhood experiences may act as risk factors for later diagnosable psychological disorders. In addition, it seeks to describe pathways along which these experiences generate psychological problems in adulthood.

There are several ways in which psychopathology in childhood may be linked to psychopathology in adulthood. First, a childhood disorder may persist into adulthood in the same form. Second, psychopathology in childhood may adversely affect subsequent development and thus indirectly lead to various forms of maladaptive behavior later in life. Third, psychopathology in childhood may represent a less cognitive precursor to a related disorder in adulthood. Fourth, a childhood disorder may leave an individual vulnerable to later life stressors.

What is the prevalence of childhood and adolescent psychological disorders?

Estimates are that 10% to 20% of children and adolescents have a diagnosable psychological disorder. Disorders are more common in men than in women, but this is reversed in adulthood. Early developmental problems and specific fears (such as potty-training delays) often resolve themselves as childhood progresses, but other problems (such as disruptive behaviors) seem more permanent.

Comorbidity is common, about 2% of children have more than one diagnosis. In addition, psychopathology in childhood is associated with physical health problems and poor academic performance. Risk factors include having one parent, parental psychopathology, repeated early parental divorce, harsh or inadequate parenting, exposure to abuse or neglect, and negative peer influence.

What is Attention Deficit Hyperactivity Disorder (ADHD)?

Attention deficit hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity-impulsivity to a greater degree than would be expected based on age or stage of development. Hyperactivity is a higher level of activity than normal. Impulsivity is reacting to a situation without thinking about the consequences.

How Is ADHD Diagnosed?

Most children show both inattention and hyperactivity (combined presentation), but sometimes one is dominant. Therefore, there are two diagnostic subtypes, namely ADHD-predominantly inattentive and ADHD-predominantly hyperactivity/impulsivity. The DSM-5 criteria for ADHD are:

A persistent pattern of inattention and/or hyperactivity and impulsivity, interfering with normal functioning or development. For inattention, at least six of the following are present for at least six months: (1) not paying careful attention to details or carelessly making mistakes, (2) difficulty sustaining attention in activities, (3) not listening when spoken to becomes, (4) ignores instructions, (5) has difficulty organizing, (6) dislikes or avoids tasks that require sustained effort, (7) loses things necessary to complete tasks, (8) is easily distracted , (9) is forgetful in daily activities. For hyperactivity and impulsivity, at least six of the following have been present for at least six months: (1) high level of agitation,

• The symptoms were present before age 12
• The symptoms are present in at least two situations
• The symptoms reduce the quality of educational, social, or occupational skills
• The symptoms do not occur during schizophrenia or any other psychotic disorder and are not better explained by another mental disorder
• ADHD has a high comorbidity with oppositional defiant disorder and conduct disorder

What is the prevalence of ADHD?

About 5% of children are diagnosed with ADHD. Half of these carry this diagnosis into adulthood.

What are the consequences of ADHD?

First, the inattention and hyperactivity can predispose the child to anger outbursts, frustration, and stubbornness, among other things. This often leads to reduced learning performance and conflicts with teachers and family. Children with mostly inattentive symptoms suffer the most in terms of learning performance and children with mostly hyperactivity symptoms in terms of peer rejection and injuries. In addition, they generally have difficulty making friends because their behavior is aggressive and disruptive.

Adults with ADHD have less success and security at work, poorer interpersonal relationships, poorer academic performance, and poorer overall life satisfaction.

What does the aetiology of ADHD look like?

There are several biological factors in the aetiology of ADHD, including heredity, brain factors, prenatal factors, and nutrients. The heritability of ADHD is about 76%, according to twin studies. In addition, several genes have been identified that contribute to the development of ADHD. Studies show that it is very likely that there is a gene-environment interaction, with vulnerability to ADHD only manifested by certain environmental influences.

MRI studies show that there are differences between the brains of individuals with ADHD and those without ADHD. The brains of children with ADHD are smaller and develop less quickly. Brain volumes of several specific brain regions are inversely related to different ADHD symptoms. For example, problems in executive functioning are related to reduced volume of the frontal lobes. Prenatal factors that interact with genetic predisposition include maternal smoking and drinking during pregnancy and birth complications such as low birth weight, respiratory problems and suffocation.

In addition, there are studies that state that hyperactivity is due to biochemical imbalances from food additives, refined sugars and lead poisoning. There are also several psychological factors in the aetiology of ADHD, including parent-child interactions and theory of mind impairments. Children with ADHD are more likely to have been raised by parents who also have ADHD, which can exacerbate symptoms caused by the genetic component alone. Psychodynamic theories also point to the possible role of inconsistent or ineffective parenting. Learning theory suggests that parental responses to disruptive and impulsive behaviors may be rewarding or reinforcing for children with ADHD.

