Chapter 2: An integrative approach to Psychopathology

 One dimensional model – very dangerous model:

Initially one-dimensional model was used. Explained behaviour in terms of a single
cause such as chemical imbalances or genetics etc. It was either one or the other,
witches or demons, then biology came, chemical imbalances, behaviour,
conditioning etc.
 We have come away from that now.
 Multidimensional models
Psychopathology is a result of a multiple of factors, interdisciplinary, eclectic and
integrative. System of influences that cause and maintain suffering. We now draw up
information from several sources. Abnormal behaviour results from multiple
influences – interplay between genes and environment.

Major influences:

When a person comes to therapy, there is a case formation. We take a history of all factors.

- Biological: what can physically be contributing, is anyone else in the family suffering
- Behavioural: what are you doing, a behaviour that is maintaining the disorder, its
maladaptive. Every behaviour has a function. Behaviour stays because it has a
purpose.
- Emotional: how are you feeling, could be a range of emotions. Could be coming from
certain thoughts.
- Social and cultural: are these behaviours appropriate culturally
- Developmental: are you having appropriate changes
- Environmental: what’s going on around you

Example of Judy:

- Behavioural factors: conditioned response to sight of blood

- Biological factors: genetics: inherited tendencies, philology: e.g. light-headedness
- Emotional factors:

New developments in the study of genes and behaviour:

- One study: heritability estimates ranged from 30-60% for cognitive traits
- Adverse life events can trump the influence of genes e.g. if one identical twin
experiences a traumatic life event, the cognitive abilities may be more discrepant
later
- Research recently suggests that genetic contributions should not be considered
without also considering the environment – sometimes environment gives nurturing
space that the genetic factors don’t get activated

The interaction of genetics and environmental effects:

 - Diathesis stress model: individuals inherit tendencies to express certain trait sor
behaviours which may then be activated under conditions of stress.
- Each inherited tendency is a diathesis, which is a condition that makes someone
susceptible to developing a disorder. When the right kind of life event, such as a
certain type of stressor, comes along the disorder develops.

Neuroscience and its contributions to psychopathology

- Understanding brain and nervous system is important for us to study

psychopathology
- The field of neuroscience: the role of the nervous system in disease and behaviour
- CNS: brain and spinal cord, sorts out important information
- PNS: somatic and autonomic branches, connects the brain to limbs and organs
- Neurons transmit information
- Forebrain: most sensory, emotional information processed here, has the cerebral
cortex
- Cerebral cortex has the frontal cortex: thinking and reasoning abilities, most of
psychopathology is involved in the prefrontal cortex, most sophisticated structure in
the brain, when most psychological disorders happen frontal cortex breaks down
- PNS: autonomic branch (sympathetic – responsible for fight or flight response,
parasympathetic – responsible for relaxation, rest and digest).
- Parasympathetic and sympathetic works side by side, sympathetic prepares body for
stressful events, pupils dilate, heartbeat increases, digestive system shuts down,
hands get cold etc. when the danger subsides, parasympathetic system works to
bring you back.
- Neurotransmitters – carry messages from one neuron to another
- Either a deficit or an excess of this communication so the relevant drug helps them
work out
- Serotonin: influences information processing, behaviour, mood and thoughts
dysregulated serotonin contributes to depression, an excitatory neurotransmitter –
increases likelihood that the next neuron will fire, very low serotonin linked to
impulsivity, SSRIs required
- Noradrenaline – involved in alarm responses, fight or flight
- Dopamine – implicated in depression and ADHD, too much dopamine can cause
schizophrenia, too less can cause parkinsons
- GABA: inhibitory, decrease the likelihood

Psychosocial influences on brain structure and function:

- More stimulating environments appear to promote neurodevelopment
- Stress and early development – stress exposed in childhood can lead to depression in
future
- Study in which they found rats who were raised in enriched environment?

Contributions of behaviour and cognitive sciences

 - Learned helplessness: rates were given occasional shocks, functioned well when
they knew how to avoid the shock, however, when they learned their behaviour has
no effect on the environment, they became helpless, learned to give up.
- Equivalent to when we face depression. People who face uncontrolled stress in their
life, they eventually learn to give up.
- Social learning: Albert Bandura. Modelling an observational learning, when we see
certain behaviours working in a social context for other people, we tend to copy
them.

