1 Abnormal Psychology This is not a course about the problems of someone else. Mental illness...
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Transcript of 1 Abnormal Psychology This is not a course about the problems of someone else. Mental illness...
1
Abnormal Psychology
This is not a course about the problems of someone else. Mental illness touches all of us at some time during our lives; if we are not the ones afflicted, then it will be a family member, loved one, or close friend.
The problem of abnormal behavior is personally relevant and emotionally charged, but in this course we will explore the problem from an objective and scientific point of view. Although we must be dispassionate in our study of the problem, it is important that we keep in mind the importance and the intense personal ramifications of what we are studying.
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PsychopathologyPsychopathology ... beyond behavior
1. Thought: problems in how and what we think
2. Emotion: problems in momentary mood and chronic temperament
3. Conation: problems in momentary motives and persistent needs
... the “subject matter” and the “data base”
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The Definition of “Psychopathology”The Definition of “Psychopathology”
Topics: The importance of the historical context
A.A. UnderstandingUnderstanding: scientific description and explanation... the history of our curiosity
B.B. InterventionIntervention: the change technologies
... the history of our compassion
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History History ... of understanding and intervention
3 broad perspectives on both:
1. Sociocultural: natural and supernatural
2. Biological: body and brain
3. Psychological: three theories of the mind
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Examples:
1.1. BiologyBiology: from the four humors to the monoamines
2.2. PsychologyPsychology: three “meta-theories”
A. Learning Theories: adaptation to the present and the behavior
and cognitive therapies
B. Phenomenological Theories: growth into the future and the
directive and non-directive therapies
C. Psychodynamic Theories: conflict from the past and the
psychoanalytic therapies
3.3. Sociocultural factorsSociocultural factors: natural and supernatural
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PeoplePeople and their ProblemsProblems... the recurrent millennia of history
Understanding problems, in the past the causes of problems
Intervening with people, in the future the course of life
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Some comparisons...Some comparisons...
1. Simple mechanical objects (cars and clocks)
... focus on causecause
2. More complex situations (soups and sauces)
... focus on effecteffect
3. The complexity of life (you and I)
... focus on resilienceresilience
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Implication... “problems” as solutions to problems
Factors in the ....
cause (past)
content (present)
course (future)
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Common confusions
A. Theory Therapyexample: “therapeutic nihilism”
B. Therapy Theoryexample: “post hoc explanations”
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HistoryHistory of psychopathology... the myth and the reality
“Those who don’t study history more
carefully are condemned
to repeat it.”
- George Santayana
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HistoryHistory of psychopathology... the myth and the reality
1. Ancient writings & archaeological evidence
Homer The Hebrews Trephining Asclepius
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HistoryHistory of psychopathology... the myth and the reality
2. Biogenesis: Hippocrates and “the four humors”
Sanguine Choleric Phlegmatic Melancholic
e.g., hysteria
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HistoryHistory of psychopathology... the myth and the reality
3. Psychogenesis: Plato and "the tripartite mind“
Affect Appetite Reason Self-management
e.g., catharsis
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HistoryHistory of psychopathology... the myth and the reality
3. The Roman Era and The Middle Ages The Roman Era : Galen and beyond
The Middle Ages : “The Dark Ages” (450 – 1450 A.D) The Arab World :
• Egypt and Avicenna The Western World :
• France • Italy • Britian• Gheel • St. Augustine
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HistoryHistory of psychopathology... the myth and the reality
4. The Renaissance
and the Revolutions
A. The Return of
the Supernatural View
Witches ... and the rise
of the asylum
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HistoryHistory of psychopathology... the myth and the reality
4. The Renaissance
and the Revolutions
A. The Return of
the Supernatural View
Witches ... and the rise
of the asylum
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HistoryHistory of psychopathology... the myth and the reality
Three Threats:Three Threats:
1. Physical: “The Black Death”
