Abnormal Psychology

 
The word "Abnormal" is often misunderstood. Who is considered
abnormal? Where do we draw the line between normal and abnormal?  
As a third year psychology student, you will learn about specific
criteria which informs a clinical diagnosis. 
 
Week 1: Intro to Abnormal Psychology
Tutorial 1
Week 1 
Unit 1: Mood disorders
Week 2: Bipolar disorders
Unit 2: Anxiety Disorders and Schizophrenia & other Psychotic disorders
Unit 3: Eating Disorders & Personality Disorders
Unit 4: Childhood Disorders

Lesson Outcomes: 
  Define abnormal behaviour
  Understand the difference between "normal" and "abnormal" behaviour
  Understand historical and modern day normal and abnormal behaviour
  Know the different approaches in treating abnormal behaviour 
 
Prescribed Readings: 

 The reading for this week is Chapter 1 from the your prescribed textbook. 

What is your understanding of abnormal behaviour?

(Define abnormal first before looking at the textbook definition
in the comments section.)
 Define of "abnormal" or "abnormal behaviour" in your
own words &
How does it differ from the textbook definition? 
 

Video Clip 1 - Defining Abnormal Behaviour

Now we will look at an American clip that gives an in depth explanation into what abnormal psychology is with
some focus on the not so normal cultural norms prevalent today.

ABNORMAL BEHAVIOUR: Criteria

 1. Behaviour that is unusual or a statistical rarity (a behaviour is seen as abnormal if it is statistically
uncommon or not seen very often in society)
2. Behaviour that is socially unacceptable (differs from one culture to another)
3. Perceptions of reality is faulty- hallucinations/delusions
4. The person is in significant personal distress- what may be regarded as an appropriate emotional
response, persists for too long and are too intense
5. Behaviour is maladaptive or self-defeating
6. Behaviour that is dangerous/harmful to self and/or others
In most cases a combination of these criteria are used 
 
The four D's of Abnormal behaviour may help you remember it better:
Article: Defining "abnormal" 
The article below provides an in-depth historical perspective on abnormal behaviour - if you haven't
got access to the textbook yet it is required that you read it for this week. If you have done the readings,
you can skim over it and keep it as another resource.
 _ramsden_ch1.pdf
Defining Abnormal psychology
  
1. The Supernatural tradition 
     Demons & Witches; evil demons took over the victims’ bodies and controlled their
behaviors.
     Treatment to "cure" abnormal behaviour: exorcism or burning at the steak.
      Moon & Stars- It was believed (and still to this day) that movements of the moon and stars
had profound effects on people’s psychological              functioning. The gravitational effects of
the moon on bodily fluids might be a possible cause of mental disorders
      There is, however, no scientific evidence to support this theory.

2. The Biological tradition 

Originally, the biological approach was proposed to define abnormal behavior as a form
disease, much like syphilis and gonorrhea 
Syphilis
Syphilis- A bacterial infection usually spread by sexual contact that starts as a painless sore.
 Ultimately, clinical investigators discovered that penicillin cures syphilis.  Abnormal
behaviour, for the first time, was traced directly to a curable infection. In other words, the
abnormal behaviour discontinued after receiving penicillin. 
Many mental health professionals then, assumed that comparable causes and cures might be
discovered for all psychological disorders. (Which is not the case)
Hippocrates Humoral theory:
The Humoral theory reflected the belief that normal functioning of the brain required a
balance of four bodily fluids or humors. Hippocrates assumed that normal brain functioning was
related to four bodily fluids or humors: blood, black bile, yellow bile, and phlegm.
Blood- came from the heart
Black bile- from the spleen
Phlegm- from the brain
Yellow bile- from the liver.
Normal functioning would be affected when there was an
imbalance in these fluids. as demonstrated below:

 
Black bile was thought to cause melancholia (depression). In fact, the term
melancholer, which means “black bile,” is still used today in its derivative form melancholy to
refer to aspects of depression. The humoral theory was, perhaps, the first example of associating
psychological disorders with a “chemical imbalance,” an approach that is widespread today.
 
How imbalance of the humors (fluids) were treated: Bloodletting and induced vomiting 
Most importantly, it linked the abnormal behavior through the understanding of chemical
imbalances in the body, which foreshadowed modern views regarding the biological approach
3. The Psychological Tradition 
In the psychological tradition, abnormal behavior is attributed to faulty
psychological development & to social context. Psychological approaches
use psychosocial treatments, beginning with moral therapy and including
modern psychotherapy. Lets recap Freud's Psychoanalytic approach: 
Psychoanlaytic theory
Freud's psychoanalytic model, the most comprehensive theory yet constructed on the
development and structure of our personalities. He also speculated on where this development
could go wrong and produce psychological disorders. Although many of Freud’s views changed
over time, the basic principles of mental functioning that he originally proposed remained
constant through his writings and are still applied by psychoanalysts today.
 Brief outline:
(1) The structure of the mind and the distinct functions of
personality that sometimes clash with one another;
Id -Overriding goal of maximizing pleasure and eliminating any
associated tension or conflicts. The goal of pleasure, which is
particularly prominent in childhood, often conflicts with social rules
and regulations
Ego-The part of our mind that ensures that we act realistically is called the ego, and it operates
according to the reality principle
Superego-represents the moral principles instilled in us by our parents and our culture. It is the
voice within us that nags at us when we know we’re doing something wrong.
(2) The stages of psychosexual development 
Freud hypothesized that if we did not receive appropriate gratification
during a specific stage or if a specific stage left a particularly strong
impression (which he termed fixation), an individual’s personality
would reflect the stage throughout adult life.
Fixation at the oral stage might result in excessive thumb sucking and
emphasis on oral stimulation through eating, chewing pencils,
or smoking.
(3) The defense mechanisms with which the mind defends itself
from these clashes, or conflicts
Our ego strives to satisfy the id's desires in realistic and socially
appropriate ways. It weighs the costs and benefits of an action before
deciding to act upon or abandon impulses.
Abnormal behavior develops when the ego is deficient in regulating
such functions as delaying and controlling impulses or in marshaling
appropriate normal defenses to strong internal conflicts.
You have covered Freud's psychoanalytical approach in first year so
this is more of a recap. Lets zoom in on "Ego defence mechanisms" 
Below are some mature ego defense mechanisms:
Defence Definition
Mechanism
Example
 Suppression Voluntarily pushing uncomfortable ideas or A student consciously chooses not to
feelings out of the conscious mind think about upcoming exams until a few
days prior to the exams

Altruism Negative feelings about oneself are alleviated by A mafia boss makes a large donation to
helping other people charity

Sublimation Replacing a socially unacceptable desire with an A man who has violent thoughts decides
action that is similar, but is socially acceptable to pursue a career as a butcher

Humour Focusing on the humorous aspect of an A nervous patient jokes about an

uncomfortable or adverse situation upcoming operation

 
Choose one of the defense mechanisms mentioned in the table and describe it in your own
words. How do you understand it?  Provide an example if you can think of one: 
 
Comments Section

End of lesson

Week 2: Mood disorders

This week we move onto mood disorders. We will cover mood disorders for 2 weeks
starting with Bipolar disorders. These include: .
Bipolar 1
Bipolar 2
Cyclothymia
Specifiers:
Rapid cycling bipolar
Bipolar with mixed features
 Lesson Outcomes:
           1. Define mood disorders
           2. Understand the difference between Bipolar l & ll, and cyclothymic disorders
           3. Understand the causes/aetiology of Bipolar disorders
           4. Know the different approaches in treating Bipolar disorders
Prescribed Readings:  Prescribed textbook: Chapter 7 Mood disorders
What is a mood disorder? 
Mood disorders are a group of disorders involving severe and enduring disturbances in
emotionality ranging from elation to severe depression.
Below you'll find some good introductory videos on mood disorders. Enjoy!

Bipolar disorders
The name "bipolar" helps describe what the disorder is all about. The term bipolar means “two
poles,” signifying the polar opposites of mania and depression. 

We also call this a "spectrum" with two extreme points. On the one extreme we find depression
and the other mania which is extreme elation.

Bipolar 1 disorder
Bipolar I disorder is defined by manic episodes or mixed manic episodes that last for at least 7
days (nearly every day for most of the day) or by manic symptoms that are so severe that the
person needs immediate medical care. Usually, depressive episodes occur as well, typically
lasting at least 2 weeks. More severe symptoms, than Bipolar 2, as it disrupts daily life.
 More severe symptoms include risky behaviours such as excessive
gambling and hypersexuality (sex addiction) 
So what is a manic episode?  
A manic episode is a period of abnormally elevated or irritable mood that may include:
Inflated self-esteem
Decreased need for sleep
Pressured speech/talk
Flight of ideas, agitation 
Self-destructive behaviour
May be accompanied by psychotic symptoms.

What is a mixed manic episode?

Mixed episodes are defined by symptoms of mania and depression that occur at the same
time . Mania with mixed features usually involves irritability, high energy, racing thoughts and
speech, and overactivity or agitation.
Dsm 5 criteria for Bipolar 1 disorder
A.    Criteria have been met for at least one manic episode 
B.    The occurrence of the manic and major depressive episode(s) is not better explained by
schizoaffective disorder, schizophrenia,    schizophreniform   disorder, delusional
disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Bipolar 2 disorder
It is the occurrence of hypomanic episodes, frequently alternating with major depressive
episodes. Bipolar II disorder has a greater tendency of recurrent cycles of mood disturbance.
What is a Hypomanic episode?
Once again, the origin of the word helps to explain what it's
about. Hypo means ‘below’; thus the episode is below the level of a
manic episode.
DSM-5 defines a hypomanic episode, as a less severe version of a manic episode that
does not cause marked impairment in social or occupational functioning and might last
only four days rather than a full week.  This is without the occurrence of psychotic
symptoms or the need for hospitalisation.
They may also occur during the course of bipolar I disorder.
DSM 5 criteria-Bipolar ll
 For the diagnosis of Bipolar II, it is necessary to meet the following criteria for
a current or past hypomanic episode AND the criteria for a current or past
Major Depressive Episode. 
A. A distinct period of persistently elevated, expansive or irritable mood,
lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
B. Criterion B the same as for mania – DIG FAST
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic
of the person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The mood disturbance not severe enough to cause marked impairment in social or
occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
Below is mnemonic device called, "DIG FAST" is a that can be used to remember the main symptoms of a
manic episode.
This is a very helpful aid for clinicians in remembering the symptoms of a manic episode. 

Case study: Billy

Before Billy reached the ward, you could hear him laughing and carrying on in a
deep voice; it sounded as if he was having a wonderful time. As the nurse brought
Billy down the hall to introduce him to the staff, he spied the Ping-Pong table. Loudly, he
exclaimed, “Ping-Pong! I love Ping-Pong! I have only played twice, but that is what I am going
to do while I am here; I am going to become the world’s greatest Ping-Pong player! And that
table is gorgeous! I am going to start work on that table immediately and make it the finest
Ping-Pong table in the world. I am going to sand it down, take it apart, and rebuild it until it
gleams and every angle is perfect!” The previous week, Billy had emptied his bank account,
taken his credit cards and those of his elderly parents with whom he was living, and bought
every piece of fancy stereo equipment he could find. He thought that he would set up the best
sound studio in the city and make millions of dollars by renting it to people who would come
from far and wide. This episode had precipitated his admission to the hospital.
Is this more characteristic of Bipolar 1 or 2? Why?
Comments Section
Answer

I will provide the correct answer and reasons before the next lesson so look out for it 

Cyclothymia
Specifiers
Causes/ Aetiology
Treatment

Key Terms
Mania/manic Period of abnormally excessive elation, euphoria, or irritability
associated with increased goal-directed activity, inflated self-esteem, decreased
need for sleep and rapid thinking and communication, often accompanied by
psychotic features lasting at least one week, unless successfully treated.
 
Hypomania/Hypomanic  Attenuated (weakened/reduced) form of mania, with similar, but less
severe symptoms and less disruption, occurring for at least four days without the occurrence of
psychotic symptoms or the need for hospitalisation.
End of lesson

PAGE GUIDE:
Below is a guide to the pages that you're required to read for each week. Remember that any additional readings will be attached to the
lesson

Unit 1:  Mood Disorders

Week 2: Bipolar disorders
pp.250-255 & pp.268-303
Week 3: Depressive disorders   
pp.256-268
Unit 2:  Anxiety Disorders, Schizophrenia and Eating Disorders
Week 4: Anxiety disorders part 1
pp.156-187
Week 5: Anxiety disorders part 2
pp.188-205
Week 6: Schizophrenia and other Psychotic disorders
pp.546-563
Week 7: Schizophrenia and other Psychotic disorders
pp. 564-585
Week 8: Eating disorder
pp.316-334
Unit 3:  Personality Disorders
Week 9: Personality disorders Cluster A
pp.508-521
Week 10: Personality disorders Cluster B
pp.522-536
Week 11: Personality Disorders Cluster C
pp. 537-542
Unit 4:  Childhood Disorders
Week 12: Autism
pp.590-592 & 605-612
Week 13: ADD/ADHD
pp. 593-600
Week 14: Conduct disorders: p503

Week 3: Depressive Disorders

 This week, we keep our focus on mood disorders but we turn our attention to Depressive disorders. We
will cover the following in today's lesson:
# Major Depressive Disorder
# Persistent Depressive Disorder (previously known as dysthymia)
# Premenstrual Dysphoric disorder
# Seasonal Affective Disorder
# Mood Dysregulation Disorder
Before we start, take a look at this introductory video briefly describing the different types of depressive
disorders:
Learning outcomes:
Define & understand MDD, PDD, PMDD,SAD,DMDD
Understand the specifiers associated with depressive disorders
Understand the duration and onset of depressive disorders
Describe first-line treatment for depressive disorders
Onset and duration
  The mean age of onset for major depressive disorder is 30 years.

Research from South Africa reveals a mean age of onset of 25.8 years for the total sample (26 years for
females and 25.6 for males). This finding is in line with the median age-of-onset distributions in international
studies
The length of depressive episodes is variable, with some lasting as little as two weeks; in more severe cases, an
episode might last for several years, with the typical duration of the first episode being two to nine months if
untreated
Occasionally, however, episodes might not entirely clear up, leaving some residual symptoms. In this case, the
likelihood of a subsequent episode with another incomplete recovery is much higher. Awareness of this
increased likelihood is important to treatment planning, because treatment should be continued much longer
in these cases.
Major depressive disorder (MDD)
  Depression is the leading cause of disability worldwide, it affects more than 280 million people
worldwide – the majority of them women, young people and the elderly. (WHO,2021)
Lets start with Major Depressive disorder:
Major depressive disorder is a mood disorder involving one or more major depressive
episodes.
It can be described as a single or recurrent episode. (Important terminology to remember)
Single, as the name suggests, is a describing an individual who has only experienced one
episode. Recurrent indicates 2 or more episodes, separated by at least 2 months.
What is a Major Depressive episode? (MDE)
 A major depressive episode (MDE) is a period characterized by the symptoms of major depressive disorder.
These include:
 Depressed mood
 Loss of interest/pleasure
 Weight loss or gain (even when not trying)
 Insomnia or hypersomnia  (hypersomnia the opposite of insomnia, sleeping too much)
 Psychomotor agitation or retardation
 Fatigue
 Feeling worthless or excessive/inappropriate guilt
 Decreased concentration
 Thoughts of death/suicide
 Untreated, a Major Depressive Episode may last, on average, about 4 months. 
In addition to above: Must have all 4:
Cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning
Episode not attributable to physiological effects of a substance or another medical condition
Episode not better explained by another disorder
No history of manic or hypomanic episode
Persistent depressive disorder (PDD)
The name "persistent" helps you understand what the disorder is all about. It is milder & fewer depressive
symptoms that “persist” for much longer than a major depressive episode but is less severe. 
PDD is a serious disorder. It is not "minor" depression. 
PDD is defined as depressed mood that continues for at least two years, during which the patient cannot be
free of symptoms for more than two months at a time, even though they might not experience all of the
symptoms of a major depressive episode.
It differs from a major depressive disorder in the number of symptoms required, but mostly in the chronicity. It
is considered more severe in the sense that, patients with persistent depression present with higher rates of
comorbidity with other mental disorders, are less responsive to treatment and show a slower rate of
improvement over time. 
To understand it better and how it is set apart from MDD, take a look at this table of differences:
Major Depressive Disorder Persistent Depressive Disorder
(Dysthymia)
(MDD)
Symptoms in common Depressed mood
Disturbed sleep
Low energy/fatigue
Poor concentration
Indecisiveness
Symptoms specific to the disorder Anhedonia No history of mania
Psychomotor symptoms No major depressive disorder in
the first 2 years
Duration of symptoms required for 2 weeks 2 years
diagnosis
(1 year for adolescents and
children)
Number of checklist symptoms 5 or more At least 2
required for diagnosis

Double depression
People who suffer from both major depressive episodes and persistent
depression with fewer symptoms are said to have double depression. Typically, a few
depressive symptoms develop first, perhaps at an early age, and then one or more major
depressive episodes occur later only to revert to the underlying pattern of depression
once the major depressive episode has run its course.
This was evident in the case study in your textbook about Jaco. After about six months,
the major depressive episode resolved and Jaco returned  to his chronic but milder state
of depression. Jaco was suffering from double depression. 

