726 terms

PSYC 245H Exam 2

STUDY
PLAY
EDs began to increase in
the 1950s and 60s and have spread insidiously since but have leveled off in recent years
• age of onset is getting earlier
• BN rates increased most dramatically
• Used to only occur in the west but now are going global but still in a relatively small segment of the population
More than 90% of ED sufferers are
young females who live is socially competitive environments
Bulimia nervosa overview
out of control eating episodes known as binges are followed by purges that can involve self-induced vomiting, laxatives, and over-exercising
• only lose about ½ the calories when purge
• do not have low body weight and not required to have distorted body image
Anorexia nervosa overview
person eats nothing beyond minimal amounts of food so body weight sometimes drops dangerouslylow body weight and distorted body image with either restricting or binge/purge
- purge through exercise (hours a day), laxatives, vomit, diuretics
- body image defines self worth and may have major body image distortions
- very hidden, private, secret disease
what is the most severe ED?
anorexia
• 20% die as a result of the disorder
• highest mortality rate of any psychological disorder
binge-eating disorder overview
individuals binge repeatedly but do not purge
• only 70% are overweight; rest are normal weight (must be due to metabolism)
all EDs are accompanied by
overwhelming, all-encompassing drive to be thin
Strongest contributor to ED, unlike most disorders, is
sociocultural
what is not considered an ED by the DSM?
obesity
obesity overview
• one of the most dangerous epidemics confronting public health
• 70% of US adults are overweight; 35% are obese
• rates increasing for decades, but now maybe leveling off in North America
• causes a myriad of health problems like cardiovascular disease, etc.
• could be considered an ED because of excessive eating
hallmark of BN
eating a larger amount of food - typically more junk food than fruits and vegetables - than most people would eat under normal circumstances and having this eating be out of control then to compensate for this binging and potential weight gain with purging techniques
• actual caloric intake of binges varies significantly from person to person
• feeling out of control is almost more important than quantity of food
BN purging techniques
vomiting; using laxatives and diuretics; exercising excessively (*rigorous exercise more AN than BN); fasting between binges
• Not efficient methods of reducing caloric intake
vomiting
reduces caloric intake by only 50%
Laxatives/Diuretics
have little effect because they act so long after the binge
Specific psychological characteristics of BN
popularity/self-esteem/social acceptance is largely determined by the weight and shape of one's body
• self-evaluation unduly influenced by shape and weight
most with BN are
within 10% of their normal weight
those with BN (and BED too) may become unattained to...
physiological cues of fullness
BN: Binges
- avg. 10/week
- often carried out in secret
- preceded by feelings of tension and or powerlessness
- followed by extreme self-blame, guilt, depression, fears of weigh gain & "discovery"
BN: epidemiology
- 1.5% of women, 0.5% of men
- subthreshold forms more prevalent
- annual incidence increasing → great in urbanized areas
- risk increased in birth cohort after 1960
- increasing incidence in countries undergoing rapid Westernization
BN stats
- not recognized as a disorder until the 1970s
- 90-95% are women
• men with BN usually have later onset and are gay or bisexual
- tends to be chronic if untreated → poor prognosis
strongest predictors of BN
childhood obesity and continuing overemphasis on the importance of being thin
onset of BN
teens to early 20s
BN course of illness
- 20-30% of women have history of anorexia
- dieting or anorexia after first step
- binge eating usually precedes purging
most common form of purging
majority of women vomit to purge
- laxatives, diuretics, emetics, and other agents also common
repeated vomiting causes
• salivary gland enlargement
• erosion of dental enamel on inner surface of front teeth
• esophageal tearing, acid reflux
• electrolyte imbalance
• calluses on fingers/back of hands from friction of contact with teeth and throat from repeatedly stimulating gag reflex
• swollen parotid glands
• GI complications
• irregular menstruation
• loss of normal bowel function
salivary gland enlargement can cause
chubby face
electrolyte imbalance
upset of the chemical balance of bodily fluids, including Na- and K+ levels
- can result in: cardiac arrhythmia, seizures, renal failure
other things associated with BN
• depressed mood
• anxiety
• alcohol and drug abuse
• low self-esteem
• irritability
• Impulsivity
• concentration/memory
alcohol and drug abuse in BN
way to avoid emotions just like binging
impulsivity in BN
impulsive spending, shoplifting, sexual impulsivity
• for the two above, Freud would say the id was breaking through
Young women with BN develop more
body fat than normal
Laxative abuse can cause
intestinal problems → severe constipation or permanent colon damage
Psychological Disorders Associated with BN
BN particularly associated with anxiety disorders (social phobia, etc.) and mood disorders (major depression, bipolar disorder)
• BUT, patients with anxiety disorders do not necessarily have an elevated rate of EDS
• BN is more associated with anxiety than depression or substance abuse
- borderline personality disorder
Depression and BN
depression seems to follow bulimia rather than cause it; may be a reaction to BN
Substance abuse and BN
alternative stress reliever in order to avoid food as a stress reliever
traits in BN that increase comorbidity
emotional instability and novelty seeking
BN: individual factors
- history of AN
- childhood anxiety disorders
- perfectionism
• these people are likely the ones with a history of restrictive AN
- low-self-esteem
- high social self-consciousness
- high novelty seeking and impulsivity
• if they had a history of AN, likely binge/purge AN
those with perfectionism and BN may have history of what type of AN?
these people are likely the ones with a history of restrictive AN
those with high novelty seeking and impulsivity and BN may have history of what type of AN?
if they had a history of AN, likely binge/purge AN
BN: Family Factors
- influenced by both genetic and environmental factors
- familial depression
- familial alcoholism
- childhood sexual abuse (nonspecific)
• sets you up for a wide variety of psychiatric disorders; can't say exactly how it will manifest in adulthood
- familial emphasis on appearance and weight
what is the treatment of choice for BN
- psychotherapy superior to pharmacotherapy
- CBT treatment of choice
• ~2/3 of patients no longer BN with brief, focused intervention
• but don't know about long-term
relapse and BN
- high risk of relapse in 6 months - 1 year after treatment
- abstinence at end of treatment predicts continued abstinence
what is essential in BN treatment
nutritional rehabilitation essential
- regulate eating habits/patterns
• also create patterns for sleep and activity
medication and BN
- SSRIs beneficial in the short term → fluoxetine (60 mg) only FDA approved medication for any eating disorder
BN outcome and mortality
- mortality not significantly elevated
- high relapse risk
- unknown how best to treat CBT nonresponders
- increasing patterns of comorbidity may be complicating treatment
Anorexia Nervosa
- so successful at losing weight that lives are put in danger
- morbid fear of gaining weight and losing control over eating, just like BN, but those with AN are actually successful
How common is AN?
AN is less common than BN but there is overlap
• may individuals with BN have a history of AN
Body weight in AN
low body weight (<85% of ideal body weight)
• if you can get people up to a BMI of 20 during treatment, it looks like they'll be able to keep it up; below 20 and will likely relapse
• Body weight must be 15% below that expected but the average is actually 25% to 30% below normal by the time treatment is sought
AN, body image and self-worth
disturbance in the way one's weight or shape is experienced, undue influence on self-evaluation, or denial of seriousness of illness
- all self-worth come from body
• gaining weight → make you worthless
- may see a completely different reflection
- often focus on a few body parts/areas
AN has intense fear of
intense fear of obesity and relentless pursuit of thinness; intense fear of gaining weight or becoming fat
• never satisfied with their weight loss
• not losing weight from day to day can cause intense panic, anxiety, and depression
how does AN usually begin
Usually begins with an overweight adolescent starting a diet that morphs into an obsession
What type of purging is coming with AN?
severe, almost punishing exercise is common with AN
how is dramatic weight loss achieved in AN?
Dramatic weight loss is achieved through
• severe caloric restriction
• caloric restriction and purging
Two subtypes of AN (refer only to the most current 3 months of the disorder)
• Restricting subtype
• Binge-eating-purging subtype
Restricting subtype of AN
individuals diet to limit caloric intake
- restrict "bad foods"
Binge-eating-purging subtype of AN
binge on relatively small amounts of food and purge more consistently than those with BN
- ~50% of those with AN are this subtype
- objective binge vs. subjective binge
• aka ate 3 cookies
- vomit after meals, abuse laxatives, exercise excessively
objective binge
society agrees it is a binge
subjective binge
just a binge for that person
usefulness of sub typing in AN
subtyping may not be useful in predicting the future course of the disorder but rather may reflect a certain phase or stage of AN
Those with AN will say
they could gain a few pounds and are underweight but then with further questioning will say they're fat and need to lose
• as such, they seldom seek treatment on their own because even though they'll parrot what they think others want to hear, they'll never believe the truth that they're underweight/sickly
some with AN show
increased interest in cooking; may be master chefs or hoard food just to look at occasionally
relationships and AN
- but relationships are disturbed
• "better relationship with ED than with me"
• bad body image → no sex
• low sex drive, exhaustion
- partners
• no physical attraction
• afraid of breaking partner's bones
age of onset of AN
around puberty or early teens
• can be rebellion
• may want to be super skinny
• may be want to have control
- documented pre-pubertal and late life onset
what is often the first manifestation of AN?
dieting (and vegetarianism) often first manifestation
what is a symptom of AN that is no longer in the DSM because it does not always occur?