2. Religion: “The Reformation”
3. Social: “The Little Ice Age”
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HistoryHistory of psychopathology... the myth and the reality
The Solution:The Solution:
Malleus Maleficarum:
(and Thesaurus
Exorcismorum)
A witching trial during the Salem Witch Hunt
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HistoryHistory of psychopathology... the myth and the reality
The Solution:The Solution:
Marvin Harris
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HistoryHistory of psychopathology... the myth and the reality
The AsylumThe Asylum
London:
St. Mary’s of Bethlehem
Paris:
LaBicêtre
Salpêtrière
St. Mary’s of Bethlehem
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HistoryHistory of psychopathology... the myth and the reality
The AsylumThe Asylum
London:
St. Mary’s of Bethlehem
Paris:
LaBicêtre
Salpêtrière
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HistoryHistory of psychopathology... the myth and the reality
The Challenge:– St. Thomas Aquinas,
from the Middle Ages
– Johann Weyer Deception of Demons
Johann Weyer St. Thomas Aquinas
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HistoryHistory of psychopathology... the myth and the reality
The Challenge:– Reginald Scot
The Discovery of Witchcraft
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HistoryHistory of psychopathology... the myth and the reality
4. The Renaissance and the RevolutionsB. The “Mental Hospital Movement”Paris:
Philippe Pinel
and Jean Baptiste Pussin
Dorothea Dix
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HistoryHistory of psychopathology... the myth and the reality
4. The Renaissance and the RevolutionsB. The “Mental Hospital Movement”
London: William Tuke ... and the York Retreat
Dorothea Dix
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HistoryHistory of psychopathology... the myth and the reality
4. The Renaissance and the RevolutionsB. The “Mental Hospital Movement”
The York Retreat
Dorothea Dix
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HistoryHistory of psychopathology... the myth and the reality
4. The Renaissance and the Revolutions
B. The “Mental Hospital Movement”America: Dorothea Dix
... and “moral management”
Clifford Beers . .. and “the mental
hygiene movement”
Dorothea Dix Clifford Beers
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HistoryHistory of psychopathology... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
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HistoryHistory of psychopathology... the myth and the reality
5. The Psychiatric Revolution:
the return of biogenesis
Louis Pasteur
Benjamin Rush
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HistoryHistory of psychopathology... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
Louis Pasteur
Ignaz Phillip Semmelweis
Edward Jenner
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HistoryHistory of psychopathology... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
John Snow
William Farr
Paul Broca
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HistoryHistory of psychopathology... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
Alzheimer
Korsakoff
Wernicke
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HistoryHistory of psychopathology... the myth and the reality
The Story of General ParesisGeneral Paresis
Diagnosis ...from cases to syndromes
History ...from correlates to causes
Treatment ...from causes to cures
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HistoryHistory of psychopathology... the myth and the reality
Ehrlich’s “magic bullet”“magic bullet”
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HistoryHistory of psychopathology... the myth and the reality
Along the way....
anti-sexualism degeneracy theory phrenology
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HistoryHistory of psychopathology... the myth and the reality
The Medical View:
Wilhelm
Griesinger
Emil Kraepelin
Jean-Martin
Charcot
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HistoryHistory of psychopathology... the myth and the reality
6. Psychodynamic theory and psychoanalysis:
The return of psychogenesis
Liebault&
Bernheim:
““psychoneurosis”psychoneurosis”
Freud&
Breuer:
The case of
Anna OAnna O
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HistoryHistory of psychopathology... the myth and the reality
7. The “Mental Health MovementMental Health Movement”
the return of sociogenesissociogenesis, again
Sociologists Anti-Psychiatry Clinical Psychology
... and then, something happened...
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HistoryHistory of psychopathology... the myth and the reality
8. The “New Psychiatry”
The return of biogenesisbiogenesis,
again
DrugsDrugs and the
search for biologicalbiological causes
The technologiestechnologies and
an integrated approachintegrated approach
Heinz Lehmann
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The Lesson Lesson of History
“The lessons of the past
were obliterated by the aspirations
of the present.”