Case study: Depressive disorders

 Alan is 70 years of age and lives with his wife Joan, also 70 years old. Both Alan and Joan retired
from work in their early 60’s due to increasing problems with health and mobility. Alan initially enjoyed
retirement and spent much of his time engaging in hobbies, such as reading, doing jigsaw puzzles, gardening,
and watching documentaries on his favourite topics. Alan and Joan also went on several international holidays
in the early years of retirement. However, due in part to further deterioration in his healthy and mobility, and in
part to financial resources, Alan and Joan are no longer able to go on holidays, even day trips are difficult. They
now live a very quiet life in relative solitude with few social connections. Due mainly to geographical distance,
Alan and Joan see their children and grandchildren only once or twice a year,
Five years ago, Alan began to experience poor mental health which has persisted to the present day. He reports
low mood and motivation, and a sense of apathy, most of the time on most days. He goes to bed early at night
and doesn’t rise until the late morning the following day, and sometimes not until the afternoon. Alan also
regularly overeats and consumes large amounts of junk food, and has gained a considerable amount of weight as
a result. Although Alan still engages in some of his hobbies, he does so in a somewhat robotic and habitual way
and reports not getting much enjoyment out of them. In the five years since these experiences and patterns
began, Alan has rarely been happy or cheerful; only very occasionally will he smile or laugh. During social
interactions he comes across as withdrawn and distant.
Joan has become increasingly worried about Alan over the years, but also frustrated and discontent. Although
Alan was happy and excited when his grandchildren were born, he now struggles to connect or engage with
them and usually prefers to sit in the background concentrating on the conversation.
Upon Joan’s insistence, Alan was recently assessed by a psychologist and was diagnosed with…
Which depressive disorder is being described here? Can you identify the relevant DSM-5 criteria to support
your answer?
Comments Section
I will post the answer before the next lesson so look out for it

Take a little break...

Specifiers for depressive disorders
 Remember last week we spoke about what a specifier is and which ones are used
specifically to describe bipolar disorders. Now lets look at the specifiers used to
describe depressive disorders.

Keep in mind: When diagnosing & planning treatment, coding is used. The presence of a specifier will affect
the code. 
Example: In this code, 296.24, the last digit of this code will indicate whether a specifier is present. You do not
need to know this. It is just to give you a visual picture of the importance of specifiers.
*Coding errors can result in medical errors & billing errors.
 

 Specifiers
1. Psychotic features specifier
Some patients in the midst of a major depressive (or manic) episode may
experience psychotic symptoms, specifically hallucinations and 
delusions  Patients may have somatic (physical) delusions, believing, for example, that their bodies are rotting
internally and deteriorating into nothingness
MDD with mood-incongruent psychotic features. You might hallucinate a
loved one, hear voices praising you, or smell something pleasant.
You might also believe someone is trying to chase you, kidnap you, or
control your thoughts.
2. Mixed features specifier
Predominantly depressive episodes that have several (at least three) symptoms of mania as
described above would meet this specifier.
Increased talkativeness and rapid speech, often characterized by frequent or sudden shifts in
topic. 

3. Catatonic features specifier

Is characterised by grossly disturbed motor behaviour. Most often, catatonia involves grossly decreased
movements with stupor.
A person does not speak or appears to be in a daze for a prolonged period. A person with
catatonic depression does not respond to what is    happening  around them and may be silent and
motionless.
4.Seasonal pattern specifier
This temporal specifier applies to recurrent major depressive disorder (and also to bipolar disorders). It
accompanies episodes that occur during certain seasons (for example, winter depression).
Changes in appetite; usually eating more, craving carbohydrates. Change in sleep; usually
sleeping too much. (In colder months)

More specifiers
Seasonal Affective Disorder (SAD)
Seasonal affective disorder occurs in climates where there is less sunlight at certain times of the year.
Symptoms include fatigue, depression, hopelessness and social withdrawal.
Treatment includes light therapy (phototherapy), talk therapy and medication.
 
 
 
 

Premenstrual Dysphoric disorder (PMDD)

Premenstrual dysphoric disorder  is a severe, sometimes disabling extension of
premenstrual syndrome (PMS).
Although PMS and PMDD both have physical and emotional symptoms, PMDD causes extreme mood shifts
that can disrupt daily life and damage relationships. Symptoms include mood disturbances such as:
Anger or irritability.
Feeling on edge, overwhelmed or tense.
Anxiety and panic attacks.
Depression and suicidal thoughts.
Difficulty concentrating.
Fatigue and low energy.
Food cravings, binge eating or changes in appetite.
Headaches. 
PMDD differ in a number of ways from the 20–40% of group of women who experience uncomfortable
premenstrual symptoms (PMS). PMS symptoms are not characterized by an impairment of functioning. PMDD
is more severe and impairs functioning. Example: Symptoms of PMDD is so severe that it affects your
ability to function at home, work and in relationships.

Disruptive mood dysregulation disorder (DMDD)

DMDD is a childhood disorder. The onset of symptoms must be before age 10. 
Condition in which a child has chronic negative moods such
as anger and irritability without any accompanying mania
Though these broader definitions of symptoms do display some similarities with more classic bipolar
disorder symptoms the danger is that these children are being misdiagnosed. In that case, the very potent
pharmacological treatments for bipolar disorder that are not without the risk of substantial side-effects would
pose more risks for these children than they would benefits.
It is  better to describe these children up to 12 years of age as suffering from a diagnosis termed disruptive
mood dysregulation disorder rather than have them continue to be mistakenly diagnosed with bipolar disorder
or perhaps conduct disorder. 
Treatment

Treatment
 

Pharmacological
ANTIDEPRESSANTS

The more commonly used medications are from the following classes:

●Selective serotonin reuptake inhibitors (SSRIs)

●Serotonin-norepinephrine reuptake inhibitors (SNRIs)

●Atypical antidepressants

●Serotonin modulators

Psychotherapy
 

Cognitive-behavioral therapy (CBT) – In CBT you work with a therapist to identify and reshape the thought
and behavior patterns that contribute to your depression.

●Interpersonal psychotherapy – In interpersonal psychotherapy, you focus on your relationships, the way
that you interact with other people in your life, and the different roles you play. Often you learn new ways to
interact that can help improve those relationships

●Family therapy – In family therapy, you attend therapy sessions along with your partner or family members
so that you can work together on the issues that are contributing to your depression.

●Psychodynamic psychotherapy – In psychodynamic therapy, you might explore childhood or historic life
events and work to reduce their influence by gaining insight into how they may be shaping your current
behavior.

Biological
 

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) can provide rapid, significant improvements in symptoms of severe
depression ECT:

It works to treat severe depression particularly when accompanied by detachment from reality

(psychosis), a desire to commit suicide or refusal to eat.

End of lesson 

Week 4: Anxiety disorders part 1

Anxiety Disorders
This week we move onto Anxiety disorders. We will focus on the following anxiety disorders this week:
Generalized anxiety disorder (GAD)
Panic disorder (PD)
Agoraphobia
Specific phobia
Social anxiety disorder (SAD)
Lesson Outcomes: 
   Know the basic definition of each anxiety disorder
   Identify anxiety disorders in case studies using knowledge of AD's
   Describe first-line treatment options for Anxiety Disorders 
 Understand differences between fear & anxiety
 Understand the relationship between PD & Agoraphobia
Prescribed Readings: 

 Prescribed textbook Chapter 5 pp.156-187

To start we will look at a "crash course" clip on anxiety disorders to set the tone for the
lesson which gives an overview of the various anxiety disorders, symptoms and causes:
Key terms
It is important to understand the difference between fear and anxiety when learning about
anxiety disorders.
Fear- Fear can be understood as our bodies response to a threatening or dangerous situation. It kicks us into
gear, often what we refer to as the "flight or fight response". In most cases fear is an emotional state that we
need in order to protect ourselves, even though it is not a pleasant emotion. 
Anxiety differs from fear, in that it is future-orientated. This means that the things that cause anxiety often have
not happened yet, and it is the thought of it happening that brings about the symptoms. In some ways, anxiety
can be considered as normal and necessary as the fear response, however it is far more likely to edge into the
dysfunctional. Dysfunctional anxiety, rather than mobilising the person into action like fear, can be crippling
and even prevent action from happening.
Normal anxiety around a big test turns into missing the test completely because of crippling anxiety. 
One way to understand anxiety is as a "false alarm", because many times anxiety is brought about by
generally harmless situations. 
 We'll cover the aetiology(causes) of anxiety disorders by using the Triple Vulnerability
Model. This applies to all anxiety disorders,

Triple Vulnerability Model: The three vulnerabilities that contribute to the development of
anxiety disorders. 
Generalised biological vulnerability. A tendency to be uptight or highly strung may be inherited. But
generalised biological vulnerability for anxiety is not sufficient to produce anxiety itself.
Generalised psychological vulnerability. You might also grow up believing the world is dangerous and out of
control and you might not be able to cope when things go wrong based on your early experiences.
Specific psychological vulnerability, in which you learn from early experience, such as being taught by your
parents, that some situations or objects are filled with danger (even if they really are not).
Possessing all 3, makes someone more vulnerable or increases the likelihood of developing an anxiety
disorder.
 Before we begin, here is a good introductory video on Generalized anxiety disorder (GAD):
Generalized anxiety disorder (GAD)
 Have you ever met someone who constantly worries about everything? They may be going through a
much greater struggle internally than most realise. Let's look at this through a therapeutic lens:
Think about it... Worrying is not always a bad thing. It can be motivating and constructive. It gets us moving
on important tasks that we may have put off for too long. It can also be a normal response to something
potentially dangerous. However, if you cannot stop cannot stop worrying, even if you know it is doing you no
good and probably making everyone else around you miserable, these features characterise Generalised
anxiety disorder (GAD).
 Generalized anxiety disorder(GAD) definition: Anxiety disorder characterised by intense,
uncontrollable, unfocused, chronic and continuous worry that is distressing and unproductive,
accompanied by physical symptoms of tenseness, irritability and restlessness.
How does it differ from normal anxiety? 
The DSM-5 criteria specify that excessive anxiety and worry – apprehensive expectation – must be present
more days than not for a period of at least six months.
It must also be difficult to control the worrying. Most of us worry for a time but can set the problem aside and
go on to another task.
Even if the looming challenge is significant, the worry ceases as soon as it is over. 
People with GAD mostly worry about minor, everyday life events, a characteristic that distinguishes GAD
from other anxiety disorders.
*In one study, When asked, ‘Do you worry excessively about minor things?’ One hundred percent of
individuals with GAD respond ‘yes’, compared with approximately 50% of individuals whose anxiety disorder
falls within other categories. 
 Whereas panic is associated with autonomic arousal, presumably as a result of a sympathetic
nervous system surge (for instance, increased heart rate, palpitations, perspiration and
trembling), GAD is characterised by muscle tension, headaches and susceptibility to fatigue.
Patients also display difficulty sleeping
 Take a look at the tabulated differences below: 

 
Treatment of Generalized anxiety disorder (GAD)
Psychotherapy:
Cognitive therapy- The patient learns to use cognitive therapy (CT) and other coping
techniques to counteract and control the worry process.
Mindfulness- focusing on the acceptance rather than the avoidance of distressing
thoughts and feelings in addition to CT. 
Pharmacological:
Benzodiazepines for the short-term relief of anxiety associated with a temporary crisis or
stressful event, such as a family problem 
Beta-antagonists (‘beta blockers’) are useful for acute symptomatic relief.
Antidepressants - for long-term management. Here, there is strong evidence for the usefulness of
antidepressants. 
*Both therapeutic and pharmacological treatments have proven reasonably effective for the treatment of
GAD.  
 
 
 Next up... We'll explore Panic disorder (PD)  & Agoraphobia:
In order to better understand what a panic attack is and the effects on the individual, we will look
at a clip on panic disorder:
Panic disorder (PD) and Agoraphobia
Panic disorder consists of recurrent unexpected panic attacks accompanied by concern about future attacks
and/or a lifestyle change to avoid future attacks.
 What is a panic attack?
Panic attack-  a panic attack is defined as an abrupt experience of intense fear or
acute discomfort, accompanied by predictable physical symptoms including
breathing changes, palpitations, tremors, chills and flushing. 
Patients with panic disorder (PD) experience severe, unexpected panic
attacks. With time, they become anxious about experiencing a panic attack and tend
to avoid situations that may possibly provoke an attack. This tendency is referred to
as anticipatory anxiety, or ‘anxiety about anxiety’.
*Many patients with PD, also experience symptoms of a closely related disorder
– Agoraphobia. 
When associated with PD, agoraphobia more often than not involves the fear of experiencing a panic attack.
However, fear of other symptoms also occurs, for example loss of bladder control or vomiting. In severe cases,
people with agoraphobia are unable to leave the house, sometimes for years on end, as in the example of Frieda.
Panic attack symptoms: 
•Chest pain and discomfort
•Chills or feeling unusually hot
•Derealization, or feeling detached
•Dizziness and feeling lightheaded
•Experiencing a strong, sudden fear of dying
•Fear of losing control or feeling as if a person is "going crazy"
•Feelings of choking
•Heart palpitations, irregular heartbeat, or rapid heart rate
•Shaking or trembling
 Sweating
Trouble breathing, feeling as if a person is smothering

Agoraphobia
Agoraphobia is an anxiety disorder characterised by anxiety about being in
places or situations from which escape might be difficult in the event of
panic symptoms or other unpleasant physical symptoms (e.g., incontinence)
 *One of the most stressful places for individuals with agoraphobia today is
the shopping mall, 
Some patients do not avoid agoraphobic situations but endure them with ‘intense dread’.
For example, people who have to go to work each day or, perhaps, travel as part of their job, will suffer untold
agonies of anxiety and panic simply to achieve their goals. Thus, DSM-5 notes that agoraphobia may be
characterised either by avoiding the situations or by enduring them with intense fear and anxiety.
Most patients with PD and agoraphobic avoidance also display another cluster of avoidant behaviours that we
call interoceptive avoidance,
Interoceptive avoidance: Is the avoidance of internal physical sensations  These behaviours involve removing
oneself from situations or activities that might produce the physiological arousal that somehow resembles the
beginnings of a panic attack. Some patients might avoid exercise because it produces increased cardiovascular
activity or faster respiration, which reminds them of panic attacks and makes them think one might be
beginning. 
SA research findings
More than 75% of those who suffer from agoraphobia are women
It appears the most logical explanation for this female preponderance is cultural
It is more socially acceptable for women to report fear, whereas men are expected to be stronger, braver and to
‘tough it out’. Women also tend to demonstrate agoraphobic avoidance more frequently and experience it more
intensely.
What happens to men who have severe unexpected panic attacks?
 Is cultural disapproval of fear in men so strong that most of them simply
endure panic? The answer seems to be ‘no’. A large proportion of males with
unexpected panic attacks cope in a culturally acceptable way: they get
drunk. Dependence is a common outcome and the alcohol problem not infrequently masks PD and
agoraphobia. In such cases, treatment for both alcohol dependence and PD with agoraphobia is
necessary.
  In a case depicting a 34-year-old taxi driver with PD and agoraphobia, almost none of the traditional
healers believed that he had a mental illness, even though 16% reported that he experienced stress. Sixty
percent believed that he had a physical illness, mostly HIV infection, heart disease or hypertension. 
Treatment of Agoraphobia
Cognitive-behavioral therapy: If untreated, agoraphobia usually waxes and wanes
in severity. Agoraphobia may disappear without formal treatment, possibly because
some affected people conduct their own form of exposure therapy. But if
agoraphobia interferes with functioning, treatment is needed.
Cognitive-behavioral therapy is effective for agoraphobia. Cognitive-behavioral
therapy involves teaching patients to recognize and control their distorted thinking and false beliefs as well as
instructing them on exposure therapy.
Selective serotonin reuptake inhibitor (SSRI)
  Many patients with agoraphobia benefit from drug therapy with an SSRI.
Treatment for Panic disorder
Panic control treatment (PCT)
Psychological treatments have recently been developed that treat PD directly even in the absence of
agoraphobia concentrates on exposing patients with PD to the cluster of interoceptive (physical) sensations that
remind them of their panic attacks. The therapist attempts to create ‘mini’ panic attacks in the office by having
the patients exercise to elevate their heart rates or perhaps by spinning them in a chair to make them dizzy. A
variety of exercises have been developed for this purpose.
Cognitive therapy
Patients also receive CT. Basic attitudes and perceptions concerning the dangerousness of the feared but
objectively harmless situations are identified and modified. Basic attitudes and perceptions concerning the
dangerousness of the feared but objectively harmless situations are identified and modified.
Pharmacological 
Antidepressants
 Let's move on to Specific phobias, although it may seem like everyone has a phobia about
something, people suffering from a Specific phobia is far more severe and debilitating. Let's
discuss: 
 A Specific phobia is an irrational (unreasonable) fear of a specific object or situation that markedly interferes
with an individual’s ability to function. 
The major characteristic of phobias is the DSM-5 criterion of:
 Marked fear and anxiety about a specific object or situation. 
 Recognising that fear and anxiety were out of proportion to any actual danger.
 Going to considerable lengths to avoid a situation in which their phobic
response might occur.
DSM 5 criteria has also grouped together specific types of phobias:
1. Animal
2. Natural environment (e.g. heights, storms, water)
3. Blood-injection-injury
4. Situational (e.g. planes, elevators, enclosed places)
5. Other (e.g. phobic avoidance of situations that may lead to choking, vomiting or contracting an illness; or, in
children, avoidance of loud sounds or costumed characters)