amenorrhea (loss of menstruation) may precede weight loss
average duration of AN
average duration (community 1.7 yrs; clinic 5 years)
• really long term → some struggle whole life
AN stats
• chronic but not as chronic as BN
• maintain low BMI over a long period
• distorted perceptions of shape and weight → continue to restrict eating even once no longer anorexic
• more resistant to treatment than BN
AN mortality rate
highest mortality rate of any psychological disorder
• higher likelihood of dying once BMI reaches 13
• body cannot sustain itself without food
• also suicide
• always have a physician on staff for anorexia
menstruation and AN
cessation of menstruation or amenorrhea (also may occur in BN)
• can be an objective physical index of the degree of food restriction but is not consistent across patients
• not longer a diagnostic criteria
Other physical signs of AN
• dry skin, dyhydration
• electrolyte imbalances
• lanugo
• growth retardation
• loss of gray matter; cognitive impairment
• brittle hair or nails
• sensitivity to or intolerance of cold temperatures/low body temperature
• lanugo → downy hair on the limbs and cheeks
• cardiovascular problems → chronically low blood pressure (hypotension) and heart rate (bradycardia)
• osteoporosis
other behavioral/psychological consequences of AN
• depression
• low self-esteem
• extreme perfectionism
• self-consciousness
• self-absorption
• ritualistic behavior
what disorder are often present in those with AN
- anxiety (social phobia, GAD) and mood disorders
- BN
- substance abuse
Which anxiety disorder is often with AN
• Anxiety disorder with AN is often OCD
o Unpleasant thoughts → gaining weight
o Compulsions → variety of behaviors some of then ritualistic to rid themselves of such thoughts; don't eat, purge actions
GAD and AN
- see gaining weight as dangerous so cope by not eating which has a calming effect
• eating increases distress level
- takes over life
AN is a strong predictor of
mortality, particularly by suicide
• A recent meta-analysis conducted by Preti and colleagues (2010) analyzed data from 40 studies presenting cause of mortality data and found that 245 suicides occurred out of 16,342 patients with AN over a mean follow-up for 11.1 years, yielding a standardized mortality ratio SMR of 31.0
AN: Individual Factors
- history of dieting
- prior history of obesity (binge/purge subtype)
- precipitating events
- perfectionism
- social self-consciousness
- temperamental factors (harm avoidance, neuroticism)
history of dieting and AN
may get too caught up in dieting and it can turn into ED like AN
prior history of obesity and AN
usually binge/purge subtype
• society rewards people for losing weight
• may remember childhood comments about weight/bullying
precipitating events and AN
may not be tied to weight per say
-Ex → women who got bit by dog developed not a dog phobia but AN
• Suggests a genetic component
perfectionism and AN
- those with AN do "body-checking"
• check for fat with hands; look in mirror
- attention to detail allows to increased control over food
- high-achieving people develop AN
social self-consciousness and AN
• i.e. social anxiety
• worried people are going to judge you based on how you look
temperamental factors and AN
harm avoidance, neuroticism
• harm avoidance → focus energy around avoiding negative things rather than seeking positive things
AN Family Factors
- influenced by both genetic and environmental factors
• low levels of oxytocin → decreases social bonding
- familial depression
- familial obsessive-compulsive personality disorder
- familial emphasis on appearance and weight
- familial obesity
family obesity and AN
• may decide you don't want to be this extreme, but don't have good role models to become the alternative
• may go from this extreme to the other (i.e. AN)
societal factors and AN
- emphasis on thinness
- dieting as normative
- emphasis on appearance
- magical beliefs about low weight
• If I have low weight, good things will happen to me
media influences and AN
- 68% of females cited books/magazines as a primary source of ED info
- 49% said media was their sole source
- 39% said this knowledge affected their own eating attitudes and behaviors
- adolescents spend on average 5 hours/day consuming media
- Today → a lot of counter efforts against these influences
• i.e. new Barbie
AN treatment is
difficult → many patients in denial
what must AN treatment be?
multidisciplinary is a must → medical, nutritional, family, psychological
- nutritional rehabilitation essential
Therapy for adolescents with AN
- family therapy superior for under 15 years
Therapy for adults with AN
- cognitive-behavioral therapy promising after weight restoration
• CBT ineffective before this because people can't think before they regain weight
medications and AN
- SSRIs may assist with weight maintenance
- no effective medications → no FDA approved medications
The Role of Couple-Based Intervention (UCAN) Within the Multidisciplinary Treatment of AN
- Individual therapy
- medical management
- dietary counseling
- couple-based intervention (UCAN)
- 5% dropout rate vs. 38% dropout rate for McIntosh
• partners likely help keep the ED sufferer in treatment
AN: Outcome and Mortality
- 5% mortality (death and suicide)
• suicide occurs when hopelessness/misery occurs
- can be a difficult and intractable disorder
- 50% of women develop BN
- rates of complete recovery are low (better with early onset and early detection)
- 10-15% develop a chronic unremitting course
- BMI<13 associated with mortality
- for those that no longer meet the diagnostic criteria, they still struggle with it; "live with in their whole life"
Features Common to both AN and BN
- dieting
- unhealthy relationship to body
- unhealthy relationship with food
• see food as the enemy, as bad
- elevated risk of self-harm/suicide attempts
• BN has elevated risk of suicide attempts but not elevated risk of suicide
- anxiety, depression, perfectionism
- substance abuse
• likely attempt at mood regulation
AN and BN differences
- weight
- distortions
- personality
- medical complications
AN and BN differences: weight
• must have low weight for AN
• can be/usually normal weight for BN
AN and BN differences: distortions
• AN has heavily distorted body image
• BN does not
AN and BN differences: personality
• AN is perfectionist, detail-oriented, constrained, shy
• BN is more impulsive, out of control, outgoing
AN and BN differences: medical complications
- worse for AN
• cardiovascular and system shutdowns
- GI complications with BN
• Unpleasant but not deadly
Binge-Eating Disorder
occurs when individuals experience marked distress because of binge eating but do not engage in extreme compensatory behaviors
- Can cause very high weight gain to obese levels (BMI 40)
• Only 70% with BED are overweight
• 30% are normal weight
BED is a disorder caused by a separate set of factors from obesity without BED and is associated with more severe obesity
unlike AN and BN, BED has...
- BED has a greater likelihood of occurring in males with a later age of onset
- greater likelihood of remission and better response to treatment with BED than with AN and BN
those with BED
- ~50% of those with BED try dieting before bingeing; the other 50% starts with bingeing then attempts to diet
• those with bingeing first have worse BED and are more likely to have additional disorders
- have concerns about weight and shape like those with BN and AN
- those with BED binge to eliminate bad moods or negative affect
BED is associated with
- rapid eating
- feeling uncomfortably full
- eating when not hungry
• just want the taste of food, like food but gets out of control
- eating alone because embarrassed
- feeling disgusted, depressed, or guilty
- marked distress regarding binge-eating
- once per week for 3 months
- no inappropriate compensatory behaviors
BED: Associated Features
- obesity (especially BMI>40)
- depression
- anxiety
- emotional eating
• mood regulating strategy
- self-disgust
- history of dieting
- low self-efficacy
BED: Epidemiology and Course
- 3.5% of females, 2% of males
- onset late teens/early 20s
- onset usually after restrictive dieting
- chronic course punctuated with slips and relapses
- common comorbid depression
BED: Treatment
- behavioral and cognitive-behavioral interventions reasonably effective at decreasing binge eating (~80% to no binges) but not lowering weight
• not necessarily cutting calories just not binging
• body goes into conservation mode once calories are cut
- Interpersonal psychotherapy similar to CBT in effectiveness
• like BN where you get people on a system of eating/pattern
- Medications
- Prozac (antidepressant) not effective
ED Statistics
- adolescent girls are most at risk for EDs
- the prevalence of AN may be underrepresented
- many cases of AN and BED but not BN begin after age 18
- median age of onset for EDs → 18-21
Cross Cultural Considerations of EDs
- AN and BN develop in immigrants who have recently moved to western countries
- African American adolescent girls have less body dissatisfaction, fewer weight concerns, a more positive self-image, and perceive themselves to be thinner than they are compared to white girls
• May be due to the fact that white males prefer skinner women than do black males
- Ethnic differences may be changing as ED rates are equalizing among ethnicities
• In fact, EDs are more common among Native Americans than other ethnic groups
Developmental Considerations of EDs
- important because many EDs begin in adolescence
- differential patterns of physical development in girls and boys interact with cultural influences to create eating disorders
• physical development takes boys closer to the ideal (tall and muscular) and girls further away from the ideal (thin and prepubertal)
- EDs in children under 11
• Usually AN → restrict food and fluid intake, not understanding the difference
- Generally, concerns about body image decrease with age
Social Dimensions of EDs
- looking good is more important than being healthy for many young women
- self worth, happiness, and success are largely determined by body measurements and percentages of body fat for females in competitive environments
• results in dieting, the first step to EDs
- pop-culture glorifies slenderness, portraying women that are thinner than the average American woman
• strong relationship between exposure to media images depicting the thin-ideal body and body image concerns in women (African American media depicts the thin ideal less, possibly contributing to much lower rates of EDs)
• Risk for developing EDs is directly related to the extent to which women internalize media messages
Thin ideal standards...
thin-ideal standards are becoming more difficult to achieve as the size and weight of the average woman has increased over the years with improved nutrition
Differences between men and women with EDs
- women rated both the attractive female and male body weights both as lower than males did
- men have different body image perceptions than women
• Men desire to be heavier and more muscular than they are
- males may be prone to the opposite type of body image distortion to women; they may see themselves as too small when they're normal/muscular
• may lead to steroid abuse
EDs and young female cliques
- young girls tend to share body image concerns with their friendships cliques but these cliques do not necessarily cause these attitudes or the disordered eating that follows; adolescent girls tend to choose friends who already share these attitudes
Parents and EDs
- affluent parents have put their chubby toddlers on diets causing them to have inadequate nutrition and severely retarded development as a result
- mothers with AN may also restrict their children's food intake
people who diet and EDs
most people who diet won't develop an ED
- BUT adolescent girls who diet are 8x more likely to develop an ED 1 year later than those who are not dieting
• May be because weight reduction techniques in adolescent girls are more likely to result in weight gain than weight loss
• Repeated cycles of "dieting" seems to produce stress-related withdrawal symptoms in the brain resulting in more eating than would have occurred without dieting
Severe risk factors for EDs
• already binge-eating and purging
• eating in secret
• express a desire for an empty stomach
• preoccupied with food
• afraid of losing control over eating
EDs and genetics
strong genetic contribution to body size so ED efforts may be fruitless
Dietary Restraint
- Experiment during WWII → for 6 months healthy men were given about half their former full intake of food then they had a 3 month rehab phase during which food was gradually increased
• lost ~25% of body weight
• participants became preoccupied with food and eating
- occurs in ballerinas, athletes - particularly females ones such as gymnasts
- dieting in one factor that can contribute to EDs along with dissatisfaction with one's body
Family Influences
- typical family of those with AN is successful, hard-driving, concerned about external appearances, and eager to maintain harmony
• mothers of girls with disordered eating act as "society's messengers" in wanting their daughters to be thin
• family may help start ED but is not sole factor
- after the onset of EDs, particularly AN, family relationships deteriorate quickly
• some parents have even used physical violence to make their daughters eat though they've felt considerable guilt and anguish
Biological Dimensions
- EDs run in families and have a genetic component
- In 23% of identical twin pairs, both twins had bulimia compared to 9% for fraternal twins
• Genetic makeup is about half the equation among causes of anorexia and bulimia → BUT no clear agreement on what is inherited
o May be emotional instability and poor impulse control
o Perfectionistic traits and negative affect
- Hypothalamus → may play an important role in EDs
• Low levels of serotonergic activity
- some neurobiological anomalies do exist in people with EDs but that may be a result of semi-starvation or binge-purge cycle rather than a cause but may contribute to the maintenance of the ED once it is established
young women with EDs often have:
- a diminished sense of personal control and confidence in their own abilities and talents
• may manifest as strikingly low self-esteem
- perfectionistic attitudes (learned or inherited) → reflects attempts to exert control over important events in their lives
• individuals must consider themselves overweight and manifest low self-esteem before this trait makes a contribution
• when perfectionism is directed to distorted perception of body image is when EDs are really likely to
- intense preoccupation with how they appear to others
- feelings of being imposters in their social groups and heightened levels of social anxiety
• may explain why they choose social groups with similar attitudes toward eating and body shape
minor events related to eating may...