- Alexander Leighton
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The Lesson Lesson of History
“It ain’t what you don’t know
that gets you; it’s the things you
know that ain’t so.”
- Mark Twain
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The Lesson Lesson of History...Limitations to Progress
1. Understanding (finding causes): post hoc explanations correlates and causes longitudinal and experimental research the problem of base rates (BR)
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The Lesson Lesson of History...Limitations to Progress
2. Intervention (finding cures): placebo effects spontaneous remission (SR) superstitious behaviour publication bias
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The Lesson Lesson of History...Limitations to Progress
Summary:
1. Understanding: it is hard to find out whywhy something
happens when it doesn’t happen very oftendoesn’t happen very often
2. Intervention: it is hard to find out if anything makes a makes a
differencedifference to the course when that course is
erraticerratic and unpredictableunpredictable
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Definitions
1. Theoretical/absolute criterion
demons diseases defects
Making inferencesinferences and pathologizingpathologizing the resultsresults
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Definitions
2. Social/cultural criterion
deviance difference disgust
Making discriminationsdiscriminations and pathologizingpathologizing the minorityminority
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Definitions
3. Personal/subjective criterion
distress dysphoria despair
Making introspectionsintrospections and pathologizing unhappinesspathologizing unhappiness
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Definitions
The common-sense criterion:
Maladaptation/symptoms
disorder dysfunction disability thoughts & perceptions
emotions & feelingsneeds & motives
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The Modern Diagnostic System(DSM)
Why diagnosis?
... a present description
...with future implications
“Diagnosis is prognosis”
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The Modern Diagnostic System(DSM)
DSM I (1952) and DSM II (1968)
DSM III (1980) and DSM IV (1994) ... TR, now
ICD 1 (1948) to 10 (1992) ... CM, now
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The Modern Diagnostic System(DSM)
What have we gained?
1. ResearchResearch: no false positives
2. PracticePractice: no false negatives
... communication – in principle
... but research biasesbiases in practice
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Diagnosis of psychopathology(DSM)
Axis I -Axis I - Clinical syndromes
Axis II -Axis II - Personality disorders (and MR)
Axis III -Axis III - Medical conditions
Axis IV -Axis IV - Stress
Axis V -Axis V - Coping (GAF)
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Diagnosis of psychopathology(DSM)
“Other conditions that may
be the focus of clinical attention”,
including psychological factors
affecting medical conditions,
and the “V” code.
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Diagnosis of psychopathology(DSM)
Issues: 1. reliability & validity
2. categories, dimensions & prototypes
(“polythetic” clarification)
3. comorbidity, artifactual & real
4. subjectivity & biases
5. the problem of labeling
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Extent of psychopathology: ...prevalence, incidence
and life-time risk
Axis Disorder PrevalenceLife-Time
RiskTreatment
Ratio
Axis 1
Anxiety disorder 18% (12%) 30% (20%) 1 in 7
Affective disorder 9% (6+%) 17% (12+%) 1 in 4
Thought disorder 1% 1+% 1 in 2
Axis II Personality disorder 7% 9% unknown
Totals 20 - 30% 30% - 40+% 1 in 5
Some “ball-park” figures: (Canada)
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Extent of psychopathology: ...prevalence, incidence
and life-time risk
Prevalence Life-Time Risk
Drugs 6% (8%) 15% (20%)
MR 2% 2%
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Causal Factors and Viewpoints
Causation in psychopathology
1. Primary / necessary and sufficient causes
2. Predisposing / contributory causes (and the concept of "relative risk")
3. Precipitating / proximal and distal causes
4. Perpetuating / reinforcing (maintaining) causes
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Causal Factors and Viewpoints
The nature of causal complexity
... not necessarily the numbernumber of causes
... but the causal patterncausal pattern
i.e., living systems are self-regulatingself-regulating
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Causal Factors and Viewpoints
An overall conception: Diathesis-Stress
... the original additive additive model
... the newer interactiveinteractive model
i.e., living systems are resilientresilient
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Theoretical Perspectives
A. Biological: ...from simplistic to sophisticated
The Psychiatric Revolution – circular reasoning
The New Psychiatry– technology– conceptualization– causation
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Theoretical Perspectives
A Modern Checklist:
1. Genesa. direct influenceb. indirect (passive, evocative, active) influencesc. interactive influence
2. Congenital Factors
3. Constitutional Factorsa. the role of neurobiological inhibitionb. the role of evolutionc. aspects of temperament
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Theoretical Perspectives
TEMPERAMENT:
CHILD ADULT
Fearfulness Negative Affect (“Neuroticism”)
Irritability/Frustration
Positive Affect Positive Affect (“Extroversion”)
Activity Level
Attentional Persistence “Conscientiousness”
Also: Sociability… “Agreeableness”
Inhibition….