True & false alarms

True and false alarms describe two different ways that phobias may develop:
A person with claustrophobia may recently have had a harrowing experience trapped in a lift.
These are examples of phobias acquired by direct experience, where real danger or pain results
and raises a true alarm. The robustness of fear conditioning sees to its maintenance. This is one
way of developing a phobia. There are other ways too:
    Experiencing a false alarm (panic attack) in a specific situation, observing someone else
experience severe fear (vicarious experience), or, under the right conditions, being told about
danger.
Treatment for Specific phobias
Exposure-based approaches-patients who expose themselves gradually to what they fear
must be under therapeutic supervision.
Does pharmacotherapy play a role in the management of phobias? The answer is not clear.
Anxiolytic (anti-anxiety medication) agents are useful to acutely contain overwhelming distress.
Anxiolytics (eg. benzodiazepines or antidepressants) may also be useful as an emergency contingency measure,
for example when a person with a phobia for flying must travel on an aero- plane. In this regard, beta-
antagonists may also be useful.
 The last anxiety disorder that we will cover today is Social Anxiety Disorder (also known as
social phobia): Social Anxiety Disorder
Social anxiety disorder (SAD) is an extreme, enduring, irrational fear and avoidance
of social or performance situations.
The most common type is performance anxiety, to which most people can relate, is public
speaking. Physical reactions include blushing, sweating, trembling and, for males, urinating in a public toilet
(‘bashful bladder’ or paruresis).  
This is truly "SAD" because the people have no difficulty eating, writing or urinating in private. Only when
others are watching does the behaviour deteriorate. Unlike other anxiety disorders for which females
predominate, the sex ratio for SAD is almost 50:50. 
Treatment for SAD
Psychotherapy:
Cognitive behaviour therapy- people learn different ways of reacting to thoughts and feelings, and they
learn to engage in different behaviors that result in decreased fear. CBT also helps people learn and
practice social skills when there is a deficit.
Exposure therapy (within CBT)- Exposure therapy is where people face a feared social situation until their
anxiety decreases or the anxiety-related expectancies are disrupted. It's a well-researched treatment for
anxiety disorders and is usually done within cognitive behaviour therapy, which also addresses the underlying
unhelpful thoughts.
Family therapy- family therapy can limit the prevalence of anxiety in children of parents with anxiety.
Pharmacotherapy:
SSRI's (selective serotonin and reuptake inhibitor)
 SSRIs treat depression by increasing levels of serotonin in the brain.
SNRI's (serotonin-norepinephrine reuptake inhibitor)
 SNRIs work by blocking the reabsorption (or reuptake) of serotonin
and norepinephrine back into the nerve cells that released them, which increases the levels of active
neurotransmitters in the brain.
Both medication and therapy have been shown effective in treating social anxiety disorder.
CASE STUDY: ANXIETY DISORDERS Case study: Sue
•Sue, 30 years old, recently left the RAN after ten years of active service
    I remember my first panic attack like it was yesterday. I guess I’d always been an anxious type, but
this was like nothing I’d ever experienced. I was at a football game about six years ago, big crowd, St Kilda
getting hammered by the Pies. I think I was a bit edgy – I’ve never liked being hemmed in, stuck somewhere I
couldn’t get out of easily. Then suddenly this thing just took over me. I got these pains in my chest and I
couldn’t breathe. I was sure I was having a heart attack and was going to die. I was thinking about my daughter
– she was two at the time – and thinking it can’t end like this, I’ve got to see her again. I was sweating, heart
racing, trembling….I had to get out of there. I managed to push my way through the crowd and I saw a St
John’s ambo. What a relief. He helped me to the ambulance and they took me straight to hospital, wired me up
to all sorts of machines and then…..they told me there was nothing wrong, that it was all in my head. All in my
head? Those pains were real, I can tell you. All they said was that I’d had a panic attack. I was so happy to be
alive, I didn’t ask them more about it. I just wanted to get home. But since then, my life has changed. I only
went back to sea once (my skills are needed more on shore than at sea, thank God) but that was terrifying. I
spent the whole time worrying about whether I’d have an attack while we were far from land and I avoided
being below decks whenever I could. Since the first time, I’ve had about a dozen attacks and each one was
terrifying. I’ve stopped going anywhere that I can’t get out of easily in case I have another one. No shopping
centres. No cinemas. No football games. No public transport. No crowded places. I left the navy because I
couldn’t face going to sea again.
Discussion questions
1. Does Sue suffer from a Panic disorder(PD)? If so, how do you know that?
 2. What other disorder matches Sue's behaviour? & Why? [Optional question, you do not have to
answer it]
Comments
 Answer: Well done to all who participated this week! A lot fewer participants! Thank you for taking the time
to engage with the case study. This one was slightly easier than week 3’s case study.
Sue meets the criteria for panic disorder. To meet the criteria for a formal clinical diagnosis of panic disorder,
the attacks need to have been recurrent (repeated) and unexpected. Both of which she has experienced.
Continuous worry and concern that another attack would occur meets the DSM 5 criteria. 4 or more symptoms
are necessary. She experienced chest pains, fear of dying, pounding heart, & trembling.
After experiencing her first panic attack, she sought to avoid places where she felt that she could not easily
escape from. She stated that she stopped going to cinemas, football games, taking public transport etc. This is
characteristic of agoraphobia. In order for her to obtain a diagnosis, she would need to be experiencing
symptoms for at least 6 months. In the case study she stated that the first panic attack was 6 years ago and since
then she’s been showing agoraphobic avoidance. She meets the criteria for Agoraphobia.
Feedback:
Everyone was able to identify the disorders present in Sue and most linked the symptoms well.
Remember, when answering the question, link the criteria/ symptoms to the case study. Do not just state all the
information you know. Be specific. This way it is clear to see whether you understand and can apply the
knowledge you’ve learned.
End of lesson

Week 5: Anxiety disorders part 2

 This week we continue exploring anxiety disorders. We will cover the following anxiety disorders:
Obsessive Compulsive disorder (OCD)
Hoarding disorder
Trichotillomania & Excoriation 
Post traumatic stress disorder (PTSD)
Body dysmorphic disorder (BDD)
Outcomes:

 Define & describe each AD

 Define obsessions and compulsions and discuss how they work together

 Know co-occurring disorders

 Know first-line treatment available for AD's

What is Obsessive Compulsive disorder?

 OCD is one of the most misunderstood disorders. TV/movie characters with OCD or implied OCD
often only portray the behavioural side of the disorder and miss the obsessions or fear and
distress that come with these compulsions. It is often portrayed through humor which could not
be further from the truth.
 Obsessive compulsive disorders consists of 2 parts:
1. Obsessions – intrusive thoughts (unwanted thoughts) that are repetitive. These unwanted thoughts and
images invade their minds and are very difficult to ignore or control. 
: Those with hand-washing compulsions are obsessed with fear of contamination  [intrusive thought]
2. Compulsions – a compulsion is a strong urge to do something you find difficult to control. When you
carry out the compulsion, this is the behaviour (rituals) that is extremely hard to resist. 
:  often wash their hands repeatedly until they are chapped, raw and sometimes even bleeding. They
may also ritualize the  process, for example, by washing each finger individually and in a specific order.
[compulsion]
 So what happens when someone does not carry out the behaviour that their mind is telling them to do?
Not carrying out a compulsion (ritual behaviour) can leads to intense anxiety and panic, even experiencing a
panic attack.
People can feel like they are going to die if they do not carry out the behaviour (ritual).
4 subtypes of OCD: 
Although these subtypes have not been made official, research has generally found that OCD can
be categorized OCD into 4 types.
 1. Symmetry obsessions account for most obsessions (26.7%),
2. ‘forbidden thoughts or actions’ (21%), 
3. cleaning and contamination (15.9%), and 
4. hoarding (15.4%)
Below is a video of a teen sharing their experience of OCD. It's helpful because it gives you a deeper
understanding of what you have just been reading: 
Case study: Alison
Watch the case study clip on Alison, a 14 year old living with OCD. She talks about "Pure 0" In your own
words, What does she mean by that? 
Comments
Answer Thank you to those who took the time to answer the question this week!  It may seem like a simple
answer, but the point here is to understand the different ways that people experience OCD.
With Pure O, which stands for “purely obsessional”, compulsions are done mentally. People observing may
feel that these individuals only experience obsessions, but
mental rituals are occurring under the surface. “No one sees it but it’s definitely still there.” “Instead of tapping
the wall 10 times, I count in my head 10 times.” Her obsessions interfere with her daily functioning as she has
mentioned she spends on average 3 hours a day doing compulsions & experiencing anxiety. She also used many
sick days when it became too much for her.
Though “Pure O” is not an official clinical/medical name, but is a commonly used term to refer to a form of
OCD. Technically, Pure O & OCD are not different. There is only one type of OCD, according to the DSM
5. People with Pure O OCD don’t always have the “typical” OCD symptoms that you see portrayed in the
movies or TV. Pure O is sometimes mistakenly seen as a “less severe” form of OCD. For those who experience
symptoms of this disorder, the characteristic intrusive thoughts can be very disruptive and distressing as we can
see here with Alison.
No feedback this week! Everyone understood the idea of “Pure O” & how distressing it still is even without the
outward behavioural rituals.
 Now lets continue with treatment for OCD...
Treatment for OCD
Pharmacology
Tricyclic antidepressant -The most effective seem to be those that specifically inhibit the reuptake of
serotonin, such as the tricyclic antidepressant, clomipramine (Anafranil) – a potent inhibitor of serotonin
reuptake,
SSRI's (example: fluoxetine – Prozac), which benefit up to 60% of patients with OCD.  Relapse often occurs
when the medication is discontinued,  
Psychotherapy
Exposure and ritual prevention (ERP) most effective psychological treatment approach, a process whereby
the rituals are actively prevented and the patient is systematically and gradually exposed to the feared thoughts
or situations. 
Body Dysmorphic disorder
 Did you ever wish you could change part of your appearance? Maybe the size of your nose or lips? This
is how it begins with individuals with BDD. However, it spirals into an
unhealthy & dangerous obsession that impairs normal functioning.
The word dysmorphia stems from the word "Dysmorphophobia" which means  "fear of
ugliness." This gives us some insight into what the disorder is all about. 
It is a preoccupation with some imagined defect in appearance, or overvaluation of a minor
imperfection, by someone who actually looks reasonably normal to others. The disorder has been referred to as
‘imagined ugliness’ OCD often co-occurs with BDD.
OCD & BDD share many similarities: People with BDD complain of persistent, intrusive, and horrible
thoughts about their appearance, and They engage in such compulsive behaviours as repeatedly looking in
mirrors to check their physical features. Same age of onset and run the same course
(childhood/adolescence)
 Many people with this disorder become fixated on mirrors. They often check their presumed ugly
feature to see whether any change has taken place. Others avoid mirrors to an almost phobic extent. Quite
understandably, suicidal ideation, suicide attempts and suicide itself are typical consequences of this disorder.
This disorder can cause considerable disruption in the patient’s life. Many patients with severe cases become
housebound for fear of showing themselves to other people.
Below are 2 individuals, singer & actor, who struggle with BDD:
“I’ve never felt comfortable in really tiny clothes,” she said, in reference to her
experience performing with a competitive dance company. “I was always
worried about my appearance. That was the peak of my body dysmorphia. I
couldn’t look in the mirror at all.”
   "Body dysmorphia, overall tremendous anxiety. I suppose it's because of these
tremendous insecurities that I never found a way to become egotistical. I don’t
have a six-pack and I hate going to the gym. I’ve been like that my whole life. I never want to take my shirt
off.” 
Treatment for BDD
 Pharmacology
Selective serotonin reuptake inhibitors (SSRI's) 
Psychological
Cognitive behavioral therapy (CBT)- Exposure and response prevention 
*CBT tends to produce better and longer-lasting outcomes compared to medication alone
Hoarding disorder
Definition: It is a persistent difficulty discarding or parting with possessions because of a perceived need to
save them. 
The three major characteristics of hoarding are:
1. Excessive acquisition of things
2. Difficulty discarding anything 
3. Living with excessive clutter 
It is extremely hard to throw anything away because :
1. Everything has either some potential use 
2. Holds sentimental value in their minds 
3. It becomes an extension of their own identity 
*Most of these individuals do not consider that they have a problem until family members or authorities insist
that they seek help. 
Example of a severe case of hoarding:
 One patient’s house and yard was condemned, because junk was piled so high it was both unsightly and a fire
hazard. Among her hoard was a 20-year collection of used sanitary towels! 
 SA study:
In a sample of 15 patients with hoarding disorder in Cape Town, South Africa, the most common motive for
hoarding was the fear of discarding items of practical value.  Six subjects reported little or no control over their
hoarding, but only one subject saw her symptoms as an ‘illness’ warranting treatment.
 The average age when these people come for treatment is approximately 50, after many years of hoarding 
Animal hoarding
People who hoard animals comprise a special group that is now being investigated more closely. Occasionally,
articles appear in newspapers describing homes occupied by one owner, usually a middle-aged or elderly
woman, and 30 or more animals, often cats.
Occasionally some of them will be dead, either lying on the floor out in the open or stored in the freezer. In
addition to owning an unusually large number of animals, animal hoarders are characterised by the failure or
inability to care for the animals or provide suitable living quarters.
Below is a good interview with a psychologist who specialises in treating individuals with Hoarding disorders:
Trichotillomania (Hair Pulling Disorder) & Excoriation (Skin Picking Disorder)
Trichotillomania: The urge to pull out one’s own hair from anywhere on the body, including the scalp,
eyebrows and arms. This behaviour results in noticeable hair loss, distress and
significant social impairments. 
Trichotillomania can be related to emotions:
 Negative emotions. For many people with trichotillomania, hair pulling is a
way of dealing with negative or uncomfortable feelings, such as stress,
anxiety, tension, boredom, loneliness, fatigue or frustration.
 Positive feelings. People with trichotillomania often find that pulling out hair feels satisfying and
provides a measure of relief. As a result, they continue to pull their hair to maintain these positive
feelings.
Excoriation disorder
Is characterised by repetitive and compulsive picking of the skin, leading to tissue damage.
Noticeable damage to skin can occur, sometimes requiring medical attention. 
In one case a young woman spent two to three hours a day picking her skin, resulting in
numerous scabs, scars and open wounds on her face. As a result, she would often be late for work or unable to
work if the open wounds were too bad. She had not socialised with friends for over a year.
*Excoriation is also largely a female disorder.
In a South African study, they found that: Dysthymic disorder was more common in those with skin-
picking disorder, while there was a 
Higher dissociation (feeling disconnected from yourself & those around you) as well as a trend
towards avoidant personality disorder in those with trichotillomania.
The difference in dysthymia was interpreted as possible different thresholds for verbalising distress, while
higher dissociation in trichotillomania confirmed the literature suggesting dissociation as a characteristic feature
of trichotillomania.
Post Traumatic Stress disorder
Post-traumatic Stress Disorder (PTSD) is a severe anxiety disorder that can occur in people
who have been exposed to traumatic life events.
These traumatic life events include: childhood or domestic abuse, sexual abuse, serious
accidents, impact of witnessing trauma such as war veterans.
*For South Africans, most traumatic events are related to crime, violence and car accidents.
The DSM 5 has many categories for diagnosing PTSD. It can be a bit much to learn all of them.  You do not
need to memorise all but, know what the 4 symptom categories are. See table below:

There are 4 symptom categories:

1. Intrusion, 2. Avoidance, 3. Negative changes in thoughts and mood,
and 4. changes in Arousal.
Treatment for PTSD
Pharmacology
SSRIs: Antidepressants such as SSRI's are effective for anxiety disorders in general have been shown to be
helpful for PTSD, perhaps because they relieve the severe anxiety and panic attacks so prominent in this
disorder.
Psychological: From the psychological point of view, most clinicians agree that victims of PTSD should face
the original trauma, process the intense emotions and develop effective coping procedures in order to overcome
the debilitating effects of the disorder 
Psychoanalytic therapy: Reliving emotional trauma to relieve emotional suffering is called catharsis.
Arranging the re-exposure so that it will be therapeutic rather than a second, reinforcing trauma.
Cognitive therapy: Cognitive therapy to correct negative assumptions about the trauma – such as blaming
oneself in some way, feeling guilty, or both – is often part of treatment
End of lesson

Week 6: Schizophrenia & other psychotic disorders (Part 1)

Schizophrenia & other Psychotic Disorders
This week we move onto Schizophrenia and other related disorders. We will focus on the following, with a greater
focus on Schizophrenia:
Schizophrenia, Schizophreniform, Schizoaffective disorder, Delusional disorder, Shared psychotic disorder
(folie à deux), Brief psychotic disorder
Outcomes: Know key terms: psychosis, associative splitting, delusions, hallucinations, Define Schizophrenia & related
disorders, Understand positive, negative & disorganized speech symptoms

Before we describe schizophrenia, it is important to understand these key terms as it forms the basis of the
psychotic disorders which we are covering for the next 2 weeks.
Key terms
Psychosis: A psychosis is a break  or split from reality.
This split from reality is  characterised by:
Hallucinations:  sensory experiences that occur within the absence of an actual stimulus. A
person having an auditory hallucination may hear their mother yelling at them when their
mother isn’t around. Someone having a visual hallucination may see something which is not present.and/or,
Delusions: The person experiencing psychosis may also have thoughts that are contrary to actual evidence.  
*So, when you enter into a psychosis, you cross over from seeing things in realistic way to seeing & or hearing
things that others do not. (Unless diagnosed with a shared psychotic disorder)