minor events related to eating may activate fear of gaining weight, further distortions of body image, and corrective schemes such as purging
anxiety and EDs
anxiety before and during snacks which is theorized to be relieved by purging
• state of relief strongly reinforces the purging
- during treatment, reducing the anxiety associated with eating is less important than countering the tendency to overly restrict food intake and the associated negative attitudes about body image that lead to bingeing and purging
mood tolerance
a certain subgroup may have difficulty tolerating any negative emotion (mood intolerance) and may binge or engage in other behaviors to regulate their mood
all eating disorders have much in common in terms of causal factors and no one factor seems to cause them
- individuals with EDs have some of the same biological vulnerabilities as those with anxiety disorders
• EDs could be anxiety disorders focused exclusively on a fear of becoming overweight
- negative emotions trigger binge eating
- social and cultural pressures to be thin
• social roles in high achieving families → emphasis on looks, achievement, perfectionistic tendencies
• result in exaggerated focus on body shape and weight
- preexisting personality characteristics may determine which disorder an individual develops
- 50% of people with EDs have EDNOS
Drug Treatments ED
- drug treatments have not been found to be effective in the treatment of AN
- Drugs may be useful for some people with bulimia, particularly during the bingeing and purging cycle
• antidepressants like Prozac → average reduction in binge eating and purging was 47% and 65% in two studies
• do not have substantial long-lasting effects on BN
Psychological Treatment EDs: until the 1980s
directed at the patient's low self-esteem and difficulties in developing an individual identity along with disordered patterns of family interaction and communication
• alone, did not have the effectiveness that clinicians hoped they might
short term CBT for EDs
target problem eating behavior and associated attitudes about the overriding importance and significance of body weight and shape
• treatment of choice for BN
Updated CBT for EDs
- variety of new procedures intended to improve outcome have been added
- has become "transdiagnostic" meaning it is applicable with minor variations to all EDs
• because features of various EDs overlap considerably
All EDs include...
All EDs include similar inherited biological vulnerabilities, similar social influences, and a strong family influence toward perfectionism in all things and seem to share anxiety focused on one's appearance and presentation to others, as well as
- CBT directed at causal factors → principal focus on the distorted evaluation of body shape and weight, and maladaptive attempts to control weight in he form of strict dieting
distorted body image
• AN patients cannot get CBT until they regain the weight
BN: early stages of CBT-E
• Teach the patient the physical consequences of binge eating and purging, the ineffectiveness of vomiting/laxatives for weight control, and the adverse effects of dieting
• Schedule patients to eat small, manageable amounts of food five or six times per day with no more than 3 hour intervals between any planned meals or snacks to eliminate alternating periods of overeating and dietary restrictions
• Arrange activities so that the individual will not spend time alone after eating reducing the chance of being able to purge
BN: later stages of CBT-E
- Alter dysfunctional thoughts and attitudes about body shape, weight, and eating
- Develop coping strategies for resisting the impulse to binge/purge
CBT-E for BN in adults shows
superior, lasting efficacy for reducing/eliminating binge/purge behavior and for distorted attitudes and accompanying depression
• Interpersonal Therapy (IPT) is less effective
• Some people though do not benefit from short term CBT
• Combining drugs (SSRIs/antidepressant) with psychological treatment might boost the overall outcome in the short term
Family therapy for adolescents with BN
when family therapy is directed at painful conflicts present in families, it can be effective for adolescents with BN
Binge Eating Disorder treatment
- CBT can be successfully adapted from BN to BED
• Prozac does not help CBT for BED
• More effective than behavioral programs with mild success such as Weight Watchers
- stopping binge eating is critical to sustaining weight loss in obese patients
- IPT is just as effective as CBT for BED
- Self-help procedures may be useful in the treatment of BED
• Maybe should be the first treatment offered for BED before engaging in more expensive and time-consuming therapist-led treatments
Different ethnic groups with BED have different concerns
• African Americans with BED → tend to have higher BMI
• Hispanics with BED → tend to be more concerned with shape and weight
• Treatment may need to be tailored to ethnic groups
If an obese person is bingeing, standard weight loss procedures will be
ineffective without treatment directed at bingeing
most important initial goal of AN treatment
restore the patient's weight to a point that is at least within the low-normal range
- inpatient treatment may be recommended if body weight is below 85% what it should be because severe medical complications (cardiac failure, etc.) could occur
- Important because starvation → induces loss of gray matter and hormonal dysregulation in the brain
• These changes are reversible when normal weight is restored
- Initial weight gain though → is a poor predictor of long-term outcome in AN
• Must also attend to patients underlying dysfunctional attitudes about body shape to avoid relapse
For restricting anorexics, must treat
- marked anxiety over becoming obese and
- undue emphasis on thinness as a determinant of self-worth, happiness, and success
Outpatient CBT for AN
Outpatient CBT is significantly better for AN than continued nutritional counseling in preventing relapse after weight restoration
Include the family to accomplish two goals
- Eliminate negative and dysfunctional communication in the family regarding food and eating
• meals must be made more structured and reinforcing
- discuss attitudes toward body shape and image distortion
family therapy is particularly effective with
young girls with a short history of the disorder
AN treatment has...
has historically worse outcomes than treatment for BN
- Family based treatment (FBT) though is working better
- CBT-E is promising for adolescents with AN
many cases of EDs are...
resistant to treatment and most individuals who do not receive treatment suffer for years or their whole lives
developing EDs in adolescents poses...
risks for problems and disorders during adulthood
• cardiovascular problems, chronic fatigue and infectious diseases, binge drinking/drug use, and anxiety/mood disorders
preventative programs must target
specific behaviors to change
• eliminate an exaggerated focus on body shape or weight and encourage acceptance of one's body
• can be done in person or over the internet
preferable way to prevent disorders
preventing these disorders through widespread educational and intervention efforts would be clearly preferable to waiting until the disorders develop
Obesity
- not formally considered an ED
- only somewhat elevated anxiety and mood disorders over normal population
- rates of substance abuse are actually lower
- in 2000, the number of adults with excess weight worldwide surpassed the number of those who were underweight
Statistics Obesity
- 35.7% of American adults were obese in 2010, making up 9.1% of US health care expenditures
• was 12% of Americans in 1991
• significantly higher mortality rates
o at BMI of 30, risk of mortality increases by 30%
o at BMI of 40, risk of mortality increases by 100% or more
• 6.3% of US pop. have BMI over 40
- no difference between men and women
- stigma of obesity has a major impact on quality of life
• overweight individuals are subjected to prejudice and discrimination
• ridicule and teasing in obese children may increase obesity through depression and binge-eating
obesity cross-culturally
- rates of obesity in eastern and southern Europe are as high as 50%
- rate of obesity is greatly increasing in developed nations
- obesity is the main driver of type 2 diabetes, an epidemic
- ethnicity and obesity
• 58% of African American women and 41% of Hispanic women are obese whereas only 32% of Caucasian women are obese
• higher rates of obesity among black and Hispanic adolescents compared to white ones
two forms of maladaptive eating in obesity
• binge eating
• night eating syndrome
a minority of patients with obesity (7-19%) present with patterns...
of binge eating
• those who do should have treatments for BED integrated into weight-loss programs
in 6-16% of obese people
night eating syndrome occurs
- those with NES eat 1/3 or more of their daily intake after their evening meal and get out of bed at least once during the night to have a high-calorie snack
• those with NES eat 1/3 or more of their daily intake after their evening meal and get out of bed at least once during the night to have a high-calorie snack
o key factor is that they are AWAKE
• usually not hungry in the morning and don't eat breakfast
key factor is that they are AWAKE
• those with NES eat 1/3 or more of their daily intake after their evening meal and get out of bed at least once during the night to have a high-calorie snack
o key factor is that they are AWAKE
• usually not hungry in the morning and don't eat breakfast
- usually not hungry in the morning and don't eat breakfast
Causes of Obesity
- related to the spread of modernization which promotes an inactive, sedentary lifestyle and the consumption of a high-fat, energy-dense diet is the largest single contributor to the obesity epidemic
• "toxic environment"
- genetics may constitute a smaller portion of the cause of obesity than cultural factors; thought to be about 30% of obesity causation
• genes influence the number of fat cells an individual has, the likelihood of fat storage, and most likely, activity level
• takes a "toxic" environment to turn these genes on
- obesity spreads through social networks
biological factors of obesity
initiation and maintenance of eating
psychological factors of obesity
impulse control, affect regulation (i.e. eating when sad) and attitudes
treatment for obesity from least to most intrusive
• self-directed weight loss programs
• commercial self-help programs
• behavior modification programs
• very-low-calorie diets and drugs
• bariatric surgery
self-directed weight loss programs
usually lose in the short term but regain in the long term
commercial self-help programs
- i.e. Weight Watchers and Jenny Craig
- better success than self-directed
- up to 80% of individuals, even if initially successful, are not successful in the long-run
behavior modification programs
- most successful programs but still not great
- people lost weight but still regained some
very-low-calorie diets and drugs
- people on diets gain a lot of the weight back
- drug treatments (lorcaserin, phentermine/topiramate)that reduce internal cues signaling hunger may have some effect when combined with behavioral approach to changing lifestyle
• concerns about cardiovascular side effects
bariatric surgery
stomach stable to severely limit food intake OR gastric bypass which creates a bypass of the stomach, limiting both food intake and absorption of calories
- 15% of patients who have bariatric surgery fail to lose significant weight
- increasingly popular for people with BMI of 40/severe risk because the surgery is permanent
- usually more successful than diets
• people lose 20-30% of their body weight and maintain loss over a number of years
- if the surgery is successful, risk of death from obesity-related issues can decrease up to 90%
- but still problems with the surgery so should not become routine until we learn more
food taxes
make healthy foods less expensive and unhealthy foods more expensive
• but would have to be substantial to have an effect
Efficacy of obesity treatments
- only moderately successful that the individual level
- higher for children and adolescents in short and long terms
• family involvement in behavior modification programs that seek to
• change dietary habits (decrease high-calorie, high-fat snacks)
• reduce sedentary habits
• currently evaluating a safer, less intrusive bariatric surgery for severely obese adolescents
time spent sleeping
- spend 1/3 of our lives sleeping
- 24 hours of sleep impairs thinking; major sleep disorders can be very impairing
• people who do not get enough sleep are more susceptible to illnesses because the immune system functioning is reduced
chronic sleep deprivation often has...