“Openness”
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Theoretical Perspectives
B. Psychological: The Three Meta-Theories
I. Psychodynamic theory – Conflict and its management
Psychoanalysis
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Theoretical Perspectives
B. Psychological: The Three Meta-Theories
II. Learning theory Adaptation and its means
a. Classical Conditioning & “experimental neurosis”
b. Operant Conditioning & “superstitious behavior”
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Theoretical Perspectives
1. Classical conditioning (“aversion”)
SHOT RSTARTLE (reflex)
CSWP - SHOT RSTARTLE
CSWP CRSTARTLE
... and extinction
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Theoretical Perspectives
2. Operant conditioning (“escape”)
SHOT RJUMP - SHOT
SHOT RJUMP
... and extinction
R(reward)
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Theoretical Perspectives
3. “Two factor” conditioning (“avoidance”)
CSWP RJUMP
CSWP RJUMP - SFEAR
... and extinction?
R
(reward?)
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Theoretical Perspectives
c. Cognition & “negative sets”
S R
S O R
Cognitive and behavior therapies
e.g. Rational-emotive and other cognitive therapies
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Theoretical Perspectives
B. Psychological: The Three Meta-Theories
III. Phenomenological (and “humanistic”) theory
Growth and its direction
“client-centered” and directivetherapies
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Theoretical Perspectives
Psychological theories and circular reasoning
A. A Modern Checklist
Psychological factors in psychopathology
1. Causes and correlates
2. The power of protective factors
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Theoretical Perspectives
C. Sociocultural: The Rise and Fall
Examples of “culture bound disordersculture bound disorders”
• Latah • Koro• Amok• Berserk • Kitsunetsuki• Pibloqtok• Lycanthropy• The Windigo Psychosis
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Theoretical Perspectives
C. Sociocultural:Sociocultural factors in psychopathology
1.1. ContentContent : how & how much
2.2. Course Course : how long
3.3. CauseCause : why
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Theoretical Perspectives
C. Sociocultural:Sociocultural theories and circular reasoning
Example:Example:the relation between
“exit events”and clinical depression
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Theoretical Perspectives
EXAMPLE: “25% of people experiencing Major Depressive Disorder (MDD) had an exit event.” “Only 5% of the control group without MDD had an exit event.” (“Exit Event”=physical departure of a significant person in the last six months”) Do exit events cause MDD? Base rate for MDD (point prevalence): 2%
Take a population of 10,000 adults...200 MDD ... 25% with exit events = 509800 not MDD ... 5% with exit events = 490
So, we have 540 exit events, with fewer than 10% associated with MDD
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Theoretical Perspectives
C. Sociocultural:Social problems and the presumption of psychiatric causes
Examples:Examples:suicidecrime
child molestation
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Stress and the Adjustment Disorders
Stress
The General The General Adaptation Adaptation Syndrome:Syndrome:
How stressors
are stressful in the
diathesis-stress modeldiathesis-stress model.