Associative splitting : Separation among basic functions of human personality (for example,
cognition, emotion and perception)
A disturbance in which thoughts become disjointed to such an extent as to no longer be unified,
complete, or coherent. The mind is fragmented, or compartmentalized. 
Some schizophrenic individuals might laugh at a funeral. This reflects disconnect between
perception & emotions. 
*Remember that this disconnect occurs as an unconscious defense. It becomes too much to deal with the harsh
reality & through splitting it serves as a protection from that reality.
*In order to better understand this, check out the video later in the lesson. 
Prevalence & Onset
Worldwide, the lifetime prevalence rate of schizophrenia is roughly equivalent for
men and women, and it is estimated to be 0.2% to 1.5% in the general population,
which means the disorder will affect about 1% of the population at some point 
  South African results:
Similar results were found in a South African study conducted in the Western Cape province, where the
annual incidence of schizophrenia was found to be 1%.
 The onset of schizophrenia is earlier for males than females, affecting males in their late teens and early
twenties, and women some ten years later. For men, the likelihood of onset diminishes with age, but it can still
first occur after the age of 75. The frequency of onset for women is lower than for men until age 36, when the
relative risk for onset switches, with more women than men being affected later in life
Women appear to have more favorable outcomes than do men.
Cultural factors
We now know that people in extremely diverse cultures have the symptoms of schizophrenia, which
supports the notion that it is a reality for many people worldwide. Schizophrenia is thus universal, affecting all
racial and cultural groups studied so far.
 South African context:
In South Africa, symptoms of schizophrenia are frequently associated with a spiritual calling, and affected
individuals are consequently taken to traditional healers who reinforce the notion by letting the people partake
in rituals where contact is made with deceased ancestors 
The name "Schizophrenia" gets a bad rap. It is often confused with "multiple personalities/dissociative identity
disorder." It has contributed to much confusion & stigma.  There is an ongoing debate about whether or not the
name should be changed. Let's get into it...
Schizophrenia
Schizophrenia, which comes from the combination of the Greek words for “split” (skhizein)
and “mind” (phren), which translates to "split mind" was coined by Swiss
psychiatrist Eugene Bleuler. He described it as a splitting of basic functions like thinking,
emotions & actions. These no longer work together like they did before. Schizophrenia is a serious psychiatric
disorder characterised by psychotic episodes consisting of hallucinations, delusions & disorganisation in
thinking, communication and behaviour.
Phases of Schizophrenia Written by Samantha Gluck
Research identifies three phases of schizophrenia: prodromal, acute or active, and residual. Although it
may seem like people suddenly develop the serious mental illness, known as schizophrenia, this simply
isn’t so. You don’t just wake up one day in the throes of fullblown psychosis. Instead, a period of
decreased function frequently precedes obvious psychotic symptoms. Once psychotic symptoms begin to
emerge, the schizophrenic exhibits a distorted way of thinking and relating to others.
Prodromal Schizophrenia
The first of the three phases of schizophrenia, prodromal schizophrenia, or prodrome, occurs when a
person just begins to develop the disorder.
The term, prodrome, refers to the period of time from when the first change in a person occurs until he
or she develops fullblown psychosis. In other words, it’s the time span leading up to the first obvious
psychotic episode.
Imagine that you begin to withdraw socially, little by little, with no apparent triggering event present.
You become uncharacteristically anxious, have difficulty making decisions and start to have trouble
concentrating and paying attention. You could be entering schizophrenia prodrome. Since these and
similar symptoms occur in several other mental conditions, people may not recognize prodromal
schizophrenia as such. Especially since onset of the illness most frequently occurs during the teen years or
early twenties, people may take the symptoms as indicating attention deficit disorder or a similar mental
condition. They may also just attribute the symptoms to "teenage behavior." (10 Early Warning Signs of
Schizophrenia)
Significance of Schizophrenia Prodrome
Researchers and mental health professionals consider schizophrenia prodrome very important because, if
recognized and treated early on, the person may not always continue on to develop fullblown
schizophrenia.
Active and Residual Phases of Schizophrenia
The active and residual phases of schizophrenia represent the periods commonly associated with the
mental disorder by others viewing the person. The active phase, also called the acute phase, is
characterized by hallucinations, paranoid delusions, and extremely disorganized speech and behaviors.
During this stage, patients appear obviously psychotic. If left untreated, active psychotic symptoms can
continue for weeks or months. Symptoms may progress to the point where the patient must enter the
hospital for acute care and treatment.
The residual stage of schizophrenia resembles schizophrenia prodrome. Obvious psychosis has subsided,
but the patient may exhibit negative symptoms, such as social withdrawal, a lack of emotion, and
uncharacteristically low energy levels. And, although frank psychotic behaviors and vocalizations have
disappeared, the patient may continue to hold strange beliefs. For instance, when you’re in the residual
phase of schizophrenia, you may still believe you have supernatural intelligence, but no longer think you
can read people’s minds wordforword.
Recovery and the Phases of Schizophrenia
It’s impossible to foretell who will recover from a psychotic episode and break free of schizophrenia.
Some people experience only one fullblown period of psychosis, but most go on to have several distinct
psychotic episodes. Further, while some recover completely, others will need mental health support and
medication for the rest of their lives to avoid relapses.
Symptoms of Schizophrenia
When the disease is active it is characterised by episodes in which the patient is unable to distinguish
between real and unreal experiences. The severity, duration and frequency of symptoms vary. Not taking
medications as prescribed, use of alcohol or illicit drugs, and stressful situations tend to increase symptoms.
Symptoms include: Positive & Negative Symptoms: 
Think about positive symptoms in this way. It is not positive as in "good/pleasant" but rather positive
meaning it adds to the individuals current state.  Think about negative symptoms in this way. It takes
away from the individual’s current state.
Positive symptoms + Negative symptoms   -
Adding to their current state. Something Involves deficits in normal behaviour. 
 added that was not there before.
 Hallucinations - hearing voices or  Deficits in communication- giving
seeing things that only exist in your one word replies or speaking in a
mind monotone (alogia)
 Disorganization of  Blunted/flat affect – lack of
speech & behaviour expression
 Delusions- false fixed beliefs  Lack of motivation and social
engagement. 
*Affect refers to emotion, mood. This is important to remember because it is and
will be a key term across disorders.
Disorganized speech : Confused and disordered thinking and speech, trouble
with logical thinking.
Disorganisation refers to a break-up of the natural, logical cohesion, or association
between ideas and behaviours. Typically, disorganisation manifests in
communication disturbances where incoherence and loss of ideational association
are most prominent. Take a look an example of disorganized speech, or also
known as "word salad":
Grossly disorganised or catatonic behaviour 
Behavioural disorganisation is characterised by strange, apparently purposeless behaviours.
Sometimes people hoard things, push around shopping trolleys full of rubbish, adorn
themselves with odds and ends and perhaps wear inappropriately hot layers of clothing,
even in the heat of summer. 
Catatonia involves motor dysfunctions that range from wild agitation to immobility and
cover a vast range of strange, inappropriate motor behaviours. On the active side of the
continuum, some people pace excitedly or move their fingers or arms in stereotyped ways.
At the other end of the extreme, people hold unusual postures.
In one form of catatonia, called waxy flexibility, the examiner can move the patient’s arm
into a certain position and the patient will maintain that posture, seemingly indefinitely and despite suspected
discomfort and fatigue.
 Remember when covering Bipolar disorder & Depressive disorders, they included episodes,  a time
when symptoms were most severe/extreme ? It is similar with Schizophrenia. Individuals suffer
from Psychotic episodes.
What is a Psychotic episode?
During the phase where the symptoms are extreme, it is called a psychotic episode or acute
schizophrenia. An individual loses touch with reality, and the world may appear to be a puzzling
mixture of images, sounds, and information depending on the severity of the schizophrenia episode.
Psychotic episodes do not only occur in individuals with Schizophrenia but also induced by drug use, during
the manic phase in Bipolar & Brief psychotic disorder. 
Below is a video of a young woman who explains her experience of a psychotic episode.  Her episode
resembles, what we have spoken about, associative splitting. The psychotic episode description starts
at  9:45. The video may not be from an official clinical website but listen to her description because it provides
much insight into the content that we are covering.
What did you think of her description? Could you see how fragmented her mind became during her psychotic
episode?
(Not compulsory to answer)
Comments
3 Phases of Schizophrenia
Schizophrenia is understood to occur in three distinct phases as
indicated by the diagram below. As you can see below,
the Prodrome phase has relatively few symptoms & is approaching the stage of psychosis.
The Acute/active phase shows individuals entering into psychosis. After the peak, the episode subsides but is
still left with some residual symptoms. Once entering treatment, the road to recovery, the Recovery
phase, begins. Some symptoms may still linger.
 You can read the 1 page content link that follows which explains the three phases in more detail.

 Phases+of+Schizophrenia.pdf
Discussion question
Case study: Caroline 
Caroline, age 22, was diagnosed with schizophrenia at age 19. She lead a relatively normal life during school-
age and high school years. She left her parents at age 17 to attend college somewhat distant to her home. She
apparently had no problems during her first year, but when she returned for Thanksgiving break during her
second year, her parents noticed a distancing about her. She spent a lot of time alone, was irritable, and had
begun chain smoking and drinking alcohol. She failed two courses that fall and was placed on probation. When
she went back to school in the spring, her former roommate refused to stay with her, saying, “She acts so crazy
sometimes. She talks out of her head, and I’m afraid of her.” In late February, Caroline’s parents got a call from
the dean of students who related the campus police had to be called to Caroline’s room to quiet her. She had
been “yelling and screaming” and no one could understand what it was all about. She apparently really
frightened the other students in the dormitory. These bizarre behaviours continued, and during spring in March,
Caroline’s parents moved her home and made an appointment with a psychiatrist for an evaluation.
During the assessment, Caroline’s thought processes were loose, vague, ad often circumstantial. She exhibited
behaviours that suggested auditory hallucinations (stopping mid-sentence and “cocking” her head to the side as
if listening). Although when questioned about whether or not she heard voices, she denied it. Paranoid
delusional thinking was evident. She made statements such as, “ There is no one I can trust at that college.
Every student in that dorm has been told to keep an eye on me. They all know I am too smart to be there, so
they will do what they can to make me fail. If I pass, then everyone else fails.” She also expressed some somatic
delusions: “I’m pregnant you know. It will be a virgin birth.”That’s another reason the college kids are out to
get me. They are jealous! I am the chosen one.”
Since that time, she has been on several antipsychotic medications, each with only minimal success, and which
she would eventually quit taking all together. She currently lives at home with her parents, who are besides
themselves with concern and frustration. The psychiatrist has admitted Caroline to the hospital at this time to
evaluate her behaviour and begin her on a trial of fluphenazine decanote, which will only be administered every
3 weeks by IM injection, in an effort to encourage increased medication compliance on Caroline’s part.
List the negative & positive symptoms of schizophrenia demonstrated in the case study:
 
Comments
Answer  

Thank you to everyone who participated this week!

Negative symptoms included withdrawal from social situations.” She spent a lot of time at home.” Her parents
noticed her distant behaviour.  A lack of motivation was evident in her academic decline & loss of interest in
familial relationships.  Her psychiatrist reported deficits in her communication upon the first assessment.
“During the assessment, Caroline’s thought processes were loose, vague, & often circumstantial." Somebody
mentioned flat affect. Yes, it would most likely be clear with more information.
Delusions, hallucinations, disorganized speech was evident. Her disorganized speech was noticed by her
roommate and others. “She had been yelling & screaming & no one could understand what it was all about.”
Possible auditory hallucinations were picked up by her psychiatrist & roommate. She expressed both
persecutory & somatic delusions. An example of her persecutory delusion was evident when she recalled her
college experience, “They all know I am too smart to be there, so they will do what they can to make me fail.”
Somatic delusions were evident when she stated that she was pregnant & “It will be a virgin birth.”
Overall, everyone seemed to understand the difference between positive & negative symptoms. Great work! 

Other psychotic disorders...
Schizophreniform disorder Like we learned with PDD & MDD, chronicity can be an important
distinguishing feature. This is the case in Schizophreniform as we will see. 
Schizophreniform disorder is a type of schizophrenia that lasts for less than 6 months. It is a type of
psychosis, in which a person can't tell what is real from what is imagined, and affects how people think, act,
express emotions and relate to others. The difference between schizophreniform & schizophrenia is the time
frame (chronicity). If symptoms last longer than 6 months, the diagnosis given is schizophrenia and not
schizophreniform.
Symptoms
 Delusions
 Hallucinations
 Disorganised speech
 Odd or strange behaviour - pacing, walking in circles or writing constantly
 Lack of energy
 Poor hygiene and grooming habits
 Loss of interest or pleasure in life
 Withdrawal from family, friends, and social activities
Schizoaffective Disorder
Can you imagine suffering from both schizophrenic & mood disorders symptoms simultaneously?
This is the reality for individuals with Schizoaffective disorder.
Schizoaffective disorder is a mental disorder whereby the individual experiences a combination of
schizophrenia symptoms & mood disorder symptoms, The two types of schizoaffective disorder which
include some symptoms of schizophrenia are:
o Bipolar type - includes episodes of mania and sometimes major depression
o Depressive type - includes only a major depressive episode
The course of schizoaffective disorder usually features cycles of severe symptoms followed by periods of
improvement with less severe symptoms. The disorder varies from person to person and is not well
documented and considered an anomaly.
Symptoms
Delusions
Hallucinations
Symptoms of depression
Periods of manic mood or a sudden increase in energy with behaviour that's out of character
Impaired communication - partially answering questions or giving answers that are unrelated
Impaired occupational, academic and social functioning
Problems with managing personal care, including cleanliness and physical appearance
 "Jane Doe's" Schizoaffective story

A women shares her testimony of being misdiagnosed with Bipolar/dissociative instead

of Schizoaffective disorder & her journey to a better quality of life after receiving
treatment for Schizoaffective disorder.
 At the age of 12, I began to experience depression and some mild paranoia, which I would only recognize as
such many years later. At 15, I had my first suicide attempt. At 16, I was regularly cutting myself because self-
mutilation had become my dysfunctional coping mechanism, along with anorexia nervosa, for which I was
hospitalized for weeks at age 17, when I was grossly underweight. 

However, none of this was the worst of it. Crippling major depression and an eating disorder were, I would
realize later, much easier for me to live with than the psychosis that followed. At 23, I became floridly
psychotic, delusional and paranoid, with constant auditory, visual, tactile and olfactory hallucinations. I
believed, at first, that I had been heinously abused as a child and blocked out the memories, but then I began
to believe I was a mind control victim of the CIA. I thought there was a microchip implanted in my body,
monitoring my whereabouts and that people were communicating with me constantly through secret “double
speak”, hidden messages and via reading my mind and sending me thoughts from theirs. I thought people on
TV and the radio were directly communicating with me, and was sure that I had a personal relationship with
Anderson Cooper of CNN, who I had never met.

Simultaneously, my severe depression swung into mania and then back to depression again. Needless
to say these symptoms and my horrendous anxiety destroyed my ability to function the way I previously had. I
went from being an honors student in a community college who was about to transfer to Smith College on
scholarship, to living in a homeless shelter and then to sleeping the back of my car with trash bags covering
the windows so no one could spy on me. This was after I was ostracized by the majority of my family for my
behavior, which they did not understand.

I had no friends, except for one former professor and some women I had met on the internet, and I ended up
moving into a room in a condo owned by the ex-boyfriend of one of those women, where I lived for three
years. I rarely left that room in three years, except to go into psychiatric hospitals.  Yet, I was still never
correctly diagnosed. Unable to recognize psychosis, due to anosognosia, the condition of not knowing one is
psychotic, I did not even know that I was seriously mentally ill. I thoroughly believed in all of my
delusions. I believed, on varying days, that I was Jesus Christ, Anne Frank and Scientology founder L. Ron
Hubbard reincarnated, because I had come to think that psychiatry was out to kill me and I found support in
my idea that medication was harmful through reading Scientology books; therefore, I decided I was a
Scientologist.

During these 6 years, I lived in three different homeless shelters in three different states, various motel rooms,
a few rented rooms and small efficiency apartments and sometimes briefly in my mother’s house. I was
basically a vagabond with nowhere to call home. I had no support system, almost no friends, since even most
of my internet friends had decided to have nothing to do with me any longer, due to my illogical behavior and
I was left to suffer alone.

I received no help after leaving hospitals, misdiagnosed as bipolar or dissociative, when in reality I was
completely psychotic the entire time and no one knew that. I never followed up to receive psychiatric care or
stay on medication. In this time period I had about eight suicide attempts, including one where I totaled my
mother’s car while driving it alone at about 100 miles per hour at the top of the Sunshine Skyway Bridge, a
popular place for suicides in St. Petersburg, Florida and trying to drive over the guardrail as the voices all
around me where screaming at me to do. I was also victimized by criminals several times, due to my inability
to protect myself and this relates to the fact that people with serious mental illnesses are far more likely to
become the victims of violent crimes than we are to perpetrate them.  Finally, I almost ended my life with
a loaded handgun, but was stopped by the police.  After that attempt, I was committed to a psychiatric
hospital for six months, through a program called SRT, Short-Term Rehabilitation Treatment. That program
saved me from the seven previous years of constant psychosis because I was forced to stay on
antipsychotic medications for the entire time, and for the first time in so long, I got a glimpse of my sanity
handed back to me, for which I will always be grateful.