profound effects, potentially causing the difficulties people experience in everyday life or may result from some disturbance common to a psychological disorder
Rapid Eye-Movement (REM) sleep
dream sleep involved with the limbic system which also is involved with anxiety
• connection to the limbic system suggests that → anxiety and sleep may be interrelated in important ways
• REM sleep seems related to depression
Insufficient sleep can stimulate
overeating and may contribute to the epidemic of obesity
Two Major categories of sleep disorders
• Dyssomnias
• Parasomnias
Dyssomnias
involve difficulties with getting enough sleep, problems with sleeping when you want to , and complaints about the quality of sleep
- insomnia disorder
- hyper somnolence disorders
- narcolepsy
- breathing-related sleep disorders
- circadian rhythm sleep-wake disorder
Parasomnias
abnormal behavior or physiological events that occur during sleep
- disorder of arousal
- nightmare disorder
- rapid eye movement sleep behavior disorder
- restless legs syndrome
- substance-induced sleep disorder
Sleep measures
• Polysomnographic (PSG)
• Actigraph
• Sleep efficiency (SE)
• observe behavior while awake
Polysomnographic (PSG)
provides most comprehensive picture of your sleep
- patients sleep in a lab and are monitored on a number of measures
Actigraph
measures arm movements during sleep and can detect when people fall asleep and wake up
Sleep efficiency (SE)
the percentage of time actually spent asleep not just lying in bed trying to sleep
- divide amount of time sleeping by the amount of time in bed
insomnia disorder (definition)
difficulty falling asleep at bedtime, problems staying asleep throughout the night, or sleep that does not result in the person feeling rested even after normal amounts of sleep
insomnia disorder
- one of the most common sleep-wake disorders
- unrelated to any other condition
- rare
- microsleeps → sleeps that last several seconds or longer
- fatal familial insomnia → degenerate brain disorder that involves a total lack of sleep that eventually leads to death
- involves a number of complaints
• Difficulty initiating sleep
• Difficulty maintaining sleep
• Nonrestorative sleep
- often overlaps with psychological disorders such as anxiety and depression
Insomnia Statistics
- 35% of older adults have insomnia per year
• older black men have the most problems
- Female:Male = 2:1
• women are more likely to report problems initiating sleep which may have to do with hormonal differences OR to differential reporting of sleep problems
- 20-40% of kids have insomnia
• don't want to sleep, throw tantrums OR wake up crying
Total sleep time often decreases with
depression, substance use disorders, anxiety disorders, and neurocognitive disorder due to Alzheimer's
• alcohol often used to initiate sleep because it small doses it makes people drowsy BUT it also interrupts ongoing sleep which causes anxiety and repeated alcohol use
as kids move to adolescence
their biologically determined sleep schedules shift toward a later bedtime but they're still expected to wake up early causing chronic sleep deprivation
• Chinese American adolescents have fewest problems with insomnia while Mexican American adolescents have the most
- number of hours we sleep decreases as we age
Causes of Insomnia
- pain, physical discomfort
- delayed temperature rhythm → body temperature doesn't drop and they don't become drowsy until later at night
- drug use
- light, noise, temperature
- other sleep disorders
• periodic limb movement disorder → excessive jerky leg movements
- stress in life worsens sleep
- anxiety
- thoughts alone may disrupt our sleep
- poor sleep may be a learned behavior
poor sleep may be a learned behavior
- people associate the bedroom and bed with frustration and anxiety that go with insomnia
- parents and learned insomnia
• parent's depression and negative thoughts about child sleep may contribute to children's sleep problems
• some children learn to fall asleep only with with a parent present
Insomnia disorders: Cultural differences
- children in the US sleep in separate rooms often alone and at a certain age are expected to self-soothe
• unmet demands can result in stress that negatively affects the ultimate sleep outcome for children
- other cultures have communal sleeping and don't ignore the cries of children
Rebound insomnia
sleep problems reappear, sometimes worse, as a result of withdrawal from sleep medication
- Taking sleep aids can perpetuate sleep problems
napping and insomnia
Napping can alleviate fatigue during the day but can also disrupt sleep at night
children and insomnia disorder
Children that wake up and receive positive attention may way up more to get the positive attention
Hypersomnolence Disorders (definition)
excessive sleepiness that is displayed as either sleeping longer than is typical or frequent falling asleep during the day
hyper somnolence disorders
- sleep too much
- excessive sleepiness despite being fully rested after a night's sleep
- subjective experience as a problem
- unrelated to other condition
• sleep apnea can cause excessive sleepiness → difficulty breathing at night; snore loudly, pause between breaths, wake up with a dry mouth and headache
- rare
- Facts and stats
• family history
• associated with exposure to viral infections
• little research
Narcolepsy (definition)
episodes of irresistible attacks of refreshing sleep occurring daily, accompanied by episodes of brief loss of muscle tone (cataplexy
Narcolepsy
- daytime sleepiness
- cataplexy
- sleep paralysis
- hypnagogic hallucinations
Narcolepsy: cataplexy
a sudden loss of muscle tone occurring while a person is awake and can range from slight weakness in the facial muscles to complete physical collapse
- Cataplexic attacks
• lasts several seconds to several minutes
• preceded by a strong emotion
• appears to result from a sudden onset of REM sleep
Narcolepsy: sleep paralysis
a brief period after awakening when a person can't move or speak that is often frightening to those who go through it
• can occur on its own as isolated sleep paralysis often with anxiety
Narcolepsy: hypnogogic hallucinations
vivid and often terrifying experiences that begin at the start of sleep and are said to be unbelievably realistic
narcolepsy statistics
• rare → occurs in 0.03-0.16%
• female:male = 1:1
• typically improves over time
• daytime sleepiness persists without treatment
breathing-related sleep disorders (definition)
(obstructive sleep apnea hypopnea syndrome, central sleep apnea and sleep-related hypoventilation)
a variety of breathing disorders that occur during sleep and that lead to excessive sleepiness or insomnia
Breathing-Related Sleep Disorders
- daytime sleepiness
- disrupted sleep at night due to brief arousals throughout the night
- sleep apnea
sleep apnea
breathing is constricted to a point where it may be stopped for 10-30 second periods
• restricted air flow
• brief cessations of breathing
• loud snoring that bothers bed partner but not the victim
• 3 subtypes
3 subtypes of sleep apnea
- obstructive sleep apnea (OSA)
- central sleep apnea (CSA)
- sleep related hypoventilation
obstructive sleep apnea (OSA)
airflow stops but respiratory system works
• airway may be too narrow or damaged
• obesity and increasing age associated with it
• MDMA use
• Most common in males, 10-20% of population
central sleep apnea (CSA)
respiratory system stops for brief periods
• associated with CNS disorders such as cerebral vascular disease, head trauma, and degenerate disorders
• wake up throughout the night but are not sleepy during the day or aware of the disorder
sleep related hypoventilation
Mixed sleep apnea → combination of OSA and CSA
• decrease in airflow without complete pause in breathing
• causes an increase in CO2 levels
circadian rhythm sleep-wake disorder (definition)
a discrepancy between the sleep-wake schedule required by a person to be rested and the requirements of the person's environment (e.g. work schedules) that leads to excessive sleepiness or insomnia
Circadian Rhythm Sleep Disorder
disturbed sleep due to the brain's inability to synchronize its slep patterns with the current patterns of day and night
- insomnia OR hypersomnia
Suprachiasmatic nucleus in the hypothalamus
- brain's biological clock
• reset by morning an evening light
- stimulates melatonin produced b the pineal gland
• production stimulated by darkness and decreased by light
circadian rhythm sleep disorders with external causes
• Jet lag type
• Shift work type
circadian rhythm disorder: jet lag type
sleep problems related to crossing time zones
- difficulty going to sleep at the proper time
- feeling fatigued during the day
- traveling two or more time zones westward usually affects people the worst
circadian rhythm disorder: Shift work type
sleep problems associated with work schedules
- i.e. nurses
circadian rhythm sleep disorders with internal causes
• delayed sleep phase type
• advance sleep phase type
• irregular sleep-wake type
• non-24-hour sleep-wake type
delayed sleep phase type
sleep is delayed or later than normal bedtime
advance sleep phase type
sleep is advanced or earlier than normal bedtime
irregular sleep-wake type
people who experience highly varied sleep cycles
non-24-hour sleep-wake type
sleep on a 25- or 26-hour cycle with later and later bedtimes ultimately going throughout the day
treatment for insomnia
Insomnia
- benzodiazepines
• short-term solutions
• can cause excessive sleepiness
• rebound insomnia
• dependence frequently occurs
• sleep-walking (Ambien)
• short-acting drugs are preferred because long-acting drugs sometimes do not stop working by morning so people report more daytime sleepiness
• some medications are being worked on to affect the melatonin cycle to help people fall and stay asleep (Rozerem)
treatment for Hypersomnia/narcolepsy
stimulants
• Ritalin, amphetamine, modafrinil
treatments for cataplexy
antidepressants → suppress REM or dream sleep, thus maintain muscle tone
treatments for Breathing-related sleep disorders
- weight loss
- mechanical devices
• CPAP machine → a mask provides slightly positive pressurized air during sleep helping people breathe more normally throughout the night
• Uncomfortable and claustrophobic
• Dental splint
- Surgery to remove blockages
- Didgeridoo → people who practiced this wind instrument had less daytime sleepiness
environmental treatments for circadian rhythm sleep disorders
- Phase delays are easier than phase advances
• phase delays → moving bedtime later
• phase advances → moving bedtime earlier
- Schedules shifts in a clockwise directions → go from day to evening schedules
- Phototherapy → use of very bright light to trick the brain's biological clock
psychological treatments
- stimulus control
- relaxation
- reduces stress
- modify unrealistic expectations about sleep
- combined medication/behavioral treatments
- CBT may be more successful treating sleep disorders in older adults than a medical (drug) intervention
- bedtime rituals set up for children
stimulus control
• regular bedtime routine
• improved sleep hygiene
improved sleep hygiene
Bedroom is a place for sleep and sex, not work or watching the news (anxiety stimuli)
- includes:
• Setting a regular sleep and wake time.