Children with ADHD often fail to understand their peers' intentions in social situations, suggesting problems with theory of mind. There is inconsistency in finding a relationship between ADHD and poor performance on theory of mind tasks. There is, however, consistency regarding the relationship between ADHD and limited performance on tasks that require executive functioning. Therefore, it is argued that ADHD symptoms are directly linked to impairments in executive rather than social functioning.

What is Conduct Disorder?

Conduct disorder is a pattern of behavior in which the child shows various behavior problems, including fighting, lying, running away from home, vandalism and truancy.

How is conduct disorder diagnosed?

The DSM-5 criteria for conduct disorder are:

A persistent pattern of behavior that violates other people's rights or social norms, manifested by at least three of the following for at least 12 months:

• Bullying or threatening others
• Starting a fight
• Using of a weapon to inflict serious physical harm
• Physical cruelty to others
• Physical cruelty to animals
• Robbing or other similar offenses
• Forcing others to engage in sexual activity
• Setting fire to destroying or seriously damaging property
• Intentionally destroying another's property
• Breaking into cars or houses
• Lying to get things
• Shoplifting or similar
• Staying out at night despite parental intervention, which starts before the age of 13
• Running away from home at least twice or once for a longer period of time, (15) often misses school starting before age 13
• The disruptions cause significant impairment in social, academic, and occupational functioning
• If the patient is over 18: the condition is not better explained by antisocial personality disorder

There are two subtypes of conduct disorder, childhood and adolescence-onset conduct disorder. Childhood-onset conduct disorder is defined by the onset of at least one characteristic of conduct disorder before age 10. Adolescent-onset conduct disorder is defined by the onset of conduct disorder symptoms after age 10.

There are three considerations in diagnosing conduct disorder. First, individuals are normally under the age of 18 and are only diagnosed with conduct disorder later in life if they do not meet the criteria for an antisocial PS. Second, the clinician must consider the social context in which the behaviors occur. In some environments, these can have a protective function. Third, there is a related category of disordered behavior called oppositional defiant disorder (ODD). This diagnosis is made when children do not meet the full criteria for conduct disorder.

What is the prevalence and course of conduct disorder?

For boys, the prevalence of conduct disorder is between 4% and 16%, for girls between 1.2% and 9%. The disorder also manifests itself differently in boys (aggression, violent behavior) than in girls (lying, running away from home). The lifetime prevalence is around 9.5%. Symptoms usually appear between mid-childhood and mid-adolescence and most resolve in adulthood, but some eventually meet the criteria for antisocial PD.

What is the aetiology of conduct disorder?

There are several biological factors in the development of conduct disorder, namely genetic, neuropsychological and prenatal factors. Twin studies show that the hereditary component is between 45% and 67%. These studies also show that the behaviors such as aggression and violent behavior are hereditary and that environmental factors probably play an important role.

Neuropsychological impairments in cognitive functioning include impairments in executive functioning, verbal IQ, and memory. However, the association between antisocial behavior and weak executive functioning appears to be mainly driven by relations between weak executive functioning and criminal behavior and externalizing behavior, rather than by specific conduct disorder. Prenatal factors in the aetiology of conduct disorder include maternal smoking and drinking during pregnancy and maternal malnutrition during and after pregnancy.

In addition, there are several psychological factors in the development of conduct disorder, namely influences from family and peers, cognitive factors and socio-economic factors. Family and parent-child relationships are important factors involved. Risk factors for developing ODD and conduct disorder include parental unemployment, having a parent with an antisocial PD, impaired care for the child, and abuse or maltreatment during childhood. Family environments that are less close-knit, have few intellectual/cultural pursuits, have a lot of conflict, and are more stressful are associated with the development of conduct disorder in the child.

Many children develop antisocial and aggressive behavior because they imitate the violent activities they see in the media and among their peers. Violent behavior can thus be facilitated, as it can become the norm if seen regularly. However, children affected by the media are often already emotionally and psychologically disturbed.

Conduct disorder is associated with the development of deviant moral consciousness. This may be because they develop highly distorted ways of interpreting the world. Dodge developed the social information processing model for antisocial and aggressive behavior, in which he argues that trauma, abuse, neglect, and insecure attachment can create specific information processing biases. For example, there is a tendency to interpret cues as malicious, even though there may be good intentions behind them, this is called the hostile attributional bias. This often results in an aggressive response. Socio-economic factors that can cause conduct disorder are poverty, low socio-economic status, unemployment, living in the city and poor educational achievement.