Delusional disorder: Delusional disorder is a condition whereby an individual displays one or more
delusions for one month or longer. It is distinct from schizophrenia and cannot be diagnosed if a person
meets the criteria for schizophrenia. Functioning is generally not impaired and behaviour is not
obviously odd, with the exception of the delusion. Delusions may seem believable and individuals may
appear normal as long as an outsider does not touch upon their delusional themes. Delusional disorder can
be specified as having bizarre content.
There are different types of delusions: (capturing the theme of someone's delusion)
1. Erotomanic:  believes that a person, usually of higher social standing, is in love with him or her.
2. Grandiose: believes that he or she has some great but unrecognised talent, a special identity,
knowledge, power, self-worth or relationship with someone famous or with God.
3. Jealous: believes that his or her partner has been unfaithful.
4. Persecutory:  believes that he or she is being cheated, spied on, drugged, followed, slandered or
mistreated.
5. Somatic:  believes that he or she is experiencing physical sensations or bodily dysfunctions, such as foul
odours or insects crawling on or under the skin, or is suffering from a general medical condition or
defect.
6. Mixed: exhibits delusions that are characterised by more than one of the above types.
7. Unspecified: delusions do not fall into the described categories or cannot be clearly
determined.  (Shared psychotic disorder could be specified here)
Most common delusion & behaviour description
The most frequent type of delusion is the persecutory type but is still considered to be rare with an estimated
0.2% of people experiencing it at some point in their lifetime.
Anger and violent behaviour may be present if someone is experiencing persecutory, jealous, or erotomanic
delusions. People with delusional disorder are not able to accept that their delusions are irrational, even if
they are able to recognise that other people would describe their delusions this way.
Delusions can be considered bizarre if they are clearly not possible and peers within the same culture cannot
understand them. Non-bizarre delusions reflect situations that occur in real life, but are not actually happening.
To follow is a clip of a man describing the reality of experiencing delusions in his life.
Brief psychotic disorder
Brief Psychotic Disorder is typically diagnosed in late 20s or early 30s and can be thought of as time-limited
schizophrenia. It is characterised by the presence  of one or more  of the following positive symptoms:
 Delusions
 Hallucinations
 Disorganised speech 
 Grossly disorganised or catatonic behaviour 
Duration of an episode is at least one day and less than one month with the individual returning to previous
level of functioning. An episode may occur as a response to extreme life stress or Post Natal Depression
onset and cannot be due to the direct physiological effects of a substance or drug or a general medication
condition.
Shared psychotic disorder (Folie à Deux)
A shared psychotic disorder is a rare type of mental illness in which a healthy person starts to take on
the delusions of someone who has a psychotic disorder such as schizophrenia.
Previous versions of DSM included a separate delusional disorder—shared psychotic disorder (folie à
deux), the condition in which an individual develops delusions simply as a result of a close relationship with a
delusional individual. The content and nature of the delusion originate with the partner and can range from the
relatively bizarre, such as believing enemies are sending harmful gamma rays through your house, to the fairly
ordinary, such as believing you are about to receive a major promotion despite evidence to the contrary. DSM-5
now includes this type of delusion under delusional disorder with a specifier to indicate if the delusion is shared
DSM-5 does not consider Shared Psychotic Disorder (Folie à Deux) as a separate entity; rather, the
physician should classify it as "Delusional Disorder" or in the "Other Specified Schizophrenia Spectrum and
Other Psychotic Disorder".
* The upcoming joker movie "Folie à Deux" is attempting to depict this specific delusional disorder.  
To conclude is a clip attempting to depict what individuals with schizophrenia experience internally.
 

*Treatment will be covered in part 2 next week

End of lesson

Week 7: Schizophrenia & other psychotic disorders (part 2)

This week we move to part 2 of Schizophrenia & related disorders. Our focus will be on aetiology (causes)
& treatment. We will cover the following:
Genetic influences
Neurobiological influences
Psychological & social influences
Prenatal & Perinatal influences
Treatment
Lesson outcomes: 
Describe the combination of causes for schizophrenia
Know first-line treatment for Schizophrenia & related disorders
Know cultural factors (including SA)  affecting treatment 

Before begin, take a look at this crash course on schizophrenia to review some of what we have already
covered:
The exact cause of Schizophrenia is unknown. It cuts across income brackets, ethnic identities, and national
boundaries. However, there are many factors that can make a person more likely to develop it. These include
genetic, biological, psychological & social factors. Let's zoom in on each:
Aetiology (causes)
1. Genetic influences: Genes play a role in increasing vulnerability to schizophrenia. 
Family studies: Families that have a member with schizophrenia are at risk not just for
schizophrenia alone but for a spectrum of psychotic disorders related to schizophrenia.
 You have the greatest chance (approximately 48%) of having schizophrenia if it has affected your identical
(monozygotic) twin, a person who shares 100% of your genetic information. Your risk drops to about 17% with
a fraternal (dizygotic) twin, who shares about 50% of your genetic information. And having any relative with
schizophrenia makes you more likely to have the disorder than someone without such a relative (about 1% if
you have no relative with schizophrenia)
*These studies demonstrate the strong genetic influence in the development of schizophrenia.
Below is a study of identical quadruplets, whose family had a history of mental illness, who all developed
schizophrenia. Their fathers brother was reported to have been hearing voices. What is interesting here is that
even though they shared 100% of their genes and their environment was identical, schizophrenia developed &
manifested differently.
Twin studies: The Genain quadruplets (born in 1930)
All four shared the same genetic predisposition, and all were brought up in the same particularly
dysfunctional household; yet there were significant differences in:
Time of onset, Symptoms and diagnoses, Course of the disorder and Their outcomes
For example, Hester, one of the Genain sisters, had more social problems than her sisters as she grew up.
Hester was the first to experience severe symptoms of schizophrenia, at age 18, but her sister Myra was not
hospitalised until six years later. This unusual case demonstrates that even siblings who are close in every
aspect of their lives can still have considerably different experiences physically and socially as they grow up,
which may result in vastly different outcomes. 
Adoption studies
Even when raised away from their biological parents, children of parents with schizophrenia therefore have a
much higher chance of having the disorder themselves. At the same time, there appears to be a protective
factor if these children are brought up in healthy supportive homes. A good home environment reduces the risk
of schizophrenia.
2. Neurobiological influences 
Too much or too little of anything is not always healthy. The "Dopamine hypothesis", suggests that
schizophrenia, more specifically psychosis is caused by an excess/ too much dopamine. 
Brain structure
 Studies show that schizophrenia patients have abnormally large ventricles. Below
demonstrated the enlarged ventricles in a schizophrenic patient vs a healthy person:

*What is interesting is that patients with more prominent negative and disorganised
symptoms tend to have larger ventricles, showing more "negative" symptoms (e.g., flat affect, withdrawal
etc.)  while...
Those with small ventricles were characterized by "positive" symptoms (e.g., delusions, hallucinations &
bizarre behaviour)
3. Prenatal & perinatal influences
Foetal exposure to viral infection, pregnancy complications and complications during labour are among the
environmental influences that seem to affect whether or not someone develops schizophrenia. Several studies
have shown that schizophrenia may be associated with prenatal exposure to the flu virus Influenza A. A
study found that those whose mothers were exposed to influenza during the second trimester of pregnancy were
more likely to have schizophrenia than others 
Pregnancy complications: Breech presentations, where the baby’s buttocks engage in the birth canal instead
of the head, are also more common among patients who develop schizophrenia. Does this suggest some postural
abnormality at play even before birth, in turn the product of subtly abnormal motor control?
4.Psychological & social influences
If having a genetic predisposition (vulnerability) for schizophrenia cannot guarantee whether or not you will
develop schizophrenia, it suggests that schizophrenia involves something in addition to just genes. Let's take
a look at psychological & social factors:
High cannabis use
Some research suggests that people who use high-dose cannabis have an increased likelihood of
developing schizophrenia. There are conflicting findings about whether or not high cannabis use
causes schizophrenia. However, there is evidence that it may trigger episodes when there is already a
predisposition to schizophrenia.
Stress: A mountain of empirical studies has accumulated showing that schizophrenia and other “mental
illnesses” are likely caused by sexual abuse, physical abuse, emotional abuse. 
Research found that individuals had experienced a high number of stressful life events in the three weeks before
they started showing signs of the disorder.
In South Africa, political, social and economic stressors such as poverty, inequality and violence all
contribute to negative outcomes for people suffering from schizophrenia. And it has been revealed as a myth the
belief that community and family life in developing countries such as South Africa contribute to better
outcomes. On the contrary, the burden of disease experienced by family members puts pressure on their already
limited resources. These types of studies point to how stress can impact people with schizophrenia and may
suggest useful treatments.
Family & relapse: Research has focused on a particular emotional communication style
known as expressed emotion (EE).  Research found that former patients who had limited
contact with their relatives did better than the patients who spent longer periods with their
families.
Additional research results indicated that if the levels of criticism, hostility & emotional over-
involvement expressed by the families were high, patients tended to relapse. High expressed emotion in a
family is a good predictor of relapse among people with chronic schizophrenia.
If you have schizophrenia and live in a family with high expressed emotion, you are 3.7 times more likely to
relapse than if you live in a family with low expressed emotion. 
Lets take a look at first-line treatments  for schizophrenia: Treatment
The exact causes of schizophrenia are unknown and there is not a known cure so treatment focusses primarily
on eliminating symptoms
Biological interventions: Antipsychotic medication: Help people think more clearly and reduce hallucinations
and delusions. They work by affecting the positive symptoms (delusions, hallucinations and agitation) and, to a
lesser extent, disorganisation. 
Difference between first generation & second generation antipsychotics:
The classical, first generation or typical agents are effective for approximately 60–70% of people who try them.
Many people are not helped by antipsychotics, however, or they experience unpleasant side- effects. The novel,
second generation antipsychotics hold somewhat more promise for helping patients who were previously
unresponsive to medications.
Psychosocial interventions (helpful additions to medication)
Social skills training: Therapists divide complex social skills into their component parts, which they model.
Then the clients do role-playing and ultimately practise their new skills in the ‘real world’, all the while
receiving feedback and encouragement at signs of progress
Assertive community treatment models (ACTS): (ACTs) are being developed in South Africa where there is
a shift away from hospital treatments to community rehabilitation. These models are characterised by low case-
loads where a multidisciplinary team, consisting of psychiatrists, psychologists, nursing staff and social
workers, focus specifically on illness management of people who are frequently readmitted to psychiatric
hospitals 
Family therapy: Behavioural family therapy resembles classroom education. Family members are informed
about schizophrenia and its treatment, relieved of the myth that they caused the disorder, and taught practical
facts about antipsychotic medications and their side-effects. They are also helped with communication skills so
that they can become more empathic listeners, and they learn constructive ways of expressing negative feelings
to replace the harsh criticism that characterises some family interactions.
Treatment across cultures
Treatment of schizophrenia and its delivery differ from one country to another and across cultures within
countries. In South Africa:
For example, the vast majority of the Xhosa people of South Africa who have schizophrenia report using
traditional healers who sometimes recommend the use of oral treatments to induce vomiting, enemas and the
slaughter of cattle to appease the spirits.
 In the USA, Hispanic-Americans may be less likely than other groups to seek help in institutional
settings, relying instead on family support Adapting treatments to make them culturally relevant – in this
case, adding important relatives to the social skills training of Hispanic-Americans with schizophrenia – is
essential for effectiveness 
Super- natural beliefs about the cause of schizophrenia among family members in Bali lead to limited use of
antipsychotic medication in treatment. 
End of lesson

Week 8: Eating Disorders

Eating disorders
This week we turn our focus to Eating disorders of which there are three main types according to the DSM 5:
Anorexia Nervosa (AN)
Bulimia Nervosa (BN)
Binge-eating disorder (BED)
Treatment
We'll also briefly cover:
Obesity
Lesson outcomes:
 Understand AN, BN & BED and their respective diagnostic criteria
 Make comparisons between the 3 types Eating disorders
 Know first-line treatment for Eating disorders 
Eating disorders: Definition
 Eating disorders are characterized by severe and persistent disturbance in eating behaviors and associated
distressing thoughts and emotions. They can be very serious conditions affecting physical,
psychological and social function.
  The DSM 5 groups Eating Disorders and Feeding Disorders together, and this can be
summarised in the following diagram:
Our focus will be on eating disorders but here is a quick breakdown of the 3 feeding disorders included in the
DSM 5:
Feeding disorders: 3 types
Pica
Pica is characterised by persistently eating one or more non-nutritive, non-food substances for a least a
month. These include ice, starch, clay, chalk, paint, paper, soap, string, soil, faeces and hair. 
Rumination disorder
A condition in which people repeatedly and unintentionally spit up (regurgitate) undigested
or partially digested food from the stomach, rechew it, and then either reswallow it or spit it
out.
Avoidant restrictive food intake disorder
 The avoidance of food and restriction of its intake characterise this condition. Some children appear
particularly averse to certain sensory qualities of foods appearance, smell and texture as well as taste.
Eating disorders & the South African context
 The exact rates of eating disorders throughout South Africa are difficult to pinpoint due to
the little research that has been conducted in this area.
The mental health community has begun to successfully chip away at the stigma surrounding eating disorders,
including the myth that they are only a Western condition.
Males in South Africa face a unique double-stigma. The misperception that eating disorders cannot affect
males is compounded by the myth that eating disorders only occur in Western populations.
Urbanization and general transitions occurring in South Africa might be contributing to increased rates of eating
disorders. Regardless, eating disorders can affect anyone in the world. This includes males of any skin color in
South Africa.
Eating disorders in general are among the deadliest of mental health disorders. Anorexia Nervosa in particular,
has the highest mortality of ANY mental health disorder.
Anorexia Nervosa: An eating disorder characterized by recurrent food refusal, leading to dangerously low
body weight. 
Left: A women with untreated anorexia, within 10 years, spiralled into an extreme low weight at about 20
kilograms, her husband performs basic daily functions for her. 
*However this is not the case for everyone suffering from the disorder. For some it is not that obvious that they
struggle with anorexia.  This is known as "atypical" anorexia.
Right:  Someone who represents the "atypical" group. Often goes undetected.  
What is it like for someone with Anorexia?
 They have an intense fear of gaining weight. They see a fat person when others  think that they are too thin.
They therefore have a distorted view of their weight. They have strict rules about eating, what they are
allowed to eat, when & where. They prefer to starve or eat less. Whereas, as we will see later, bulimics eat
heavy meals followed by purging. 
Physical signs of Anorexia
Thin appearance
Dry skin, brittle hair or nails and
Intolerance of cold
lanugo, downy hair on the limbs and cheeks.
Absence of menstruation (Amenorrhea) 
Low blood pressure and heart rate
If vomiting is part of the anorexia, electrolyte imbalance
& oesophageal rupture may occur
DSM 5 Diagnostic criteria
a. Restriction of energy intake
b. Intense fear of gaining weight or becoming fat or behaviour interfering with
weight gain
c. Body image disturbance (inappropriate self-evaluation of body weight)
2 types: Restricting type
This subtype describes presentations in which weight loss is accomplished primarily
through dieting, fasting, and/or excessive exercise.
*Does not mean that they do not purge but their primary means of reducing body
weight is through restricting. 
Binge-eating purging type
Recurrent episodes of binge eating or purging behaviour
*Remember that purging is not only self-induced "vomiting" it can also include the misuse
of laxatives, diuretics or enemas.
Well then you might ask, so what is the difference between the Binge-purging type &
Bulimia?
Anorexia and bulimia can both cause binging and purging. People with anorexia often have a very low body
weight. Individuals with bulimia may occasionally fast for a day or two, but do not have the characteristic long
term weight suppression of those with anorexia nervosa. For this reason the issue of malnourishment is not quite
as critical as the anorexic. 
Below is a clip of two women who have struggled with anorexia for 20 years. 
Question:
1. Which type of anorexia do they suffer from & why? (not compulsory)
Comments Section
Anorexia & Co-morbid disorders
Anxiety disorders and depressive disorders are often present in individuals with anorexia. Up to 71% of
patients experience major depression at some point during their lives. OCD is a common comorbid condition.
In anorexia, unpleasant thoughts are focused on gaining weight, and individuals engage in a variety of
behaviours, some of them ritualistic, to rid themselves of such thoughts. Future research will determine whether
anorexia and OCD are truly similar or simply resemble each other.
Having the highest mortality rate of all mental health disorders, it would be important to know what ultimately
causes death in anorexics. 
Most common causes of death 
Most common causes of death in anorexics
Cardiac arrest The malnutrition often connected to anorexia can directly stop your
heart from beating or weaken the muscle to the point where it
(occurs when the heart suddenly and struggles to pump enough blood to the body.
unexpectedly stops pumping)

Sudden death The abrupt and unexpected occurrence of fatality for which no
satisfactory explanation of the cause can be ascertained.

Suicide The severe toll anorexia and starvation can take on the body and to
the hopelessness the illness causes. Some who suffer from chronic
anorexia may resort to suicide.
Co-morbid disorders such as substance use, anxiety, or depression
are common. The immense difficulty of living with an eating
disorder in addition to a co-occurring disorder may lead to suicidal
thoughts & actions.

Treatment for Anorexia 

 First
With anorexia, the most important initial goal is to:
Restore the patient’s weight to a point that is at least within the low-to-normal range
Next...
The difficult stage begins. Attention to the patient’s underlying dysfunctional attitudes about body shape, as
well as interpersonal disruptions need to be addressed. 

Psychological treatments
Enhanced Cognitive behavioral therapy (CBT-E)
 This type of CBT therapy is adapted specifically to meet the unique need of those who
suffer from eating disorders. It is one of the most effective treatments for anorexia & has higher
rates of preventing relapse than nutrition counselling alone.
Treatment focuses on their undue emphasis on thinness as a determinant of self-worth, happiness and
success. For restricting anorexics, the focus of treatment must shift to their marked anxiety over becoming
obese and losing control of eating.
In this regard, effective treatments for restricting anorexics are similar to those for patients with bulimia
nervosa.

Pharmacological treatments
Currently, pharmacological treatments have not been found to be effective in treating anorexia nervosa.
A study reported that the SSRI fluoxetine, an agent typically used as antidepressant, had no benefit in relapse
prevention following weight restoration in patients with anorexia nervosa. Antidepressant medication may well
be valuable in treating co-morbid depressive, anxiety and OCD symptoms.
Let's move on now to studying BulimIa Nervosa (BN):
Bulimia nervosa
Up to 3% of females and more than 1% of males suffer from bulimia nervosa during their lifetime. This of
course reveals that more females suffer from BN than males.
Definition 
Bulimia nervosa is an eating disorder involving recurrent episodes of uncontrolled excessive (binge)
eating followed by compensatory actions to reduce the caloric, or energy, impact of the food or to rid the body
of the food itself.
Key terms
Binging
Relatively brief episode of uncontrolled, excessive consumption of food & or drink. To meet the
diagnostic criteria binging needs to occur at least once a week for 3 months.
Compensatory actions
Out-of-control eating episodes, or binges, are followed by compensatory behaviours to
offset the intake of excessive food.
These include self-induced vomiting, excessive use of laxatives and diuretics as well
as excessive exercise. 
So what is it like for someone with Bulimia?
They struggle with a critical inner voice that can prompt them to feel guilt &
shame because of their eating behaviour, weight & body image. Never feeling
good enough. Hence, anxiety & depression are common co-ocurring disorders.
They start off with strict dieting attempting to lose weight fast but over time the
strict dieting triggers them to binge eat. A trigger, such as a stressful event or a bad
feeling about body image, can cause them person to slip and break the strict diet (Binge-purge cycle).This is
when the binging starts. They know their behaviour is out of control. which further fuels the feelings of
shame & guilt.