• Avoiding use of caffeine and nicotine.
• Educating parents and others about normal sleep and sleep behavior.
• Eating a balanced diet.
• Going to bed when sleepy and getting out of bed if unable to sleep within 15 minutes.
• Reducing noise, stimulation, and temperature in the bedroom
relaxation
reduces physical tension that seems to prevent people from falling asleep
Preventing Sleep Disorders
- improving sleep hygiene
• setting regular sleep and wake times
• avoiding stimulants
o caffeine and nicotine
- educating parents about child's sleep patterns
Parasomnia types
- disorder of arousal
- nightmare disorder
- rapid eye movement sleep behavior disorder
- restless legs syndrome
- substance-induced sleep disorder
disorder of arousal (definition)
motor movements and behaviors that occur during NREM sleep including incomplete awakening (confusional arousals), sleep walking, or sleep terrors (abrupt awakening from sleep that begins with a panicky scream)
nightmare disorder (definition)
frequently being awakened by extended and extremely frightening dreams that cause significant dishes and impaired functioning
rapid eye movement sleep behavior disorder (definition)
episodes of arousal during REM sleep that result in behaviors that can cause harm to the individual or others
restless legs syndrome (definition)
irresistible urges to moe the egg as a result of unpleasant sensations (sometimes labeled creeping, tugging, or pulling in the limbs) (otherwise referred to as Willis-Ekbom disease)
Substance-induced sleep disorder (definition)
severe sleep disturbance that is the result of substance intoxications or withdrawal
Parasomnias: REM sleep
nightmares
nightmares
- Experiences must be so distressful that they impair a person's ability to carry on normal activities
- Awaken the sleeper
- Involves dreams
• Distressing and disturbing
• Disrupt sleep, cause awakening
• Interfere with functioning
- More common in children
- Treatment
• Antidepressants
• Relaxation training
Parasomnias: NREM sleep
- sleepwalking
- sleep terrors
sleepwalking
aka somnambulism
• Probably not acting out a dream
• Usually during first few hours of deep sleep
• Person must leave the bed
• Primarily problem during childhood; 15-30% of kids
• Difficult (not dangerous) to wake
• Genetic component
• Can be associated with violence
• Usually resolves on its own
• Related to nocturnal eating syndrome
- Person eats while asleep
• Sexsomnia → action out sex or masturbation while asleep
sleep terrors
• More common in children
• Piercing scream
• Signs of elevated arousal (e.g. sweating)
• Person looks extremely upset
• Difficult to awaken
• Little memory of the event
• Prevalence
- Children 6%
- Adults 2%
• More boys than girls
treatment for sleep terrors
- "wait-and-see" if they disappear
- scheduled awakenings → awaken children ~30 minutes before a sleep terror which usually occurs at the same time each night
sexual dysfunction is
the most frequent diagnosis in the US
Sensory input affects
desire
arousal
motor response
desire
local vasocongestive response (influx of blood)
female desire
• vaginal lubrication - makes intercourse possible/vastly more comfortable esp. for the female
- if everything is physiologically fine, then lack of means there is no desire
• clitoris enlarges → cluster of sensory nerves
male desire
• penal erection
• partial elevation of testes
female arousal
• vagina expands
• uterus elevates
• orgasmic platform
• clitoral stimulation
male arousal
• testes elevate and increase in size
• prostate enlarges
plateau
specialized phase of arousal
Motor response
orgasm
female orgasm
• Rhythmic contraction in orgasmic platform at 0.8 second intervals
• Contractions in uterus
male orgasm
- Ejaculatory inevitability
• Prostate gland contract
• Seminal vesicles contract
- Orgasm proper
• Urethra contracts
• Penis contracts → 3 to 7 spurts of semen at 0.8 second intervals
female resolution
• Vagina returns to normal
• Uterus lowers
• Orgasmic platform disappears
male resolution
- Erection disappears
• Can cause timing issues if the male has an orgasm well before the female does
- Testes descend and loss of congestion
refractory period
After occurrence of some event, a waiting time period before it can occur again
- Males experience a refractory period after resolution phase, often increases with age
• May be as long as a day for older men
- Females are not physically refractory to orgasm
Biphasic Nature of Human response Cycle
• Lubrication and swelling phase
• Motor or orgasm phase
Lubrication and swelling phase
- Primarily sensory input (tactile, auditory, visual, olfactory, etc.)
- Parasympathetic arousal
• If sympathetic arousal occurs, then it makes sexual arousal more difficult
- Vasocongestion of genitals
• ~50% of males say they have trouble getting or maintaining an erection/arousal at one time or another
Motor or orgasm phase
- Motor or muscular response
- Sympathetic arousal
current views
current views tend to be quite tolerant of a variety of sexual expressions, even if they are unusual, unless the behavior is associated with a substantial impairment in functioning or involves nonconsenting individuals such as children
sexual dysfunction
difficulty functioning adequately while having sex
Paraphilic disorders
sexual deviation in which arousal occurs primarily in the context on inappropriate objects or individuals
Gender Dysphoria
incongruence and psychological distress and dissatisfaction with the gender one has been assigned at birth
almost all men and women are
sexually experienced
• by age 15, 25% of males and female have had vaginal intercourse
• 90% of men and 88% of women have had oral sex
• 40% of men and 35% of women have had anal sex
• 23.3% of men have had 20 or more partners but more than 70% had only have 1 partner during the previous year
• 29% of men but only 9% of women reported 15 or more partners in their lifetime
• sexual behavior continues well into old age
men and women tend toward
monogamous patterns of sexual relationships but gender differences do exist
Gender Differences in sexual attitudes
- 98% of men vs. 64% of women masturbate
• frequency for those who do was 2.5 greater for men
• may be due to female associations of sex with intimacy and men with physical gratification
• more likely due to ease of anatomy
- men have more permissive attitudes toward casual sex and pornography
• casual sex or "hooking up" increases with alcohol use for women but sex within a romantic relationship is still 2x more likely for young women
- NO differences between attitudes about homosexuality, the experience of sexual satisfaction, or attitudes toward masturbation
- Men are more accepting of premarital sex and sex outside of a marriage
differences in patterns of arousal
- men are more aroused by specific stimuli
• heterosexual men respond only to female stimuli
• homosexual men respond only to male stimuli
- women whether heterosexual or lesbian experience arousal to both male and female sexual stimuli, demonstrating a broader, more general pattern of arousal
Pelpau's 4 Main Theories
• Men show more sexual desire and arousal than women
• Women emphasize committed relationships as a context for sex more than men
• Men's sexual self-concept, unlike women's, is characterized partly by power, independence, and aggression
• Women's sexual beliefs are more plastic in that they are more easily shaped by cultural, social, and situational factors
sexual attraction and thus behavior is
closely tied to evolutionary mandates reflecting the importance of this behavior for the species
Cultural Differences
- The Sambia in Papua New Guinea believe that semen is not naturally produced so young boys engage in oral sex with older boys until later adolescence when they begin exclusively heterosexual activity
- The Munda of northeast India require adolescents and children to live together and engage in petting and mutual masturbation, all heterosexual
Differences within Western cultures
- Acceptable perceived age of first coitus for men and women is young in Sweden than in the US
- 73.7% of Swedish women and only 56.7% of American women used contraception during their first intercourse
- differences between cultures within Western cultures
• Asian American women were less likely to rate sex as important whereas African American women were more likely to
The Development of Sexual Orientation
homosexuality runs in families and is more common among identical than fraternal twins
- homosexuality is shared in 50% of identical twins
- genes account for 34-39% of the cause of male homosexuality and 18-19% of the cause of female homosexuality with the rest coming from the environment
• one major environmental cause is hormone exposure in utero to atypical levels of androgen
- boys with older brothers are more likely to be gay and each additional older brother increases this likelihood by 1/3
An Overview of Sexual Dysfunctions
specific sexual dysfunctions for each stage of the sexual response cycle → desire, arousal, orgasm
- disorders generally have parallels in each sex but some are sex-specific
• Dr. Baucom does not agree with all of these
- Disorders can be lifelong or acquired as well as occurring generally or specifically
problems can occur without being distressing and in these cases they are not disorders
Sexual Desire Disorders
- Male Hypoactive Sexual Desire disorder
- Female Sexual Interest/Arousal Disorder
- 22% of women and 5% of men have these disorders in the US whereas 43% of women internationally present with this
- prevalence increases with age in men but decreases in age with women
Male Hypoactive Sexual Desire disorder
little or no interest in sex that is causing significant distress in the individual
• different from aversion which is disgust
Female Sexual Interest/Arousal Disorder
deficits in interest or the ability to become aroused in women
• combined because in females low sexual interest is almost always accompanied by a diminished ability to become excited or aroused
Sexual Arousal Disorders
- Erectile Disorder
- in women
Erectile Disorder
difficulty attaining or maintaining erections in men
• men often feel more impaired because the disorder makes sex almost impossible
• most common complaint for men who seek help
Sexual arousal disorder in women
inability to achieve or maintain adequate lubrication
- may be less impairing to women because they can just use a commercial lubricant
• female sexual interest/arousal disorder (little or no desire to have sex)
- why we assume females who have arousal disorder don't have desire is unsure; we have women who do have desire but can't achieve arousal → seems sexists
Orgasm Disorders
- delayed ejaculation
- Female orgasmic Disorder
- Premature Ejaculation
Delayed Ejaculation
men who orgasm with great difficulty or not at all
• 8% of men
• not to be confused with retrograde ejaculation
retrograde ejaculation
ejaculatory fluids travel backward into the bladder rather than forward almost always due to the effects of certain drugs or a coexisting medical condition
Female orgasmic Disorder
inability to achieve an orgasm despite adequate sexual stimulation
• most common complaint for women who seek help
• 25% of women have significant difficulty attaining orgasm
Premature Ejaculation
ejaculation that occurs well before the man and his partner wish (after approximately 1 minute)
• 21% of men
• perceived lack of control over orgasm may be more important than fast length of time
• occurs primarily in inexperienced men with less education about sex
Sexual Pain Disorder
- Genito-pelvic pain/penetration disorder
Genito-pelvic pain/penetration disorder
a sexual dysfunction specific to women referring to difficulties with penetration during attempted intercourse or significant pain during intercourse
• can be just pain that can even cause panic attacks before intercourse but usually presented as vaginismus
• Occurs more in younger, less educated women
vaginismus
when the pelvic muscles in the outer third of the vagina undergo involuntary spasms when intercourse is attempted
Statistics of Sexual Dysfunctions
- most prevalent class of psychiatric disorders in U.S.