What is childhood anxiety?

Childhood anxiety manifests itself as withdrawn behavior. Many anxiety disorders are similar to those seen in adults, but some are specific to children, such as separation anxiety.

What are the characteristics of anxiety problems?

Separation anxiety is the intense fear of being separated from parents or caregivers. The prevalence is about 4% for children aged 6-12 months and has a 12-month prevalence of 1.6% for adolescents. The DSM-5 criteria for separation anxiety are:

Excessive fear of separation from those to whom the individual is attached, manifested by at least three of the following:

• Disproportionate distress when separation from home or attachment figures is experienced or anticipated
• Ongoing and unnecessary care about losing attachment figures or possible things that could happen to them
• Persistent and unnecessary worry about unexpected events that may cause separation from attachment figures
• Persistent aversion to going out or going far away from home because of fear of separation
• Persistent and unnecessary fear of being left alone or without the attachment figures
• Persistent aversion to sleeping alone or sleeping far away from home
• Repeated nightmares about separation
• Complaints about physical symptoms such as headaches or nausea upon separation from attachment figures or in anticipation thereof.
• The fear is present for at least four weeks in children and six months in adults
• The disruption causes significant impairment in key areas of functionality
• The disturbance is not better explained by another mental disorder.

OCD in childhood is very similar to OCD in adulthood. The characteristics are intrusive, repetitive thoughts, obsessions and compulsions. The manifestations of the disorder are slightly different in children than in adolescents. For example, obsessions in children include symmetry and contamination, but in adolescents religious and sexual obsessions. OCD in childhood is comorbid with a variety of disorders such as tic disorders, Tourette's syndrome, other anxiety disorders and eating disorders. Tic disorders are uncontrollable physical movements such as facial and mouth twitching and rapid blinking. Tourette's syndrome is a disorder in which motor and vocal tics occur frequently during the day for at least a year.

Generalized anxiety disorder in children and adolescents often takes the form of anticipatory anxiety, with chronic worry about potential problems and threats. Pathological worry is the persistent worry that is perceived by the individual as uncontrollable. The number of concerns increases with age.

Specific phobias are common in normal development. However, if a fear persists and becomes more problematic, it can affect daily life. An example of this is a social phobia, which starts with a fear of strangers and can grow into a fear of social situations and strangers.

Tics often begin in childhood and diminish in adolescence. Simple tics are short-lived, such as blinking, shrugging, sniffing, and grunting. Complex motor tics are of longer duration and may consist of combinations of simple tics. Tourette's syndrome and behavioral tics are often comorbid with OCD. Treatments used for OCD can also be effective for behavioral tics.

What is the aetiology of anxiety problems?

Twin and family studies show that there is a combination of hereditary and environmental factors. Trauma and stress in childhood are risk factors for a variety of psychological disorders in adulthood. These experiences cause psychological stress and anxiety. In addition, illnesses such as asthma and the death of a pet can cause anxiety and depression. Also, children are very bombarded with information about possible dangers and threats. If negative information is given by an authority figure, it can lead to changes in fear beliefs and avoidance. Because children depend on their parents or caregivers for guidance and emotional support, it is not surprising that dysfunctional forms of parenting can cause problems in childhood. Both overprotective and avoidant parenting styles have negative effects and facilitate anxiety.

What is Childhood and Adolescent Depression?

In childhood, depression manifests as clingy behavior, not wanting to go to school, and exaggerated fears. In addition, there is a greater degree of somatic problems. In adolescence, depression manifests as sulking, withdrawal from family activities, weight disturbances, loss of energy, feelings of worthlessness and guilt, and in extreme cases suicidal thoughts.

How is depression diagnosed in childhood and adolescence?

The diagnostic criteria are essentially the same as for adults. However, some symptoms change with age. Certain complaints are more prominent in younger children than in adolescents. Depression occurs in less than 1% of pre-school children. Prevalence is between 2% and 3% for school-age children and between 4% and 8% for adolescents. Depression is comorbid with other anxiety and substance use disorders. This has negative consequences for learning performance, social functioning and is associated with an increased risk of suicide, among other things.

What is the aetiology of depression in childhood and adolescence?

There are several risk factors for developing depression:

• Dispositional factors and existing psychological problems
• Stressful experiences
• Weak coping skills
• Weak social support
• Problems in physical health
• Weak learning performance

There appears to be a genetic component to childhood depression, but studies differ in their findings. Studies suggest that genetic influences are indirect and have their effect in combination with environmental factors. There is a strong link between child depression and parental depression, which may indicate heredity on the one hand, but parental depression may also create negative early experiences that may precede child depression.