The rise of emotion in psychopathology:

- The nature of emotion: Charles Darwin, humans and animals who experience the
fight flight response activates us to certain behaviours because of this survival
mechanism. The whole purpose is to mobilise us to face the danger. Evolutionary
purpose.
- Action tendency is different from affect (something that is observable, e.g.
demeanour) and mood (sustained emotion)
- Components of emotion: behaviour (what are we doing), physiology (what is
happening to us), cognition
- Anxious thoughts – precede emotion.
- Freeze – escape – approach behaviour.
- Physiology of brain: emotional centre of the brain is amygdala.
- Cognitive aspect of emotion: how we are interpreting information, how do we
process that. If we view the world as a dangerous place, we will be fearful and
hyperattentive.

Anger and your heart:

- Chronic hostility increases risk for heart disease.

- Heart disease is found more in men than in women because men are found to
become angry more often than women.
- The effect is stronger than many physiological risk factors.
- Efficacy or heart pumping is decreased when angry
- The effect is revered when people practice forgiveness toward an offense
- Supressing any negative emotions increases sympathetic (fight flight) nervous
system activity
- Dysregulated emotions (feeling emotion at the wrong time) are key features of many
mental disorders

Culture, social and interpersonal/factors in psychpathology:

- Gender effects: men and women may differ in emotional experience and expression.
Examples – 90% of insect phobia sufferers are female
- Effect of social support: low social support especially important in the elderly, when
people put in elderly homes, they decline both cognitively and emotionally, either
isolate themselves from everyone else there and pass quickly or embrace all of the
other people around them
 - Low social support is related to mortality, disease, psychopathology

Social stigma of psychopathology:

- Culturally, socially, interpersonally situated

- Problems with social stigma: may limit the degree to which people express mental
health problems. E.g. concealing feelings of depression, unable to recieve support
from friends
- Women won’t show anger, men won’t show sadness
- May discourage treatment seeking

Global incidences of psychological disorders:

- Mental health accounts for 13% of world disorders

Summary of multidimensional perspectives:

- Multiple causation
- Take a broad, comprehensive, systematic perspective: biological and neuroscience,
cognitive and emotional, social, cultural and developmental factors

Chapter 3: Clinical Assessment and Diagnosis

Intelligence tests:

- The tests provide a score known as intelligence quotient or IQ

- Current tests use what is callad a deviation IQ – a person’s score is compared only
with scores of others of the same age. The IQ score is then an estimate of how much
a child’s performance in school deviates from the average performance of others of
the same age
- IQ should not be confused with intelligence

Neuropsychological testing:
- Assess broad range of skills and abilities
- Goal is to understand brain behaviour relations
- Examples: Luria Nebraska and Haalstead-Reitan batteries: designed to asses for brain
damage, test diverse skills ranging from grip strength to sound
- Neuroimaging: picture of the brain, to check various brain structures and functions
by mapping metabolic or chemical activity in the brain. Any disruption neuroimaging
will pick it up.
- CAT: utilizes x rays
- MRI: utilizes strong magnetic fields, better resolution than CT scans
- PET
- SPECT: traces substances less accurate and less expensive than PET, fMRI: brief
changes in brain activity, immediate response to brain
Diagnostic classification:

- Classification is central to all sciences

- Assignment to categories based on shared attributes or relations

Widely used classification systems:

- DSM: gets updated every 10-20 years, current edition DSM-5 came out in 2013
- Used worldwide, people responsible are APA
- ICD-10: International classification of diseases, published by WHO, exactly similar like
DSM-V give or take a few disorders
- Prior to 1980, diagnosis was made on biological or psychological dimensions
- Axis I-V
- DSM IV introduced in 1994, DSM-IV-TR incorporated new research and slightly
altered criteria accordingly

DSM V:

- Removed axial system

- Clear inclusion and exclusion criteria for disorders
- Disorders are categorized under broad headings
- Empirically grounded, prototypic approach to classification: a disorder which has
many possible features/properties are listed, so any client need to have enough of
them not all of them to be diagnosed with it
- The problem of comorbidity: an individual could have two or more disorders, high
comorbidity is extremely common so it becomes hard to propose treatment

Clinical assessment and diagnosis:

- Aims to fully understand the client

- Aids in understanding and ameliorating human suffering
- Based on reliable, valid and standardised information

Chapter 5:

Generalised Anxiety Disorder:

Statistics:
- 3.1% year
- 5/7% lifetime
- Similar rates worldwide
- Onset around early adulthood
- Chronic course: lasts for a lot of time, require techniques to overcome it

GAD in the elderly:

- Worry about failing health, people around them also dying
- Up to 10% prevalence
 - Use of minor tranquilizers, 17 to 50%: have proofed to be beneficial for at least short
term, sometimes prescribed for medical problems or sleep problems, increased risk
for falls and cognitive impairments

Causes of GAD:
- Inherited tendency to become anxious
- Neuroticism: negative thinking.
- Frontal lobe activation: Cognitive activity in the left frontal lobe not high, suppress
activity in the brain that helps to generate images. Sometimes images are required
to process information. Lots of worrying that ensues without any actual resolution to
the problem.
- High threat sensitivity. Quicker to detect things in the environment than other
people. Will look at worse case scenarios. Will look at bad things that’s going to
happen.