• men and women experience parallel versions
• Male = 31%
• Female = 43%
- average sexual encounters
• avg. length of sexual encounter is 15 minutes
• upper third of Americans have sex multiple times per week
• middle third of Americans have sex 1/week
• lower third is variable
• married people have sex more frequently than single people
o 1/3 of males engage in infidelity/concurrent sexual relationships
Qualifiers for Sexual Dysfunctions
classification
- lifelong vs. acquired
- generalized vs. specific
- psychological factors
• may maintain the disorder if its not what kicked it off in the first place
- psychological and medical conditions
Assessing Sexual Behavior --> 3 major aspects to the assessment of sexual behavior
• Interviews
• Thorough medical evaluations
• Psychophysiological assessments
Interviews
- clinicians should
• demonstrate to the patient through their action and interviewing style that they are comfortable talking about these issues
• cover nonsexual relationship issues and physical and psychological disorders
• interview the partner concurrently
• use questionnaires to cover things patients may be nervous to discuss
Medical Examination
- a variety of drugs disrupt sexual arousal and functioning
- hormone levels should be checked
Psychophysiological Assessment
- assess the ability of individuals to become sexually aroused under a variety of conditions by taking psychophysiological measurements while the patient is awake or asleep
• erection can be measured using a penile strain gauge
• vaginal photoplethysmograph
vaginal photoplethysmograph
a device smaller than a tampon with a light source at the tip and two light-sensitive photoreceptors on the sides of the instrument that measure the amount of light reflected back from the vaginal walls because blood flows to the vaginal walls during arousal so the amount of light passing through the walls decrease with increasing arousal
Sexual Desire Disorder
Male hypoactive sexual desire disorder
- little or no interest in sexual activity
- decreased frequency
• masturbation
• sexual fantasies
• intercourse
female sexual interest/arousal disorder
- combines desire with arousal
Sexual Desire Disorders: Causes
- low sexual drive
- sex is "bad"
- fear of intimacy
- fear of sexual failure
Sexual Desire Disorders: Causes - sex is "bad"
learned and can lead to aversion not just disinterest
• learned "turn off mechanism"
• sometimes totally avoid thinking about or engaging in sex so it looks hypoactive because they stayed away from it but once exposed to sex it appears to be an aversion
• overgeneralization from when sex was inappropriate
Treatment of Sexual Desire Disorders
- cognitively explore why sex has negative connotations
- sensate focus
- focus on erotic sensations
- explore quality of interpersonal relationship
- treat other conditions such as depression
- biochemical interventions (testosterone)
Treatment of Sexual Desire Disorders - sensate focus step 1
often forbid intercourse
- if sex causes stress to a couple, eliminating intercourse could
• eliminate the sex stressor and allow a real issue to come to light
• could cause extinction to what causes sex stress
• you want what you can't have
• might eliminate anticipatory anxiety
Treatment of Sexual Desire Disorders - sensate focus step 2
- in hierarchical manner, create a hierarchy of physical touch to what is more arousing to more distressing and work up to enjoying physical touching in nonthreatening context (e.g., massages, backrubs)
• like exposure and response prevention
• 3 types of physical touch for the hierarchy
3 types of physical touch for the hierarchy
• Comfort → to decrease negative mood state
• Affection → to increase positive mood state
• Sex → reproduction, bonding, drive reduction, recreation, intimacy
Different things required to want to have sex
• Some people want to feel close to someone to have sex with them
• Other people want to have sex with someone to feel closer to someone
Treatment of Sexual Desire Disorders - treat other conditions such as depression
other conditions can cause decrease in libidinal (sex) drive so these conditions must be treated first because low sex drive may be (partially) caused by this other condition
Sexual Arousal Disorder
- Male erectile disorder
• difficulty achieving and maintaining an erection
- Female sexual interest/arousal disorder
• low interest in sex OR low arousal during sexual activities
Sexual Arousal Disorders: Causes
- Physical
- Psychoanalytic
- Behavioral
- Inadequate stimulation
• especially for women
Sexual Arousal Disorders: Causes - Physical
arousal disorders may be due to medical/physical reasons
- stress and fatigue
- undiagnosed diabetes
- significant alcohol use
• people use alcohol to "relax" more but heavily drinking actually works contrary to sexual arousal
- parasympathetic medication interfering with arousal
Sexual Arousal Disorders: Causes - Psychoanalytic
unresolved Oedipal or Electra complex
unresolved Oedipal or Electra complex
instead of deciding to find a mate similar to the opposite gender parent you're attracted to, you decide that like being attracted to your opposite gender parent, being attracted/aroused to someone like them is wrong causing sexual arousal disorders and may even cause homosexuality according to Freud (displacement)
- castration anxiety for male
- lack of arousal prevents incestuous guilt or behavior
Sexual Arousal Disorders: Causes - Behavioral
due to high level of anxiety (*likely over simplistic basis)
- fear of sexual failure
- pressure to perform
- inability to abandon self to sexual feelings →"spectatoring"
• people think too much about the activities, especially if they're doing a "good" job/if they're partner is enjoy it
Sexual Arousal Disorders: Behavioral Treatment
- Decrease anxiety and promote pleasure
• sensate focus
• permission to be selfish and focus on erotic sensations
• for males, squeeze technique to overcome fear of losing erection
- increase level of stimulation
• different sexual positions
• manual stimulation
• explore different types of sensory stimulation (e.g. music, incense, food)
Sexual Arousal Disorders: Biological Treatment - Males
• injection of vasodilating drugs into the penis
• penile prosthesis or implants
• vascular surgery
• vacuum device therapy
• Viagra
- in one study 61% of males had sufficient erections but only 32% rated sex as satisfactory
Sexual Arousal Disorders: Biological Treatment - Females
lubricants
• especially necessary as women age
Orgasm disorders in men
- in men delayed ejaculation
• rare in adult males
• 8% delayed or absent
Orgasm disorders in women
in women the condition is referred to as female orgasmic disorder
- adequate desire and arousal
- unable to achieve orgasm
- common complaint of adult females
• 25% report difficulty reaching orgasm
• 50% of adult females report experiencing regular orgasms
Female/Male Orgasm Disorder: Causes
- psychoanalytic
- behavioral
Female/Male Orgasm Disorder: Causes - psychoanalytic
unconscious fear of having orgasm, often related to unresoled Oedipal or Electra complex → fear of completing incestuous relations
Female/Male Orgasm Disorder: Causes - behavioral
- Punished for having orgasm or fear of orgasm
• Female became pregnant or fear of pregnancy
- Conditioned inhibitory physiological response
• Automatic "shutdown" process as become aroused
- Discomfort with loss of control → feels threatening to some people
• Real vulnerability with sexual activity that makes some people feel very uncomfortable
Female/Male Orgasm Disorder: Behavioral Treatment
- have person have orgasm under whatever conditions possible, even alone
• masturbation
• vibrator
• exotic material
- have to take into account people you're working with and their value systems
• Ex → some religions may prohibit masturbation
- use hierarchy for having orgasm under conditions increasingly closer to incercourse
- maximize sexual arousal prior to coitus
- increase tone of pubococygeal muscles (muscles surrounding the vagina) to make them stronger for orgasm because they're the muscles that contract
worries about vibrators
- some worry that people may become "hooked" on vibrators and will not be able to have orgasm with normal human but this is not the case
- actually, once people can have orgasms with a vibrator, it makes having orgasms in general easier
Orgasm Disorders: Premature Ejaculation
- before the man or partner wishes, 1 minute
- most prevalent male sexual dysfunction
• M=21%
• Declines with age → men gain control over arousal, but still cannot directly control orgasm just sort of "time" it or hold off
- Common in young, inexperienced males
Premature Ejaculation: Causes
- Psychoanalytic
- "Common sense" perspective → WRONG
• too sensitive to erotic sensations
- Behavioral
Premature Ejaculation: Causes - Psychoanalytic
intense, unconscious sadistic feelings toward women; deprives female of pleasure
Premature Ejaculation: Causes - Behavioral
• initially learned to have orgasm quickly
• male has not focused on sensations prior to ejaculation and therefore cannot control
Premature Ejaculation: Behavioral Treatment
- focus attention on erotic sensations and their mounting quality NOT on things that make you dealy orgasm (i.e. DON'T distract yourself with thoughts of exams, negative thougths)
- semans "start-stop" technique to become comfortable with increasing level of arousal
- explore different sexual positions which allow for less arousal in early treatment
Sexual Pain Disorders
Genito-pelvic pain/penetration disorder → now just one disorder, used to be two
Genito-pelvic pain/penetration disorder description
- marked pain during intercourse
- extreme pain during intercourse
- adequate sexual desire, arousal, orgasm
• if females are not lubricated well enough and its causing pain it's an arousal disorder
- must rule out medical reasons
• often associated with something physical like a tear so must have a comprehensive medical examination first
Genito-pelvic pain/penetration disorder description previously differentiated into
- Vaginismus → muscular spasms
- Dyspareunia → pain for either sex
vaginismus description
- Females only
- Involuntary pelvic spasms
• Outer third of vagina
- feelings of ripping, burning, or tearing
- prevalence = 6%
- related to conservative views of sexuality
Vaginismus: Causes
- Psychoanalytic
- Behavioral
Vaginismus: Causes - Psychoanalytic
• a conversion symptom that represented desire to castrate male, penis envy
Vaginismus: Causes - Behavioral
• history of association between intercourse and painful stimulus (e.g. sex at early stage or rape)
• conditioned muscular response
Vaginismus: Behavioral Treatment
- extinguish the conditioned vaginal response
• gentle insertion of graduated catheters into vagina
- treatment of psychological fear or aversive response
• address whatever makes inercourse fearful or unpleasant
- address past negative experiences
Causes of Sexual Dysfunction
- individual sexual dysfunctions seldom occur in isolation
Causes of Sexual Dysfunction - Biological Contributions
- many physical and medical conditions contribute to sexual dysfunction
- chronic illness can indirectly affect sexual functioning
- prescription medication is a major cause of sexual dysfunction
- Alcohol and other drugs of abuse cause widespread sexual dysfunction in frequent users and abusers
chronic illness can indirectly affect sexual functioning
• those with heart attacks may be wary of physical activity such as sex which can cause disorders
• coronary artery disease and sexual dysfunction coexist
prescription medication is a major cause of sexual dysfunction
• antihypertensive medications → drug treatment for high blood pressure may contribute to sexual dysfunction
• SSRIs and other antidepressant/anti-anxiety medication
many physical and medical conditions contribute to sexual dysfunction
- neurological diseases and other conditions that affect the nervous system such as diabetes and kidney disease may directly interfere with sexual functioning by reducing sensitivity in the genital area and commonly cause erectile dysfunction in males