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Stress and the Adjustment Disorders
Measurement
DSM – (Axes IV and V)
Self-report procedures – (LCUs and beyond)
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Stress and the Adjustment Disorders
Results
– Frustrations– Conflicts– Pressures
e.g. the hassle list and stress-induced analgesiastress-induced analgesia
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Stress and the Adjustment Disorders
Coping:1. Task-oriented, problem solving method2. Defense-oriented, emotion focused method
“God grant me the serenityto accept the things I cannot change,
the courage to change the thingsI can, and the wisdom to
know the difference”
- Reinhold Niebuhr
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Stress and the Adjustment Disorders
Coping:The big factor in choosingchoosing: “self –perceived competence”
... and its ramifications
The big factor in copingcoping: social support
... e.g. the Alberta Study
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The Special Case of Extreme Stress
Results:1. “transient decompensation”2. “residual fear”
e.g. The Disaster Syndrome : shock, suggestibility and survival
The conventional findings ... and the caveat
e.g the “allostatic load”
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The Special Case of Extreme Stress
Coping:The “Ur” defenses (“Positive illusions”)
1. Our immortality2. The omnipotent servant3. Our kindness to one another
Also: The Polyanna PrincipleThe Belief in a Just World
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Adjustment Disorders
Dx: inference of the causal importance of stress
Types: – depressed– anxious– conduct disturbance ...– ... “mixed” types– “N.O.S”
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Anxiety Disorders Related to Extreme Stress
Acute Stress Disorder and Post-Traumatic Stress Disorder (PTSD)
Crucial for Dx: re-experiencing of an extremely traumatic event
The demographics of PTSD: BR and SR
Why do some people develop PTSD?– The nature of the trauma– The nature of the person– The nature of subsequent experience
Implications for treatment:– Social support, “debriefing”, exposure & stress-induced analgesia– The crisis in “Crisis-Counseling”
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Anxiety Disorders
Note: Adjustment disorder with anxious moodSubstance-induced anxiety disorderAnxiety disorder due to general medical condition
Prevalence Life-Time Risk
Phobia 1-2% 6+%Panic 1-2% 3+%Generalized anxiety 3-4% 5+%Obsessive-compulsive 1-2% 2+%Acute stress and PTSD 1-5% 7+%
10 - 12% 15 - 20%
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Anxiety Disorders
Anxiety
Normal vs. abnormal, Primary vs. secondary diagnoses An aspect of temperament (trait) and mood (state)…. …with biological components: GABA and the
monoamines in “negative emotionality”
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Anxiety Disorders
1. Phobia: specific, social and agoraphobia
BR: irrational fears and phobias
Treatment and SR
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Anxiety Disorders
Understanding phobiasa. Learning theory: situational causes e.g. Little Albert
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Anxiety Disorders
Specific phobias:
Traumas and dispositional factorse.g. “the immunization effect”
Note: “preadaptation” and “the inflation effect”
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Anxiety Disorders
Social phobias:
Experiential and dispositional factorse.g. “social sensitivity” & “automatic thoughts”
Treatments
Exposure: systematic desensitization (vs.flooding) and chemotherapies
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Anxiety Disorders
2. Panic: with or without agoraphobia
BR: with or without phobia
Understanding panica. Biology: monoamines in “the fear network”
Nature and nurture
b. Psychology: “anxiety sensitivity”Conditioning: “Fear of Fear
Model”Cognition: “Cognitive Model”
Treatments Chemotherapy and PCT
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Anxiety Disorders
3. Generalized Anxiety (GAD)
BR: primary and secondary GAD
Understanding GAD Psychodynamic theory: personality
Learning theories: conditioning and cognitiveBiology of negative emotionality
TreatmentsChemotherapies (from the beta-blockers to the
benzodiazepines, Buspar & antidepressants)Psychotherapies (exposure and beyond)
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Anxiety Disorders
4. Obsessive-Compulsive Disorder (OCD)
Descriptive featuresBR: OCD and “OCD Spectrum Disorders”
Understanding OCD Psychodynamic and Learning theories
Modern cognitive psychology: though suppression and its vicissitudes
Modern neurobiology: monoamines and the caudate nucleus
TreatmentsChemotherapy and psychotherapyThe special case