DSM 5 Criteria
A.    Recurrent episodes of binge eating:
1.    Eating, in a discrete period of time (e.g. within any two-hour period), an amount of food that is definitely
larger than most people would eat during a similar period of time and under similar circumstances.
2.    A sense of lack of control over eating during the episode 
B.    Recurrent inappropriate compensatory behaviour in order to prevent weight gain (vomiting; misuse of
laxatives, fasting; or excessive exercise)
C.    The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a
week for three months.
D.    Self-evaluation is unduly influenced by body shape and weight.
E.    The disturbance does not occur exclusively during episodes of anorexia nervosa.

Physical symptoms
Severe dehydration from frequent vomiting means that your body doesn’t have enough water.
In turn, your hair can become dry and frizzy. You may even experience hair loss. It can also
cause electrolyte imbalance
Tooth decay- high acid content of vomit may cause tooth sensitivity and decay
Scarred & calloused hands- scars commonly found on the backsides of hands can occur from
the finger coming in contact with the incisors (teeth) if the person uses their fingers to induce
vomiting. Callouses on the fingers also develop because of repeated friction of the fingers
against the teeth and throat when inducing vomiting.
Rupture esophagus (cause blood in vomit)- tearing of the oesophagus may occur during vomiting. caused by
high acid content in vomit
Face swelling- generally caused by swollen parotid glands which are located near the ears often
requiring medication to treat.
 
South African case of Bulimia Nervosa
A 2018 South African study indicated that only about 15% of men actually seek treatment for eating
disorders.
*Bandla Fakazi is one of them -- but it took him almost a decade to seek help. Bandla Fakai interviewee:
Huffpost SA (news site in SA).
The 31-year-old from Lanseria, in Johannesburg, said he battled bulimia for most of his twenties. At varsity,
Fakazi says he "just exploded" [referring to weight gain]. No one knew until a girlfriend found out when he was
in his late twenties.
"Not even my mother knows, only an ex-girlfriend and that's because you know, I thought she was the one and
oh I got caught," he jokingly added. "I was always the chubby guy, you know and people made sure I knew it.
Like it was the acceptable joke and at first I didn't mind and then it kinda stung." "I tried the gym and running...
maybe I was not patient but I did not see change. "He admits that it depressed him a lot. "I knew there was
something wrong but I also didn't think I was sick. I just wanted to lose weight fast and this way worked." [It's
around this time that he started purging after eating.] "I mean it's harder to squeeze time after dinner to go throw
up when your girlfriend is always there or you have visitors. She only found out very late actually," Fakaza
said. "I am in treatment, but I have relapsed I won't lie... but the treatment I can say has really helped." [And it
is after this is that he sought help.]
Below is a short clip of a man sharing his experience of suffering from bulimia. Admitting to suffering from
an eating disorder is extremely difficult for men. There is still a perception that eating disorders are a "female"
problem. However, the numbers for men are growing & many are left undiagnosed.
Treatment
CBT-E: First stage: teaching the patient the physical consequences of binge eating and
purging, ineffectiveness of vomiting and laxative abuse for weight control.
The adverse effects of dieting are also described, and patients are scheduled to eat small, manageable amounts
of food five or six times per day with no more than a three-hour interval between any planned meals and snacks,
which eliminates the alternating periods of overeating and dietary restriction that are hallmarks of bulimia.
Next: CBT-E focuses on altering dysfunctional thoughts and attitudes about body shape, weight and eating.
Coping strategies for resisting the impulse to binge and/or purge are also developed, including arranging
activities so that the individual will not spend time alone after eating during the early stages of treatment
Efficacy for CBT-E on Bulimia
CBTs for bulimia have been good, showing efficacy that is superior to credible alternative psychological
treatments, not only for bingeing and purging but also for distorted attitudes and accompanying depression.
Furthermore, these results seem to last. although there were a number of patients who improved only modestly
or did not benefit.
In the largest study to date, CBT was significantly superior to supportive psychotherapy (in which the therapist
is understanding and sympathetic and encourages patients to achieve their goals) in the treatment of bulimia
nervosa
Family therapy
There is also good evidence that family therapy directed at the painful conflicts that exist in families with an
adolescent who has an eating disorder can be helpful
Pharmacological treatment
Antidepressant medication (Alongside CBT-E)
SSRI medication- modestly increased the benefit of CBT. 
Case study: J.M
J.M., a 23-year-old woman, was admitted to the psychiatric unit last night after assessment and treatment at a
local hospital emergency department (ED) for “blacking out at school.” As you begin to assess her, you notice
that she has very loose clothing, she is wrapped in a blanket, and her extremities are very thin. She tells you, “I
don’t know why I’m here. They’re making a big deal about nothing.” She appears to be extremely thin and pale,
with dry and brittle hair, which is very thin and patchy, and she constantly complains about being cold. As you
ask questions pertaining to weight and nutrition, she becomes defensive and vague, but she does admit to losing
“some” weight after an appendectomy 2 years ago. She tells you that she used to be fat, but after her surgery she
didn’t feel like eating and everybody started commenting on how good she was beginning to look, so she just
quit eating for a while. She informs you that she is eating lots now, even though everyone keeps “bugging me
about my weight and how much I eat.” She eventually admits to a weight loss of “about 20 kilograms and I’m
still fat.”
Discussion question 
1.Given the information, what disorder does she most likely suffer from? _________________.
2. How would you determine the diagnosis of ________________  from what you have observed?
Comments Section
Answer: Thank you to all who participated!   It's good practice in practical application. 
J.M meets the diagnostic criteria for Anorexia nervosa. Her blackout may have been caused by low blood
pressure where her brain could not get enough oxygenated blood causing her to blackout. This is common in
anorexia because not eating enough food and being dehydrated can cause low blood pressure. It can also cause
severe electrolyte imbalance where cardiac arrest can occur where the heart stops pumping blood.
 In this case we know that she restricts more than she binges or purges. She admits that she restricts her food
intake & others have also bugged her about her not eating enough. However, this does not mean that she has
not engaged in binging or purging behaviour. So, she is more likely a restricting type. A body image
disturbance is clear. Even though she is significantly & dangerously under-weight, her perception is that she is
still “fat.” This is therefore an inaccurate and inappropriate self-evaluation. Though she does not admit to
holding a fear of gaining weight, she does show persistent behaviour that interferes with weight gain. When
many people started commenting on how good she looked with a lower weight, she quit eating. She may later
reveal an intense fear of gaining weight, but further information is needed. 
She also shows some physical signs of anorexia. She has a thin appearance, thin/brittle
hair and intolerance of the cold.
Feedback:
When answering these case studies, you do not need to go into as much detail as I have. Applying the DSM 5
criteria to the case is sufficient.
Criteria B- she shows behaviour that interferes with weight but what may be revealed later is her intense fear of
gaining weight. For now, we can infer from what we have heard.
Remember that she does meet the criteria for Body image disturbance since her self-evaluation was
inappropriate or inaccurate. Being underweight, she still considered herself “fat.”  She also lacks the recognition
of the seriousness of her low body weight.
Overall, everyone answered the question well & showed a good understanding of the diagnostic criteria and
physical symptoms involved.
Binge eating disorder

Binge eating disorder

A serious mental health illness characterized by
regularly eating large amounts of food (binging) and
feeling out of control. 
After binging, they are left
feeling disgusted, ashamed and depressed because
of their behaviour.
Unlike with bulimia, they do not perform
compensatory behaviors after. 
Individuals who meet preliminary criteria for BED are often found in
weight-control programmes.
In a study, mildly obese participants in a weight-control programme
identified 18.8% who met the criteria for BED.
About half of individuals with BED attempt modified, weight-restricting diets before bingeing, and half
start with bingeing before modifying diet 

Body Image
Individuals with BED have some of the same concerns about shape and weight as people with
anorexia and bulimia
Negative emotions or negative affect play a role in binging as a way to alleviate bad moods. 
The body weight of those who struggle with this eating disorder can vary in range from normal
to severe obesity. (See image on the right)
Many individuals who are dealing with binge eating disorder may experience weight gain as a
result of abnormal eating. habits. Irrespective of body weight, a person with binge eating   may
deal with low-self esteem or disgust about his or her body.
DSM 5 Criteria for BED

 
Binge-Eating Disorder:
Specific Treatment
 

Interpersonal therapy (IPT) & Cognitive behavioural therapy (CBT)

In contrast to results with bulimia, it appears that IPT is every bit as effective as CBT for binge eating.
Self-help

Self-help procedures may be useful in the treatment of BED. For example, CBT delivered as guided self-help
was demonstrated to be more effective than a standard behavioural weight-loss programme for BED both
after treatment and at a two- year follow-up.
*Much as with bulimia, however, more severe cases may need the more intensive treatment delivered by a
therapist, particularly cases with multiple (comorbid) disorders in addition to BED, as well as low self-esteem
Obesity
 

Although obesity cannot be considered a mental disorder, it is a serious public health concern.

Obesity in the modern world, across developed and developing societies is a primary factor in a
range of serious afflictions, from hypertension, to arterial disease and even dementia.
 

South Africa has the highest rate of obesity in sub-Saharan Africa, with nearly two-thirds of adult
women overweight and 40% obese; one-third of adult men classifiable as obese
 

There are two forms of maladaptive eating patterns in people who are obese. The first is binge
eating and the second is night eating syndrome. It is important to note that only a minority of
patients with obesity, between 7 and 19%, present with patterns of binge eating.
Occasionally, non-obese individuals will engage in night eating, but the behaviour is overwhelmingly
associated with being overweight or obese. There is a relationship of night eating syndrome with
increasing levels of obesity

End of lesson

Week 9: Cluster A Personality Disorders

Cluster A: Personality disorders
This week will begin with an introduction to
personality disorders. We will look at Cluster A which
include: 
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder 
Outcomes

Understand and define personality disorders 

Understand  the differences & similarities between PD's

Know first-line treatment

What is a Personality Disorder?

The DSM-5 divides the personality
disorders into three groups, or clusters
A personality disorder is a persistent
pattern of emotions, cognitions and
behaviour that results in enduring
emotional distress for the person affected
and/or for others, and may cause
difficulties with work and relationships. 
 
We probably all demonstrated behaviour
that is dramatic, suspicious, outgoing,
getting upset easily. However, when
personality characteristics interfere with
relationships with others,
cause personal distress or generally disrupt activities of daily living, we consider these to be
‘personality disorders’ 

Treatment in general
 One factor important to the success (or lack of success) of treatment is how the therapist feels
about the client. The emotions of therapists brought out by clients (called ‘countertransference’) tend
to be negative for those diagnosed with personality disorders.
 Therapists especially need to guard against letting their personal feelings interfere with treatment
when working with people who have personality disorders.
 

Being cautious of someone's intentions is not a bad thing. After all, there are real dangers in the
world. However, being too distrustful can interfere with relationships, working with other
people and getting through daily interactions in a functional way.

Paranoid Personality Disorder

People with paranoid personality disorder are excessively mistrustful
and suspicious of others, without any justification. They assume other
people are out to harm or trick them; therefore, they tend not to confide
in others
Even events that have nothing to do with them are interpreted as
personal. This is known as "unjustified trust"
 Example: Someone may view a neighbour’s barking dog or a delayed airline flight as a
deliberate attempt to annoy them.
Such mistrust often extends to people close to them and makes meaningful relationships
difficult.
They are also sensitive to criticism.  

Symptoms of PPD include:

Suspicion Concern with hidden motives
Expects to be exploited by others Inability to collaborate
Social isolation Poor self image
Detachment Hostility

Treatment
People with paranoid personality disorder have difficulty developing the trusting relationships
necessary for successful therapy. Because they are so mistrusting they will often rebel against
their therapist. Therefore, the first step is to:
Establishing a meaningful therapeutic alliance between the client and the therapist.
Therapists try to provide an atmosphere conducive to developing a sense of trust.
They often use cognitive therapy to counter the person’s mistaken assumptions about others,
focusing on changing the person’s beliefs that all people are malevolent and most people cannot
be trusted.
*To date there are no confirmed demonstrations that any form of treatment can significantly
improve the lives of people with paranoid personality disorder.
 

To follow are two clips, one explains PPD in greater detail and the other depicting life (some
aspects) with PPD:

We probably all know or have seen someone who we could say is a " loner."
Some people seem to just prefer to spend their time by themselves. This
behaviour is magnified in people who have a Schizoid personality disorder. 

Schizoid Personality Disorder

   A pervasive pattern of detachment from social relationships and a restricted
range of expression of emotions.
They seem neither to desire nor to enjoy closeness with others, including romantic or sexual
relationships. As a result, they appear cold and detached and do not seem affected by praise or
criticism

Unfortunately, homelessness appears to be prevalent among people with this personality disorder,

perhaps as a result of their lack of close friendships and lack of dissatisfaction about not having a
sexual relationship with another person

 They do not seem to have the unusual thought processes that characterise the other disorders in
Cluster A  

For example: People with paranoid and schizotypal personality disorders often have ideas of
reference – mistaken beliefs that meaningless events relate just to them

Symptoms of SPD include:

Does not desire or enjoy close relationships even with family
Avoids social activities that involve significant contact with other
people
Chooses solitary activities
Little or no interest in sexual experiences with another person
Indifferent to praise or criticism
Shows emotional coldness, detachment or flattened affect
 

  

Treatment: Schizoid personality disorder

 It is rare for a person with this disorder to request treatment except in response to a crisis such
as extreme depression or losing a job.

CBT with a focus on social skills training 

Therapists often begin treatment by pointing out the value in social relationships. The person
with the disorder may even need to be taught the emotions felt by others to learn empathy.
Because their social skills were never established or have atrophied through lack of use, people
with schizoid personality disorder often receive social skills training. The therapist takes the part
of a friend or significant other in a technique known as role-playing and helps the patient
practise establishing and maintaining social relationships

Schizotypal Personality Disorder

People given a diagnosis of schizotypal personality disorder have psychotic-like (but not
psychotic) symptoms (such as believing everything relates to them personally), social deficits,
and sometimes cognitive impairments or paranoia. 
They have ideas of reference; for example, they may believe that somehow everyone on a
passing bus is talking about them, yet they may be able to acknowledge this is unlikely. 
 
They have have odd beliefs or engage in ‘magical thinking’, believing, for example, that they are
clairvoyant or telepathic.
*Important to note:
They report unusual perceptual experiences, including such illusions as feeling the presence of
another person when they are alone. Notice the subtle but important difference between
feeling as if someone else is in the room and the more extreme perceptual distortion in people
with schizophrenia who might report there is someone else in the room when there is not.
 

Cultural factors
 
Because people with schizotypal personality disorder often have beliefs with religious or
spiritual themes, clinicians must be aware that different cultural beliefs or practices may lead to
a mistaken diagnosis of this disorder. 
 
Some people who practise certain religious rituals – such as speaking in tongues, practicing
witchcraft, or mind-reading – may do so with such obsessiveness as to make them seem
extremely unusual, thus leading to a misdiagnosis .
 
Mental health workers have to be particularly sensitive to cultural practices that may differ from
their own and can distort their view of seemingly unusual behaviours.
 
This is imperative in the multicultural South African context, where African traditional
healing is intertwined with cultural and religious beliefs.

Treatment
Personality Disorders are notorious for being difficult to treat. This is due to few proven therapeutic
interventions and poor therapy adherence. Most personality disorders involve difficulty in getting
along with other people in all kinds of contexts and a general stubbornness, leading individuals to
drop out of treatment early on.
People with schizotypal personality disorder who request clinical help also meet the criteria
for major depressive disorder. Treatment includes some of the medical and psychological
treatments for depression.
 A combination of approaches, including antipsychotic medication & social skills training, to
treat the symptoms  were found to  reduce their symptoms or postponed the onset of later
schizophrenia.
The idea of treating younger people who have symptoms of schizotypal personality disorder
with antipsychotic medication and cognitive behaviour therapy (CBT) in order to avoid the onset
of schizophrenia is proving to be a promising prevention strategy. 

Let's look at some of the differences & similarities between Cluster

A disorders.

Case study: Mark

Notes of first therapy session with Mark, male, 36

Mark sits where instructed, erect but listless. When I ask him how he feels about attending therapy, he shrugs
and mumbles "OK, I guess". He rarely twitches or flexes his muscles or in any way deviates from the posture
he has assumed early on. He reacts with invariable, almost robotic equanimity to the most intrusive queries
on my part. He shows no feelings when we discuss his uneventful childhood, his parents ("of course I love
them"), and sad and happy moments he recollects at my request. 

Mark veers between being bored with our encounter and being annoyed by it. How would he describe his
relationships with other people? He has none that he can think of. In whom does he confide? He eyes me
quizzically: "confide?" Who are his friends? Does he have a girlfriend? No. He shares pressing problems with
his mother and sister, he finally remembers. When was the last time he spoke to them? More than two years
ago, he thinks.

He doesn't seem to feel uneasy when I probe into his sex life. He smiles: no, he is not a virgin. He has had sex
once with a much older woman who lived across the hall in his apartment block. That was the only time, he
found it boring. He prefers to compile computer programs and he makes nice money doing it. Is he a member
of a team? He involuntarily recoils: no way! He is his own boss and likes to work alone. He needs his solitude to
think and be creative.

That's precisely why he is here: his only client now insists that he collaborates with the IT department and he
feels threatened by the new situation. Why? He ponders my question at length and then: "I have my working
habits and my long-established routines. My productivity depends on strict adherence to these rules." Has he
ever tried to work outside his self-made box? No, he hasn't and has no intention of even trying it: "If it works
don't fix it and never argue with success."

If he is such a roaring success what is he doing on my proverbial couch? He acts indifferent to my barb but
subtly counterattacks: "Thought I'd give it a try. Some people go to one type of witch doctor, I go to another."