- vascular disease is a major cause of sexual dysfunction by preventing blood flow to the penis and vagina
alcohol and sexual dysfunction
- At low to moderate levels alcohol reduces social inhibitions so that people feel more like having sex (and perhaps are more willing to request it)
- BUT it's a CNS suppressant so it makes the physical response cycle more difficult for both men and women
- Chronic alcoholism → neurological damage, virtually eliminate sexual response cycle, fertility problems
other drugs of abuse and sexual dysfunction
- Some say that cocaine and marijuana makes sex more pleasurable but no proof
- Cigarette smoking is associated with increased erectile dysfunction
two vascular problems in men
- constricted arteries → make it difficult for blood to reach the penis
- venous leakage → blood flows out too quickly for an erection to be maintained
Causes of Sexual Dysfunction - Psychological Contributions: for years, principle cause of sexual dysfunction thought to be
anxiety
- not that simple
- in certain circumstances, anxiety increases sexual arousal
• proven by shock-threat-film study
-- arousal increased in normal men threatened with shock while watching the film
-- arousal decreased in dysfunctional men threatened with shock while watching the film
Causes of Sexual Dysfunction: Psychological Contributions
• partially caused by distraction
• men with erectile dysfunction report far less arousal than normal men when their penile gauge strain is equal (also true for women)
• in normal people, playing sad or happy music directly affected arousal
• several components of performance anxiety
distraction and psychological dysfunction
- narrative while watching film study
• normal men were less aroused when forced to pay attention to a narrative during the film
• dysfunctional men were NO less aroused when forced to pay attention to a narrative during the film
several components of performance anxiety
- arousal
- cognitive processes
- negative affect
people with sexual dysfunction
expect the worst and find the situation to be relatively negative and unpleasant
- decreased arousal during performance demand
- experience negative affect
- are distracted by nonsexual stimuli
do not have a good idea of how aroused they are
normal people
react positively, not becoming distracted
- show increased sexual arousal during "performance demand" conditions
- experience positive affect
- are not distracted by nonsexual stimuli
- have a good idea of how aroused they are
Causes of Sexual Dysfunction: Social and Cultural Contributions
- many people learn early that sexuality can be negative and somewhat threatening and the responses they develop reflect this belief → erotophobia
• predicts sexual dysfunction
• may be learned early in childhood or after a negative/traumatic sexual experience
- marked deterioration in close interpersonal relationships can cause sexual dysfunction
- feeling unattractive can lead to sexual dysfunction
- script theory of sexual functioning → we all operate by following "scripts" that reflect social and cultural expectations and guide our behavior
• vaginismus is much more common in Ireland and Turkey than in North America
Causes of Sexual Dysfunction: Interaction of Psychological and Physical Factors
socially transmitted negative attitudes about sex may interact with a person's relationship difficulties and predispositions to develop performance anxiety and, ultimately, lead to sexual dysfunction
Treatment of Sexual Dysfunction
- education is surprisingly effective for treating sexual dysfunction
• ignorance of the most basic aspects of the sexual response cycle and intercourse often leads to long-lasting dysfunctions
- Psychosocial Treatments
Psychosocial Treatments for Sexual Dysfunction
• Human Sexual Inadequacy - Masters and Johnsons 1970s
• Treatment for disorders combines this general therapy with specific
Human Sexual Inadequacy - Masters and Johnsons 1970s
• Involves a male a female therapist to facilitate communication between the dysfunctional partners
• Therapy conducted daily over 2-weeks
• Provides basic education about sexual functioning, altering deep-seated myths, and increasing communication to eliminate psychologically based performance anxiety
• Gives detailed instruction of progression
Psychosocial Treatments for Sexual Dysfunction - Premature ejaculation
squeeze technique to reduce arousal to give control
Psychosocial Treatments for Sexual Dysfunction - Lifelong female orgasmic disorder
explicit training in masturbatory procedures
Psychosocial Treatments for Sexual Dysfunction - Vaginismus/genitopelvic pain/penetration disorder
gradually insert dilators at the woman's pace carried out in the context of pleasure
Psychosocial Treatments for Sexual Dysfunction - Low sexual desire
reeducation and communication with the addition of masturbatory training and exposure to erotic material
Medical Treatments
- almost all focus on erectile function disorder
- important to combine medical treatment with a comprehensive education and sex therapy program
• Viagra
• Testosterone
• Injection of vasodilating drugs
• Penile prostheses or implants
• Vacuum device therapy
Viagra
→ successful in getting erection, but doesn't always increase satisfaction
• Better satisfaction when combined with CBT
Testosterone
→ only negligible effects
Injection of vasodilating drugs
papavarine or prostaglandin directly into penis
• Lots of people stop using because it is slightly painful
Penile prostheses or implants
• Semirigid rod that can be bent for intercourse
• Small pump that can be squeezed
Used as a last resort
Vacuum device therapy
→ creates a vacuum in a cylinder placed over the penis which draws blood into the penis and is then trapped by a specially designed ring placed around the base of the penis
• Awkward and artificial but effective
Summary of treatments for Erectile Dysfunction
availability for drugs for erectile dysfunction is widespread but psychosocial and medical treatments are not readily available everywhere
Paraphilic disorders
when someone is aroused by something other than a consenting adult and it causes distress or impairment to the individual, personal harm, or the risk of harm to others
• people often suffer from multiple paraphilias but one is usually dominant
• often comorbid with mood, anxiety, and substance abuse disorders
frotteuristic disorder
→ unwanted touching in public
Fetishistic Disorder
when a person is sexually attracted to nonliving objects
- associated with two classes of objects or activities
• an inanimate object (usually women's undergarments and shoes)
• a source of specific tactile stimulation (i.e. clothing made of rubber)
- partialism → fetish for a body part
Voyeuristic disorder
the practice of observing, to become aroused, an unsuspecting individual undressing or naked
• risk is necessary for arousal
Exhibitionistic disorder
achieving sexual arousal and gratification by exposing genitals to unsuspecting strangers
• often associated with lower levels of education but not always
• repeated or compulsive behavior
• thrill and risk are necessary for sexual arousal
Tranvestic Disorder
sexual arousal is strongly associated with the act of (or fantasies of) dressing in clothes of the opposite sex or cross-dressing
- men sometimes overcompensate by joining the military or participating in macho organizations but usually not
- occurs in 3% of men
• wives can be quite supportive if it's a private matter
- if sexual arousal is primarily focused on the clothing itself the diagnostic criteria requires the specification "with fetishism"
- autogynephilia → a pattern of sexual arousal associated not with clothing itself but rather with thoughts or images of oneself as a female
• different from gender Dysphoria
sexual sadism
associated with either inflicting pain or humiliation and becoming sexually aroused is specifically associated with violence and injury in these conditions
sexual masochism
suffering pain or humiliation (masochism) and becoming sexually aroused is specifically associated with violence and injury in these conditions
Sadistic Rape
- rape is not considered Paraphilic because in most cases the perpetrator has non-paraphilic patterns of sexual arousal
- most rapists have antisocial personality disorder but many can be described as sadists
• arousal to sexual and non-sexual violent material
Pedophilic disorder
sexual attraction to children
• 12% of men and 17% of women reported being touched inappropriately by adults when they were children
• 90% of abusers are male, 10% women
• being charged with child porn offense is one of the best diagnostic indications of pedophilic disorder
• tend to be young children
incest
sexual attraction to family member
• tend to be girls beginning to mature physically
• have more to do with availability and interpersonal issues ongoing in the family
child molesters often...
child molesters often rationalize their behavior as "loving" the child and teaching them lessons on sexuality not as psychologically damaging
Paraphilic Disorders in Women
previously believed women did not have paraphilic disorders but ~5-10% of all sexual offenders are women
Causes of Paraphilic Disorders
- low levels of arousal to appropriate stimuli
- sexual problems
- social deficits
- early experiences
• inappropriate arousal/fantasy
- high sex drive
- low suppression of urges/drives
- reinforcement via orgasm
psychophysiological assessment for paraphilia disorders
• deviant patterns of arousal
• desired arousal to adult content
• social skills
• ability to form relationships
psychosocial interventions for paraphilia disorders
• behavioral
• covert sensitization
• orgasmic reconditioning
• family/marital therapy
• coping
• relapse prevention
psychosocial interventions for paraphilia disorders - behavioral
→ target deviant and inappropriate sexual associations
psychosocial interventions for paraphilia disorders - covert sensitization
→ treatment carried out imaginatively where patients associate sexually arousing images in their imagination with some reasons why the behavior is harmful or dangerous
psychosocial interventions for paraphilia disorders - orgasmic reconditioning
→ patients are instructed to masturbate to their usual fantasies but to substitute more desirable ones just before ejaculation
psychosocial interventions for paraphilia disorders - relapse prevention
→ like what is used with addicts; patients taught to recognize the early signs of temptation and to institute a variety of self control procedures before their urges become too strong
efficacy of psychosocial interventions for paraphilia disorders
- poorest outcomes = rapists/multiple paraphilias
• chronic course
• high relapse rates
- prevention efforts are effective
• CBT intervention in children and adolescents have mostly positive outcomes
medications for paraphilia
• cyproterone acetate
• medroxyprogesterone
cyproterone acetate
most popular drug to treat paraphilia
- "chemical castration" drug eliminates sexual desire and fantasy by reducing testosterone levels dramatically
- fantasies and arousal returns as soon as drug is stopped
medroxyprogesterone
treatment for paraphilia; a hormonal agent that reduces testosterone
efficacy drugs for paraphilia
• greatly reduce desire, fantasy, arousal
• high relapse when discontinued
• may be useful for dangerous sexual offenders who do not respond to alternative treatments to temporarily suppress sexual arousal in patients who require it
Summary of treatments for paraphilia
- mixed evidence for psychosocial treatment of paraphilic disorders
• more success in outpatient settings with presumably less severe, more stable patients
Gender Dysphoria
when a person's physical sex (male or female anatomy) is not consistent with the person's sense of who he or she really is or with his or her experience gender
• can occur on a continuum, with the most extreme being those desiring sex-change
• often feel trapped
clinical overview of gender dysphoria
• feels trapped in the body of the wrong sex
• assumes identity of the desired sex
- because society is often not accepting people often have a lot of confusion and even shame
Must distinguish gender dysphoria from...