Psychological factors include the parent-child relationship and the development of dysfunctional cognitions that shape depressive thinking. Depressed parents can transfer their negative mood to their child through interactions with the child. In addition, depressed parents may not be able to respond appropriately to their child's emotional experiences, which may leave the child feeling helpless or unable to learn how to regulate emotions. Children of depressed mothers have more interpersonal limitations and a risk of interpersonal dysfunction, which can then exacerbate and perpetuate depression in the child. Research on cognitive factors has mainly focused on the role of a pessimistic inferential style, in which negative events are attributed to stable causes. Children with this style are more likely to have an increase in depressive symptoms due to negative events than children who do not have this style. In addition, this style interacts with daily hassles in predicting an increase in depressive symptoms.

The prototype adolescent most at risk for depression is a 16-year-old female with early or late puberty. She experiences low self-confidence, negative body image, feelings of worthlessness, pessimism and self-blame. She is self-conscious and very dependent on others, but she says she receives little support from family. She experiences major and mild stressors, such as conflict with parents and poor school performance, and she has a weak coping style. Other forms of psychopathology are present, including anxiety disorders, smoking, and past suicidality.

What drug treatments are there?

SSRIs were first used to treat depression, but this has been shown to increase the risk of suicide. However, new studies call for this to be reconsidered, as the benefits would outweigh the risks. Fluoxetine is used in the treatment of anxiety disorders. However, there are several reasons why drug treatment in children should be treated with caution:

• Complete resolution of symptoms is rarely achieved, especially in the treatment of depression with SSRIs
• SSRIs have unpleasant side effects, such as nausea, headache and insomnia
• Safety and effectiveness have not been proven, as studies vary widely in methodology
• Doubts about the safety of various antidepressant drugs in children exist in both the US and the UK, to the extent that official warnings have been issued against their use.

With regard to ADHD, more is known about drug treatments. Ritalin (methylphenidate) is the most commonly used form of stimulant medication to treat hyperactive children. The exact effect is not known, but it probably acts on the neurotransmitters noradrenaline and dopamine in areas of the brain that regulate attention and behavior. Disadvantages of Ritalin are that the long-term effects are not known that there are various side effects (such as sleeping problems and memory loss), and that it is an amphetamine, which means that it can also be abused.

How can Behaviour Therapy be used?

A commonly used classical conditioning method to treat nocturnal enuresis is the bell-and-battery technique. A sensor is placed in the underwear of the child and if it detects urine, an alarm will sound. As a result, the child learns to associate a full bladder with waking up.

Specific behavioral therapy techniques such as systematic desensitization can also be used to treat anxiety problems. Selective reinforcement techniques are used to improve learning performance in children with ADHD and conduct disorder. Desired behaviour is rewarded, and disruptive behaviour is ignored. Time-out (TO) is a means of reducing disruptive behavior (aggression, breaking things, not listening) by taking the child out of the situation and, for example, having him/her sit in a specific TO chair for a period of 5 to 15 minutes.

Behavior management techniques are treatment methods that can be used in a variety of settings and can even be taught to parents as a tool to monitor and respond appropriately to their children at home.

What family interventions are there?

Systematic family therapy is based on the view that childhood problems stem from inappropriate family structure and organization. The therapist focuses on the boundaries between parents and children and how they communicate. Parent management training seeks to teach parents how to adjust their responses to their children so that acceptable behavior, not antisocial behavior, is rewarded. This is used in families with children with conduct disorder. Functional family therapy (FFT) combines elements of systematic family therapy and CBT. The treatment focuses on strengthening family relationships by opening up communication between parents and children.

These forms of therapy are used for conduct disorder, ADHD, depression, anxiety and eating disorders and are more useful than no treatment or alternative treatments.

How can Cognitive Behaviour Therapy (CBT) be used?

CBT is mainly used to treat depression in adolescents. The individual is then made aware of pessimistic and negative thoughts, depressive beliefs and erroneous attributions. The individual is then taught to replace these with more realistic and constructive cognitions. CBT has been successful in treating anxiety disorders such as OCD, generalized anxiety disorder, specific phobias, social phobia and separation anxiety. Family interventions can be successful by teaching parents how to apply basic CBT procedures to their child's anxiety.

What is Play Therapy?

Play therapy includes a variety of play-based therapeutic and assessment techniques that can be used with younger children who are less able to communicate and express their emotions. It also allows children to develop a positive relationship with the therapist, learn to communicate, express feelings, modify behavior, and develop problem-solving skills. This form of therapy appears to be effective and also has positive effects on behavior in general, social adjustment and personality.