Does he have any hobbies? Yes, he collects old sci-fi magazines and comics. What gives him pleasure? Work
does, he is a workaholic. What about his collections? "They are distractions". But do they make him happy,
does he look forward to the time he spends with them? He glowers at me, baffled: " I collect old magazines." -
he explains patiently - "How are old magazines supposed to make me happy?".
Discussion question 
 Which Cluster A personality disorder does his behaviour resemble more? Why?

Comments Section
Answer 

Thank you to all who participated this week!

Mark meets sufficient criteria for Schizoid personality disorder.
He has shown flat affect throughout their session. He prefers solitary activities to being with other people. He
stated that he prefers to work alone. He shows little desire in sexual encounters as he mentioned that he
finds sex boring. He shows little desire for close relationships with others and his family. He states
emotionlessly, that his last encounter with his family was about two years ago. He was quite unmoved and
uncaring by the criticism of his only client. When being somewhat criticised by the therapist for the reason he
has come, he remains apathetic or unconcerned in his responses. He takes pleasure in one activity. He states
that work gives him pleasure and the rest are only distractions.
Feedback:
One key difference between schizotypal and schizoid personality disorder is that people living with schizoid
personality disorder have a limited desire for social relationships, whereas those with schizotypal personality
disorder have a desire for social relationships but struggle with social interaction due to their
eccentricities. So, those with schizoid personality disorders withdraw socially as much as possible.
Schizophrenia is easier to differentiate as it includes the experience of hallucinations and delusions.
END OF LESSON

Week 10:
Cluster B Personality Disorders
This week move onto Cluster B Personality Disorders which are characterized by dramatic, overly
emotional or unpredictable thinking and behaviour. They include:
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Lesson Outcomes: 
Define Cluster B Personality Disorders
Understand and the diagnostic criteria for the Cluster B disorders and evaluate the differences
Apply diagnostic criteria and use critical thinking
Know aetiology & treatment options available 
We all know people who can be characterised as "moody" and needing to walk on egg shells around them. This
is taken to unbearably extreme levels for individuals with Borderline personality disorder who struggle to
control turbulent emotions.

Borderline Personality Disorder

BPD is a serious mental illness that centres on the inability to manage emotions
effectively.
The disorder occurs in the context of relationships and it usually begins during adolescence
or early adulthood.
Individuals with BPD are often high functioning in certain settings but their private lives can be in turmoil.
Sufferers experience problems regulating their emotions and thoughts, impulses and sometimes engage in
reckless behaviour and unstable relationships.

Symptoms
 Borderline personality disorder symptoms vary from person to
person, occurring mostly in women. Common symptoms include:
1. Unstable self-image - Rapid changes in self-identity and
self-image that include shifting goals and values, and seeing
yourself as bad or as if you don't exist at all
 2. Feelings of isolation, boredom and emptiness
3. Lack of cognitive empathy- they struggle with black and white thinking so it is hard for them to
understand another persons situation in a heated moment since it is extremely hard for them to control
their emotions 
4. History of unstable relationships- Can change drastically from intense love and idealisation to intense
hate
5. Intense fear of abandonment -persistent fear and extreme emotional reactions to
perceived abandonment and rejection
6. Intense, highly changeable moods that can last for several days or for just a few hours
7. Anxiety, worry and depression
8. Impulsive, risky, self-destructive and dangerous behaviours-  such as gambling, reckless driving,
unsafe sex, spending sprees, binge eating or drug abuse, or sabotaging success by suddenly quitting a
good job or ending a positive relationship
9. Inappropriate, intense anger- such as frequently losing your temper, being sarcastic or bitter, or
having physical fights
These symptoms are experienced consistently through adulthood and not in the range that is considered normal.
Individuals with BPD appear to "border" on psychosis, neurosis and other disorders. Intense fear and reaction to
perceived rejection is a core symptom of BPD yet sufferers seem to crave it most. However, extreme emotional
responses and mood changes tend to alienate those they crave love and attention from.

Comorbidity
Making a diagnosis of BPD is very difficult due to the overlap in symptoms
between BPD and other disorders.
Mood & anxiety disorders
People with BPD often show signs of mood and anxiety disorders
(neurosis) as well as psychotic behaviours (psychosis) so there is a high
co-morbidity rate between BPD and other psychological disorders
like Bipolar Disorder, Depression, PTSD.

DSM 5 criteria:
This is a long list of criteria. Only five are required to meet the diagnosis.
The nine criteria for BPD are:
1. Chronic feelings of emptiness
2. Emotional instability 
3. Frantic efforts to avoid real or imagined abandonment
4. Identity disturbance with markedly or persistently unstable self-image or sense of self
5. Impulsive behavior in at least two areas that are potentially self-damaging (e.g., spending, sex, substance
abuse, reckless driving, binge eating)
 6. Inappropriate, intense anger or difficulty controlling anger 
7. A pattern of unstable and intense interpersonal relationships characterized by extremes between
idealization and devaluation 
8. Recurrent suicidal behavior, gestures, threats, or self-harming behavior
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
 Causes of BPD
There's no single cause of borderline personality disorder (BPD) and it's likely to be caused by a combination
of factors as follows:
Genetics
Twin studies and studies of families suggest that personality disorders may be inherited or
strongly associated with other mental disorders among family members. It is somehow linked
to mood disorders.
Brain Abnormalities
Some research has shown changes in certain areas of the brain involved in emotion regulation,
impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such
as serotonin, may not function properly.
   Environmental Factors: A number of environmental factors are common among people
with BPD, including:
 Being a victim of emotional, physical or sexual abuse
 being exposed to chronic fear or distress as a child
 Being neglected by one or both parents
 Growing up with another family member who had a serious mental health condition (bipolar disorder or
substance abuse disorder)
 Relationship with parents and family have a strong influence on how people view the world and what
they believe about other people.
 unresolved fear, anger and distress from childhood can lead to a variety of distorted thinking patterns in
adulthood.
Comorbidity: BPD statistics
Mood disorders are common among people with borderline personality disorder. 20% having Major
depression and about 40% having Bipolar disorder.
Eating disorders are also common, particularly bulimia. Almost 25% of people with bulimia also have
borderline personality disorder.
 Up to 67% of the people with borderline personality disorder are also diagnosed with at least one Substance-
use disorder.

Treatment
One of the most effective treatment is psychotherapy, more specifically Dialectical Behaviour Therapy (DBT).
DBT was developed by psychologist Dr Linehan in the 1980's in response to the need for specific BPD
treatment. 
DBT is a cognitive behavioural approach that places emphasis on the psychosocial aspects of treatment. The
theory is that some people are prone to react in a more intense way toward emotional situations found in
romantic, family and friend relationships. DBT theory suggests that individuals with DBT's arousal levels in
such situations increase far more quickly than the average person’s and they attain a higher level of emotional
stimulation. This takes a significant amount of time to return to baseline arousal levels.

Dialectical behaviour therapy 

Cognitive-based 
 DBT aims to identify thoughts, beliefs and assumptions that make life harder:
Examples are: “I have to be perfect at everything.” “If I get angry, I’m a terrible
person." DBT helps people to learn different ways of thinking that will make life
more bearable: Examples are: “I don’t need to be perfect at things for people to care
about me”, “Everyone gets angry, it’s a normal emotion.
Support-oriented
 It helps to identify their strengths and builds on them so that the person can feel better about him/herself
and their life.
Collaborative 
 DBT encourages people to work out problems in their relationships with their therapist and the
therapists to do the same with them. DBT asks people to complete homework assignments, to role-play
new ways of interacting with others and to practice skills such as soothing oneself when upset. These
skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and
referred to in nearly every group. The individual therapist helps the person to learn, apply and master the
DBT skills.
They've been described as social predators who charm, manipulate and ruthlessly plough their way
through life, leaving a trail of broken hearts and shattered expectations while completely lacking in
conscience and empathy. Let's take a look at Antisocial personality disorder.

Anti-Social Personality Disorder

Antisocial personality disorder (ASPD) also known as sociopathy, is a disorder whereby a person consistently
shows no regard for right and wrong and ignores the rights and feelings of others. A person with ASPD shows
no guilt or remorse for behaviour and tends to antagonise, manipulate and treat others harshly with callous
indifference. 
 ASPD is common amongst those who violate the law and they may lie, behave violently or
impulsively and have and alcohol use problems. People with this disorder typically can't fulfil responsibilities
related to family, work or school.
A diagnosis for ASPD is not made before the age of 18 and children or adolescents with a later diagnosis of
ASPD would often have been diagnosed with conduct disorder, having displayed the above characteristics
towards animals and other people. People with ASPD can be dangerous and should not be treated outside of a
clinical setting when criminal behaviour is evident.

Difference between sociopaths & psychopaths

Psychopathy 
Manipulation through superficial charm and a  lack of remorse are key characteristics. The DSM 5 does not
list psychopathy as an official clinical diagnosis. However, antisocial diagnoses are at times referred to as
psychopathy or sociopathy. It is similar to antisocial personality disorder but with less emphasis on overt
behaviour.
Cleckley, a psychiatrist, who created the list of criteria for psychopathy, did not deny that many psychopaths are
at greatly elevated risk of criminal and antisocial behaviours, he did emphasise that some have few or no legal
or interpersonal difficulties. In other words, some psychopaths are not criminals and some do not display the
outward aggressiveness that was included in the DSM criteria for antisocial personality disorder. What
separates many in this group from those who get into trouble with the law may be their intelligence quotient
(IQ).
Sociopathy
Antisocial personality disorder is sometimes called sociopathy. This is a person who consistently shows no
regard for right and wrong and ignores the rights and feelings of others. Some experts see sociopaths as “hot-
headed.” They act without thinking how others will be affected. Psychopaths are more “cold-hearted” and
calculating. They carefully plot their moves, and use aggression in a planned-out way to get what they want.

Diagnostic Criteria for Anti-Social Personality Disorder

For a diagnosis of antisocial personality disorder, patients must have
 A persistent disregard for the rights of others
 This disregard is shown by the presence of ≥ 3 of the following:
1. Disregarding the law, indicated by repeatedly committing acts that are grounds for arrest
2. Being deceitful, indicated by lying repeatedly, using aliases, or conning others for personal gain or
pleasure
3. Acting impulsively or not planning ahead
4. Being easily provoked or aggressive, indicated by constantly getting into physical fights or assaulting
others
5. Recklessly disregarding their safety or the safety of others
6. Consistently acting irresponsibly, indicated by quitting a job with no plans for another one or not paying
bills
7. Not feeling remorse, indicated by indifference to or rationalization of hurting or mistreating others
Treatment : Antisocial personality disorder
 They rarely identify themselves as needing treatment. Because of this, and because they can be manipulative
even with their therapists, most clinicians are pessimistic about the outcome of treatment for adults who have
antisocial peronality disorder, and there are few documented success stories
Psychcotherapy
Cognitive behavioral therapy is a type of counseling that focuses on changing a person’s thinking and behavior.
Therapy for ASPD may help people think about how their behavior affects others. Someone with ASPD may
benefit from individual therapy, group therapy or family therapy.
Clinicians encourage identification of high-risk children so that treatment can be attempted before they become
adults
One large study with violent offenders found that CBT could reduce the likelihood of violence five years after
treatment 
he most common treatment strategy for children involves parent training (Patterson, 1986; Sanders, 1992).
Parents are taught to recognise behaviour problems early and to use praise and privileges to reduce problem
behav- iours and encourage prosocial behaviours.
Pharmacotherapy 
Medication generally only helps people with aggression, depression or erratic moods alongside ASPD. Your
healthcare provider may recommend:
 Antidepressants, which can regulate serotonin levels in your brain. Examples
include sertraline and fluoxetine.
 Antipsychotics, which can control violent behavior or aggression. Examples
include risperidone and quetiapine.
 Mood stabilizers, which help manage severe changes in mood or behavior. Examples
include lithium and carbamazepine.
The next group describe those who are overly dramatic and often seem almost to be acting, thereby given
the name "histrionic", which means theatrical. Let's explore Histrionic personality disorder:
 Histrionic Personality Disorder
Individuals with histrionic personality disorder tend to be overly dramatic and often seem almost to be acting,
which is why the term histrionic, which means theatrical in manner, is used.
Histrionic personality disorder is a personality disorder involving a pervasive pattern of excessive
emotionality and attention seeking.
They also tend to be vain, self-centred and uncomfortable when they are not in the limelight. They are often
seductive in appearance and behaviour, and they are typically concerned about their looks. 
In addition, they constantly seek reassurance and approval and may become upset or angry when others do not
attend to or praise them. People with histrionic personality disorder also tend to be impulsive and have great
difficulty delaying gratification.
Symptoms
At least five of the following traits needed to be
recorded for a diagnosis to be indicated:
1. A compulsion to be the center of
attention that results in discomfort if unmet
2. Inappropriate sexual, seductive
or provocative behavior when interacting
with others
3. Shallow, rapidly shifting emotions
4. The use of physical appearance to draw
others’ attention
5. Dramatic speech that lacks detail
6. Exaggerated, theatrical emotional
expression
7. Easily influenced by others or situations
8. Assumes relationships are more
intimate than they are
 
Below is a clip of a well-known psychiatrist who gives a good explanation of the symptoms of Histrionic
personality disorder:

Treatment 
 Psychotherapy 
A large part of therapy for these individuals usually focuses on the problematic interpersonal relationships.
They often manipulate others through emotional crises, using charm, sex, seductiveness or complaining People
with histrionic personality disorder often need to be shown how the short-term gains derived from this
interactional style result in long-term costs, and they need to be taught more appropriate ways of negotiating
their wants and need.
We all know people who think highly of themselves warranting special treatment from others. In Narcissistic
personality disorder, this tendency is taken to its extreme.

Narcissistic Personality Disorder

An exaggerated sense of self-importance and are preoccupied with receiving
attention. These are the main characteristics of those with NPD. 
   They have an intense need for admiration 
They are so pre- occupied with themselves that they lack sensitivity and compassion for
other people. Therefore, lack of empathy for others is a key characteristic of NPD. 
So what is behind this inflated sense of self-esteem?
 Behind all the grandiosity lies a pathological low self-esteem that's vulnerable to the slightest criticism. 
Others may not enjoy being around them, and they may find your relationships unfulfilling. 
A narcissistic personality disorder causes problems in relationships, work, school and financial affairs.
People with NPD are generally unhappy and disappointed when they are not given the special favours or
admiration they believe they deserve. 
Diagnostic Criteria for Narcissistic Personality Disorder - DSM-V
Indicated by 5 (or more) of the following:
1. Has a grandiose sense of self-importance 
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with,
other special or high-status people (or institutions)
4. Requires excessive admiration
5. Has a sense of entitlement 
6. Is interpersonally exploitative (i.e. - takes advantage of others to achieve his or her own ends)
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
8. Is often envious of others or believes that others are envious of him or her
9. Shows arrogant, haughty behaviors or attitudes.

Treatment: Narcissistic personality disorder 

Psychotherapy 
Treating NPD is very difficult as narcissists tend to not stay in therapy once they perceive they are being
criticised. Research has shown that NPD is best treated in a group therapy setting.
Psychotherapy often focuses on their grandiosity, their hypersensitivity to evaluation and their lack of empathy
towards others
Cognitive therapy strives to replace their fantasies with a focus on the day-to-day pleasurable experiences that
are really attainable. Coping strategies such as relaxation training are used to help them face and accept
criticism. Helping them focus on the feelings of others is also a goal.

Comorbidity
Depression
Those with NPD often fail to live up to their own expectations, they are often depressed. As individuals with
this disorder are vulnerable to severe depressive episodes, particularly in middle age, treatment is often initiated
for the depression.
 Case study: Tommy 
Tommy is a 19 year old teenager who migrated to Turkey with his mother recently. He only moved there with
his mother as his father was arrested and sent to prison due to his severe criminal acts. In addition to this, he and
his mother forced to migrate there because the war is going on in their homeland, so they struggled with severe
security and economic problems, and they hoped to find a safe place in the host country. Unfortunately, the war
started when he was 17 years old, so he grew up in such harsh conditions without enough family support.
His father has been in jail for a year, so Tommy and his mother lived together for a while. Furthermore, she
decided to divorce him immediately after he was jailed. He has not attended his high school since the war
started, so he decided to continue his education in the host country. He does not attend school regularly and
does not do his homework. He was involved in many physical fights, especially with male peers. His teachers
are always complaining to his mother about these severe problems, but she does not know what to do because
he lies to his mother. His mother does not have a job, they get financial aid from the Turkish government, but
the support is not enough that he tried to shoplift many supermarkets around his neighbourhood due to lack of
money.
His robbery was not limited to this. He also tried to steal cell phones while walking by people. He disregards
what is right and wrong. He has used alcohol and tobacco products since he was 16 years old, and he continues
to do so. Noticeably, he also started to use illegal drugs when he and his mother migrated to Turkey. He was
arrested twice for that, and he was in custody for seven days. Furthermore, he tried to destruct his neighbour’s
house, but he escaped  from the  police; however, when he tried to commit arson on that same neighbour’s car,
he was apprehended. He acts in a way that he does not think about the consequences of actions, and he defends
himself by blaming his mother that she does not give him enough support.
Discussion question
1. Which disorder is best suited to describe Tommy's symptoms?
2. From an integrative approach, describe the possible causes of this diagnosis?
 
*This week's question requires a bit more from you but it is good practice for the final exam. You may need to
consult your textbook.
Comments Section
Answer Thank you to everyone who participated last week! I gave some more time for those who still
wanted to contribute since we had a long weekend.
Antisocial personality disorder best suits his symptoms. However, since it cannot be diagnosed until after 18, he
is likely to have suffered from Conduct disorder when mentioning his behaviour before the age of 18.