Treatments of GAD:
- Pharmacological: Benzodiazepines (they do provide relief, but risks involved – lose
alertness, dependency issues) antidepressants
- Psychological: similar benefits to drugs and better long-term results. Cognitive
behavioural treatments: exposure to worry process, confronting anxiety provoking
images, coping strategies
- Meditation: mindfulness based approaches so the client becomes more tolerant

Panic Disorder and Agoraphobia

Clinical description:

- Unexpected panic attacks

- Anxiety, worry or fear of another attack
- Persists for I month or more
- Agoraphobia: fear of avoidance of situations/events. Concern about being unable to
escape or get help if something wrong happens
- Avoidance can be persistent, might not step out. Can lead to a lot of seclusion.
- Use and abuse of drugs and alcohol to cope
- Interoceptive avoidance: sensations similar to having a panic attack, will avoid
activities that will conjure these sensations such as exercising (will increase
heartbeat/cardiovascular activity, will remind them of panic attack)
- Statistics: 2.7% (year), 4.75 (life), female:male = 2:1, acute onset, most common in
young adulthood (ages 20-24).

Diagnostic criteria for panic disorder:

- Recurrent unexpected panic attacks

- At least one attack has been followed by significant worry or maladaptive changes in
behaviour

Diagnostic criteria for agoraphobia:

 - Marked fear/anxiety for two or more: public transportation, open spaces, standing in
line, enclosed spaces, being outside the home alone
- Avoids these situations
- Situations always provoke fear

Nocturnal Panic:

- 60% with panic disorder experience nocturnal panic

Causes of nocturnal panic:

- Generalised biological vulnerability – alarm reaction to stress

- Cues get associated with situations – conditioning occurs
- Generalised psychological vulnerability – anxiety and future attacks, hypervigilance,
increase interoceptive awareness

Panic treatment:

- Benzodiazepines
- SSRIs

Psychological intervention:
- Exposure based
- Reality testing
- Relaxation and breathing skills
- Example: panic control treatment - exposure to interoceptive cues, cognitive
therapy, relaxation/breathing
- High degree of efficacy
- Combined psychological and drug treatments – no better than CBT or drugs alone,
CBT is better for the long run

Specific Phobias:

Clinical description:

- Ectreme and irrational fear of a specific object or situation

- Feared situation almost always provokes anxiety
- Significant impairment or distress

Diagnostic criteria:

- Marked fear or anxiety about a specific object or siutaion

- Phobic object
Blood injection phobia: decreased heart rate
Situational phobia: fear of flying, driving
Natural environment phobia
Animal phobia: dogs, snakes, mice, insects

Statistics:
- 12.5% (life) 8.7% (year)
- Female: male = 4:1
- Chronic course

Causes of phobia:
- Direct experience
- Vicarious experience: seeing someone else encounter a feared object
- Information transmission: learning about a situation/object being dangerous
- Preparedness: when we have acquired phobias of things that would have been
useful for our ancestors to fear (snakes etc). through natural selection we have
learned to fear certain things more than others.

Treatment of phobias:

- CBT: Exposure – graduated, structured

- Relaxation – used to be practiced more, now often not a part of empirically
supported treatment

Social Anxiety Disorder:

Clinical description:

- Extreme/irrational concern about being negatively evaluated by other people

- Sometimes (not always) manifests as shyness
- Leads to significant impairment and distress
- Avoidance of feared situations, or endurance with extreme distress
- Subtype: performance only – anxiety only in performance situations (public
speaking)

Statistics:

- 12.1% (life) 6.8% (year)

- Female: male = 1:1
- Onset = usually adolescence, peak age of onset = 13

Causes:

- Generalised psychological vulnerability e.g. belief that threatening events are

uncontrollable
- Generalised biological vulnerability e.g. propensity towards anxiety
Treatment:
- Medications: beta blockers, benzodiazepines (for performance anxiety), SSRI (Paxil,
Zoloft, Effexor), D-cycloserine
- Psychological: CBT – challenging of anxious thoughts about the consequences of
social judgement, exposure to anxiety provoking situations, rehearsal, role-play
- Highly effective