Biological causes
His father displayed criminal behaviour. Therefore, his father may suffer from the same or closely related
mental disorder. With more information it might be revealed that his father also suffers from antisocial
personality disorder as ASPD is common amongst those who violate the law. There is evidence that genetic
factors do make people more vulnerable to developing ASPD. We know that this behaviour started before the
age of 18. He would therefore most likely have already had a conduct disorder. Many children diagnosed with
conduct disorder are boys, who then develop ASPD after 18. Genetic factors may be more important in the
presence of harsh environments.

Environmental causes
Tommy was exposed to a harsh environment during his adolescent years. He lived in a war zone and lived with
a father who committed severe criminal acts. This combined with a genetic vulnerability may have caused him
to develop ASPD. Moving to a new country can have its own challenges such as loss of peer group, educational
disruption, resentment for leaving etc. This then combined with the abovementioned may increase his
vulnerability to developing the disorder. His mother’s divorce from his father is another stressor that he is
needing to deal with in addition to everything else.

Psychological causes
When parents give in to problem behaviours when they are children, this may teach them that if they keep
fighting, they will get their way. Tommy’s mother, being a single mom, did not intervene or assist his
schoolteacher when he got into trouble. Her lack of intervention with his behaviour during his school years may
have taught him that he can always get what he wants without any consequences. So, a lack or inconsistent
discipline may have contributed to the diagnosis.
Feedback
From an integrative approach we need to firstly understand that different factors combine to produce ASPD or
any mental disorder. We cannot just say for example, that someone’s environment alone will cause them to
develop a disorder. When you describe this, organize your answers under each approach as I have.   
Link the causes to the case study. Don’t mention a cause that is not found in the case study. Otherwise, you are
just listing information and do not show that you can practically apply the information.
An integrative approach does not mean just list many causes. You need to discuss causes from different areas.
Genetic influences is one group. You can then discuss whether he/she may have or has a genetic vulnerability.
Some of you answered this well by making a link between his fathers’ behaviour. You may not know for sure,
but you can suggest, given the information. Then you may move on to talk about environmental factors. What
kind of environment did they grow up in? Was it a emotionally or physically abusive space? Was it a supportive
environment? 
If you have any further questions about your answer, please reach out

End of lesson 

__________________________________________________________________________________________
____

Week 11:
Cluster C Personality disorders
This week we conclude our study on personality disorders with Cluster C.  They are characterized by anxious,
fearful thinking or behavior. These include 3 types: 
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Lesson outcomes
Define & describe each Cluster C PD
Known relevant symptoms & comorbidities
Understand treatment options or lack of options available
Apply knowledge of PD's practically 
The next personality disorder describes people who feel
extremely uncomfortable in social situations and seek to avoid these as much as possible. It's important to
note that their avoidance is more from a place of rejection by others than fear of the actual activity. 
 Avoidant personality disorder
Definition: Avoidant personality disorder is a pervasive pattern of social
inhibition, feelings of inadequacy, and hypersensitivity to criticism.
The core concern or worry for these individuals is rejection by others. This is why
they are hypersensitive to criticism. This then makes sense why they choose to avoid
social situations altogether since they don't run the risk of getting hurt by others. Unlike asocial types, who are
disinterested in relationships with others, Avoidant personality types desire relationships with others.
What causes someone to develop APD?
 Genes, biological & psychosocial influences
 Occurs more often in relatives of people who have schizophrenia.
Individuals may be born with a difficult temperament or personality characteristics. As a result, their parents
may reject them, or at least not provide them with enough early, uncritical love. This rejection, in turn, may
result in low self-esteem and social alienation, conditions that persist into adulthood.

Treatment
Psychotherapy: Cognitive Behavioral therapy (CBT)
Behavioural intervention techniques for anxiety and social skills problems have had
some success. Because the problems experienced by people with avoidant
personality disorder resemble those of people with social phobia, many of the same
treatments are used for both groups.
Therapeutic alliance – the collaborative connection between therapist and client –
appears to be an important predictor for treatment success in this group.
Pharmacotherapy
   In most cases, avoidant personality disorder is not treated with medication unless there is
another underlying condition. No strong evidence suggests medication is an effective stand-alone
treatment for avoidant personality disorder, but it can be helpful if one also experiences mood and
anxiety disorders.
In the case of anxiety or mood disorders co-occurring, SSRI'S can be used to ease symptoms of depressed
mood or anxiety. 
We have all depended on other people to support us in some way throughout our life.  To people with DPD,
this dependence on people takes over all aspects of their lives so that they cannot take care of their basic
needs on their own. 

Dependent personality disorder

People with Dependent personality disorder often
feel helpless, submissive or incapable of taking care of
themselves. They have trouble making simple decisions without
the help of someone they trust. This results in an unreasonable
fear of abandonment.
 Symptoms:

1.They rely on others to make ordinary/routine decisions.

2.Agree with people when their own opinion differs so as not to be rejected.
3.Their desire to obtain and maintain supportive and nurturing relationships may lead to their other behavioural
characteristics, including submissiveness and passivity.
4. Requires others to assume responsibilities which they should
be attending to.
5. Difficulty starting projects without support from others.
6. Feels vulnerable and helpless when alone.
7. Desperately seeks another relationship when one ends.
8. Unrealistic preoccupation with being left alone and unable to
care for themselves. 
How different is Dependent personality
disorder from Avoidant personality disorder?
People with this disorder are similar to those with avoidant personality disorder in their feelings of inadequacy,
sensitivity to criticism and need for reassurance. However, people with avoidant personality disorder respond to
these feelings by avoiding relationships, whereas those with dependent personality disorder respond
by clinging to relationships.
Causes/Aetiology
We are all born dependent on other people for food, physical protection and nurturing. Part of the socialisation
process in most cultures involves helping us live independently. It was thought that disruptions such as
the early death of a parent or neglect or rejection by caregivers could cause people to grow up fearing
abandonment. It is also clear, however, that genetic
influences are important in the development of this disorder. 

Treatment
Little research exists to show whether a particular treatment
is effective.
Because of their attentiveness and eagerness to give
responsibility for their problems to the therapist, people with
dependent personality disorder can appear to be ideal
patients. That very submissiveness, however, negates one of
the major goals of therapy, which is to make the person more
independent and personally responsible. Therapy therefore
progresses gradually as the patient develops confidence in his
or her ability to make decisions independently.
There is a particular need to take care that the patient does
not become overly dependent on the therapist.
Typical type of thought process of someone with DPD:
 
Obsessive-Compulsive personality disorder
Definition:  A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal
control at the expense of flexibility, openness and efficiency.
People who have obsessive-compulsive personality disorder are characterised by a fixation on things being done
‘the right way’. Although many might envy their persistence and dedication, this preoccupation with detail
prevents them from completing much of anything.
They have poor interpersonal relationships.
 So how is it different to OCD?
This personality disorder seems to be only distantly related to obsessive-compulsive disorder (OCD), one of the
anxiety disorders. Patients tend not to have the obsessive thoughts and the compulsive behaviours seen in the
like-named OCD.

Causes/aetiology
There seems to be a weak genetic contribution to
obsessive-compulsive personality disorder. Some
people may be predisposed to favour structure in their
lives, but to reach extreme levels may require parental
reinforcement of conformity and neatness. 
Below is a video that gives a detailed breakdown of
the 8 symptoms of OCPD.  The description of each
symptom starts at 7:50.

Treatment 
Therapy often attacks the fears that seem to under- lie
the need for orderliness. These individuals are often afraid that what they do will be inadequate, so they
procrastinate and excessively ruminate about both important matters and minor details. Therapists help the
individual relax or use distraction techniques to redirect the compulsive thoughts. This form of CBT – following
along the lines of treatment for OCD (see Chapter 5) – appears to be effective for people with this personality
disorder. 

Comorbidity: OCPD
There is a co-occurrence with depression, bipolar disorder, and eating disorders (in particular with anorexia
nervosa)
End of lesson
Below is a link to a recent article (2022) that nicely summarises significant research findings for Avoidant
personality disorder.  https://www.ncbi.nlm.nih.gov/books/NBK559325/

Avoidant personality disorder is a chronic and pervasive maladaptive behavioral pattern. The onset is
insidious and affects all aspects of the individual's life. This activity reviews the evaluation and the management
of avoidant personality disorder and highlights the role of the interprofessional team in managing patients with
this condition.
Objectives:
 Describe the postulated etiologies and risk factors that increase the diathesis for avoidant personality
disorder.
 Identify the list of differential diagnoses for avoidant personality disorder.
 Outline the typical presentation of a patient with avoidant personality disorder.
 Explain the importance of improving care coordination amongst the interprofessional team to enhance
the delivery of care for patients with avoidant personality disorder.
Introduction
In the 5th century B.C., Hippocrates offered his hypothesis regarding the origin of behavior with his humoral
theory, postulating temperament was derived from the heterogeneous balance of the four distinct humors in the
body. The four humors consisted of black bile - melancholic, yellow bile - irritable, phlegm - apathetic, and
blood - sanguine. The humors and their subsequent temperaments supposedly embodied the elements of earth,
fire, water, and air, respectively.[1] References to this nascent personality classification would be observed
throughout antiquity up until the 20 century. The first nosological listing of personality types manifested with
the creation of the diagnostic and statistical manual of mental disorders (DSM) I in 1952, in which seven
distinct personality types were identified. This initial list was modified in subsequent editions of DSM,
ultimately precipitating the ten personality disorders, evident in the current DSM (DSM V - 2013).[2] 
These ten disorders are further categorized into three clusters – clusters A, B, and C. Cluster A contains
paranoid, schizoid, and schizotypal. Cluster B consists of antisocial, histrionic, narcissistic, and borderline
personality disorders. And cluster C includes avoidant, dependent, and obsessive-compulsive personality
disorders. Personality disorders can be described as chronic life-long maladaptive behavior patterns that are
inflexible and pervasive, infiltrating all aspects of an individual’s life. Of salience for this review will be
avoidant personality disorder (AVPD). AVPD was first introduced in the psychiatric nosology in DSM III in
1980. It is associated with an overly sensitive hyper-vigilant temperament, with a general longing to relate to
others.[3] Sentiments regarding the formal designation of AVPD have been mixed, as some essentially view it
as a more severe variant of social anxiety disorder (SAD).
Etiology
Genetic predisposition, infantile temperament, early childhood environment, and attachment style have all been
postulated to play a role in the development of AVPD. The heritability coefficient for AVPD has been estimated
to be 0.64.[4] Infantile temperament traits associated with a greater diathesis for AVPD include rigidity,
hypersensitivity, low novelty seeking, high harm avoidance, and overactive behavioral inhibition.[5][6] 
Studies reveal that the dynamic relationship between temperament and attachment can further exacerbate the
development of AVPD. This phenomenon manifests as the already minimally expressive infant’s distress is met
with dismissive responsiveness from the caregiver, potentiating maladaptive behavior patterns.[7] These early
interactions with caregivers result in fear of intimacy and trust, further engendering a state of hypervigilance.
Ultimately, these negative schemas precipitate avoidant coping strategies to obviate perceived prospective
distress. Other pertinent factors include minimal parental encouragement, caregiver guilt-engendering, neglect,
and abuse.
Epidemiology
Some experts question the validity of AVPD as an independent psychiatric manifestation rather than a disorder
within the spectrum of anxiety-related pathology. Nonetheless, studies investigating the prevalence of this
“questionable” disorder reveal rates ranging from 1.5% to 2.5%, with women being slightly more predisposed
towards the development of AVPD.[8][9]
History and Physical
An inferiority complex coupled with a coexisting fear of rejection is the quintessential constellation pattern of
AVPD. Behaviorally, this manifests as widespread avoidance of social interaction, which is ultimately the
salient diagnostic feature of AVPD. This intense aversion towards rejection leads to an excessive suppression of
affective expression, resulting in extreme schizoid-like introversion. Often this terrible dread of rejection
emanates from a repeated history of disappointing relationships in which the patient places the onus on
himself/herself, thus further diminishing self-esteem. This poor self-concept is more descriptively identified as a
state of malignant self-regard (MSR). MSR further exacerbates feelings of shame, personal inadequacy,
alexithymia, and perfectionism, and can also be observed in masochistic, self-defeating, depressive, and
vulnerable narcissistic personalities.[3]
Evaluation
The initial interview with the avoidant patient will prove a challenge for the clinician. These patients are often
reticent and laconic. Their constant fear of the potential embarrassment of 'saying something stupid' will disrupt
the interview process. The interviewer must use tact to create a therapeutic alliance in which the patient feels
confident enough to be forthcoming.
The categorical identification of AVPD in DSM-V implements the following diagnostic criteria:
Feelings of inadequacy, a pervasive pattern of social inhibition, and hypersensitivity to negative evaluation are
present in a variety of contexts, beginning by early adulthood as indicated by 4 (or more) of the following:
1. Avoidance of activities related to an occupation that involve significant interpersonal contact due to
fears of such issues as disapproval, criticism, or rejection.
2. Do not want to get involved with people unless they are sure of being liked.
3. Displays restraint within intimate relationships because of the fear of being ridiculed or shamed.
4. Is preoccupied with being rejected or criticized in normal social situations.
5. Shows inhibition in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, and inferior to other people.
7. Is unusually reluctant to take personal risks or engage in new activities because they may prove
embarrassing.
The alternative dimensional model of AVPD identifies the internalization of distress, high levels of negative
affectivity, behavioral inhibition and avoidance, and low levels of extraversion as salient diagnostic features.
Treatment / Management
As with most personality disorders not included within cluster B, little to no research has been conducted to
treat AVPD.[12] With this antecedent noted, post hoc analyses of studies investigating social anxiety disorder
(SAD), with comorbid AVPD, indicate the potential benefit of cognitive-behavioral therapeutic (CBT)
approaches to alleviate AVPD symptomatology.[13] 
CBT emphasizes the acknowledgment of negative automatic thoughts and how these thoughts can negatively
influence behavior. This enlightenment is then followed by the implementation of prosocial behavior to correct
the aforementioned dysfunctional schemas. Some experts believe interpersonal therapy (ITP) can be beneficial
for overcoming social anxiety and developing trust. Although no FDA-approved pharmacologic agent exists for
the treatment of AVPD, anecdotal reports reveal the improvement of symptomatology following administration
of psychotropics indicated for SAD, such as serotonin-specific reuptake inhibitors.[14] Furthermore, treating
comorbid psychiatric illnesses will undoubtedly improve the patient’s quality of life.
Differential Diagnosis
As mentioned previously, AVPD was initially believed to represent a classification within the spectrum of
pathological anxiety. Experts postulated that the phenomenology of AVPD could only exist in parallel with
SAD; however, this assumption has since been dispelled, as roughly two-thirds of individuals with AVPD do
not meet the standard criteria for SAD.[15] Shared vulnerability factors and common diagnostic criteria result in
similar clinical presentations with other cluster C disorders, such as dependent personality disorder (DPD).
[16] Although undoubtedly similar, the underlying foundational anxiety and desire for physical proximity in
DPD result from a fear of abandonment, whereas ruminations of possible rejection consume those with AVPD.
[3] 
The pervasive isolation witnessed in both AVPD and schizoid personality disorder can be diagnostically
differentiated by contrasting the active-detachment of AVPD against the schizoid trait of passive-detachment.
The former constitutes a state of "actively" avoiding social engagement with the impetus to circumvent
rejection, whereas the latter ambivalent "passive" isolation precipitates from a complete lack of interest.
Furthermore, those who have schizoid personality disorder are insensitive to social rejection and indifferent to
interpersonal engagement.[3] In effect, behavioral patterns of AVPD can mimic varying pathologies. Thus, to
ensure the diagnosis's veracity, clinicians will be wise to investigate the underlying impetus of behavioral
manifestations.
Prognosis
AVPD is considered to be a chronic disorder, as implied by its designation within the family of personality
disorders. However, some studies have suggested that, with time and treatment, a subset of those diagnosed
with AVPD will eventually no longer meet diagnostic criteria. Specifically, one study revealed stability of
diagnosis, ten years after the initial diagnosis, estimated to be 0.51.[17] 
Although this possibility of expiation from the disorder engenders hope, evaluations of those still meeting the
diagnostic threshold of AVPD reveal minimal to nonexistent symptom diminishment.[18] The prognosis for this
latter group is not hopeful. Research indicates that those with AVPD are more likely to be unemployed, less
educated, single, and more likely to be on disability when compared to controls.[19] Persons with AVPD are
also more likely to express worse physical health, frequent doctor visits, and more significant mental distress.
[20]
Complications
Avoidant personality behavior patterns generally engender further psychiatric comorbidities and a general lack
of dissatisfaction with life. It is not uncommon for someone with AVPD to suffer from depression, substance
abuse, and eating disorders. This discontent is represented statistically as those with AVPD have a higher
incidence of suicidal ideation and suicide attempts.[15] 
Less obvious but no less serious, the aforementioned malignant self-regard experienced by the avoidant patient
can lead to dysfunctional perfectionism, which can precipitate increased diathesis for postpartum depression.
[21] Because of these detrimental complications, early identification of AVPD with subsequent intensive
intervention is paramount.
Deterrence and Patient Education
Insidious in nature, AVPD is a chronic and pervasive disorder, without a defining inciting event or
distinguishable time of onset. Recommendations for deterrence are relegated to caregivers and entail providing
a nurturing and encouraging childhood environment. Psychoeducation of the social-psychological aspects of
AVPD can be profoundly insightful, ultimately leading to fruitful behavioral adaptations.
Enhancing Healthcare Team Outcomes
The prompt identification and management of AVPD are paramount if the patient is to lead a fruitful and
satisfying life. This goal can only be accomplished with a quality dynamic between the interprofessional team.
Most likely, this disorder will require not only pharmacological intervention but also intense psychotherapy and
unconditional support. Staff will need to be available around the clock in the event of emergent
decompensation. A well functioning team will consist of a psychiatrist, psychologist, social worker, nurses, and
medical assistants.