• transvestic fetishism which involves sexual arousal strongly associated with the act of (or fantasies of) dressing in clothes of the opposite sex
• disorders of sex development, formerly known as intersexuality or hermaphroditism
• homosexual arousal patterns
gender dysphoria can occur in those with
Disorders of Sex Development (DSD; intersexuality; hermaphroditism) → those born with ambiguous genitalia associated with documented hormonal or other physical abnormalities
• some with DSD have gender assignment surgery and hormone therapy from birth and then they experience gender Dysphoria
- most with gender dysphoria do not have DSD
Gender Dysphoria: Statistics
- prevalence = rare
- female:male = 1 : 2.3
- rates are similar across cultures
• status differences across cultures, revered in some
Gender Dysphoria: Causes - Biological
- unclear, but likely genetic contributions
• 62-70%
- hormones
• in vitro exposure
• brain structure abnormalities
- slightly higher levels of testosterone or estrogen at certain critical periods of development might masculinize a female fetus or feminize a male fetus
Gender Dysphoria: Causes - gender nonconformity
• spontaneous gender nonconformity in boys is typically discouraged but when its consistent its not discouraged and sometimes encouraged
• excessive attention and physical contact on the part of the mother, may also play some role
• lack of male playmates during the early years of socialization
• very loose relationship between gender nonconforming behavior and later sexual development
Treatment for gender dysphoria
begin with least intrusive steps then to partially reversible steps of hormones then to non-reversible step of sex reassignment surgery
• for sex reassignment surgery → must live in the desired gender for 1 to 2 years and be psychologically, financially, and socially stable
• transmen generally adjust better than transwomen but overall rats of satisfaction is about 90%
Treatment of Gender Nonconformity in Children
- gay gender noncomforming boys experience more psychological distress than lesbians
- attempt to lessen gender dysphoria
- "watchful waiting" to see how gender unfolds
- actively affirming and encouraging cross-gender identification
• may be a problem because gender nonconformity often does not continue
Treatment of Disorders of Sex Development (Intersexuality)
• males, females, herms (both), merms (more male than female), ferms (more female than male)
• waiting might be better
depressed individuals...
- have difficulty doing everyday things due to lack of motivation and fatigue
- often opposite of certain behaviors will occur
• begin sleeping a lot if didn't sleep a lot
- decreased stress drive
- sad mood; flat affect; blunted affect
- sometimes experience increased anxiety or anger
• anger occurs more in males
• 2:3 female:male ratio
• negative cognitive distortions
- of themselves, the world
mood disorders
disorders characterized by gross deviations in mood; the fundamental experiences of depression and mania
Depression-related episodes
• major depressive episode
• less intense depressive episode
major depressive episode
extremely depressed mood state that lasts at least 2 weeks and includes cognitive symptoms and disturbed physical functions
- general loss of interest in things
- inability to experience any pleasure
- most central indicators → physical (somatic or vegetative changes)
- behavioral and emotional "shutdown"
- At least 5 of the below, for at least 2 weeks. Must have one of first two symptoms listed.
• Depressed mood most of the day
• Diminished interest or pleasure in activities
• Significant appetite/weight changes
• Sleep problems
• Psychomotor agitation or retardation
• Fatigue, loss of energy
• Feelings of worthlessness, intense inappropriate guilt
• Unable to concentrate or make decisions
• Recurrent thoughts of death, suicidal ideation, or suicide attempt
- Significant distress or impairment
mania-related episodes
• manic episode
• hypomanic episode
manic episode
- duration of 1 week needed for diagnosis, lasts 3-4 months if untreated
- impulsivity
- sensation seeking
- inflated sense of self
- euphoria
- flight of ideas → speaking so rapidly about so many exciting ideas that speech becomes incoherent
- highly energetic
• sometimes also angry
• combo of energy and anger can lead to harm of self or others
hypomanic episode
less severe manic episodes that does not cause market impairment in social or occupational functioning
- need last only 4 days
- not necessarily problematic but contributes to the definition of several mood disorders
Mixed episode
depression and mania at the same times or rapid vacillation between the two sets of symptoms
unipolar disorder
either depression OR mania
• unipolar mania is rare because most people with a unipolar mood disorder eventually develop depression
Depressive Disorders
- major depressive disorder, single episode
- major depressive disorder, recurrent
- Persistent Depressive Disorder (Dysthymia)
- Double Depression
major depressive disorder, single episode
- no mania/hypomania
- single episode
• rare
- avg. onset = 30
- incidence of depression and suicide seem to be steadily increasing
major depressive disorder, recurrent
• 4-7 episodes (lifetime)
• duration → 4-5 months
• tend to become more rapid and longer-lasting over time
Persistent Depressive Disorder (Dysthymia)
- milder symptoms but may remain relatively unchanged over long periods (20-30 years or more)
- 2+ years, chronic, persistent
- often goes undiagnosed because of long-lasting, chronic, persistent course
- people with this disorder
• have worse relationships
• worse careers
• less happiness
- avg age of onset = early 20s but those who get it earlier have
• greater chronicity
• poor prognosis
• stronger likelihood of the disorder running the in the family
- more likely to attempt suicide
Double Depression
• cycle of/fluctuation between major depressive episodes and dysthymic disorder
• dysthymia often first
• severe psychopathology
• poor course
Specifiers for Depressive Disorders
- Psychotic features
- Anxious distress
- Mixed features
- Melancholic
- Atypical features
- Catatonic features
- Peripartum onset
- Seasonal pattern
Specifiers for Depressive Disorders - Psychotic features
• hallucinations
• delusions
• can be mood congruent (seem directly related to depression) or mood incongruent (seeming inconsistent with depressed mood)
hallucinations
having a sensory experience that doesn't exist/isn't really occurring/doesn't have a stimulus
- smell, sight, touch experience without stimulus
delusions
false belief; distorted interpretation of information
Specifiers for Depressive Disorders - Anxious distress
- comorbid disorders or anxiety symptoms
• more likely to have anxiety without depression but more common to have depression plus anxiety
- often social anxiety disorder because of:
• decreased self-esteem
• fear of embarrassment
- indicates a more severe condition
Specifiers for Depressive Disorders - Mixed features
• at least 3 symptoms of mania
Specifiers for Depressive Disorders - Melancholic
• severe somatic symptoms
• anhedonia → diminished interest or pleasure in activities
Specifiers for Depressive Disorders - Atypical features
• consistently oversleeping and overeating
• more present in women
• associated with earlier age of onset, more symptoms, more severe symptoms, more suicide attempts, higher rate of comorbid disorders
Specifiers for Depressive Disorders - Catatonic features
• catalepsy
• absence of movement (stuporous state)
catalepsy
muscles are waxy and semirigid
Specifiers for Depressive Disorders - Peripartum onset
just before and/or after birth
• 13-19% of women meet criteria for depression
• those depressed before birth are more likely to be depressed after birth of child
• more common after birth
Specifiers for Depressive Disorders - Seasonal pattern
bipolar → manic is summer, depressed in winter
seasonal affective disorder (SAD)
- 2.7% of population
- mostly in very northern or southern latitudes
- melatonin phototherapy
• more melatonin in winter because less light
• exposure to really bright light early in the morning to decrease melatonin production
- CBT
• Best when combined with light therapy
natural grief
- usually natural grieving process peaks in first 6 months though some may grieve for a year or longer
- acute grief usually evolves into integrated grief
integrated grief
grief in which the finality of death and its consequences are acknowledged and the individual adjusts to the loss
- bittersweet, positive feelings/memories
- recurs at significant anniversaries
From Grief to Depression
- for 7% of people normal grief becomes a disorder
• suicidal thoughts increase
• difficulty imagining future because loved one will not be there
• difficulty regulating one's emotions
- sudden loss of parent in children and young adults makes them particularly vulnerable to severe depression beyond the normal time for grieving
many of the psychological and social factors related to mood disorders in general also predict the development of
complicated grief
- can develop without a preexisting depressed state
- persistent intense symptoms of acute grief
- treatment involves talking about the loved one, the death, and the meaning of loss while experiencing all the associated emotions, until the person can come to terms with reality
• incorporating positive emotions
• hope to achieve integrated grief
Other Depressive Disorders
- Premenstrual Dysphoric Disorder (PMDD)
- Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder (PMDD)
• 2-5% of women meet criteria
• depression that occurs just before or right after a period
• may get sadness but a lot of irritability and agitation
Disruptive Mood Dysregulation Disorder
- children have increased diagnoses for bipolar 40% between 1995 and 2005
• bipolar not otherwise specified (NOS)
• children with chronic irritability, anger, aggression, hyperarousal, frequent temper tantrums but NO evidence of periods of elevated mood (mania)
• at increased risk for additional depressive and anxiety disorders rather than manic episodes
Mania
- manic episode
- hypomanic episode
Manic episode
• exaggerated elation, joy, euphoria but also maybe anger or agitation
• increased goal-directed activity
• 1 week or more
• cognitive symptoms → speeds sometimes interferes with precision, focus, attention
• duration - usually 3-4 months if untreated
• denial of problem
hypomanic episode
• states that are less than full manic
key identifying feature of bipolar disorder
tendency of manic episodes to alternate with major depressive episodes in an unending roller-coaster ride from the peaks of elation to the depths of despair
Bipolar I Disorder (Manic History)
in which major depressive episodes alternate with full manic episodes or a single full manic episode
- a manic episode at some time, either past or present
• two months between manic episodes for them to be separate
- may or may not have had a major depressive episode, either past or present
- facts and statistics
• average age of onset is 15-18 years
• can begin in childhood
• tends to be chronic
• suicide is a common consequence
Bipolar II Disorder (Hypomania + Depression)
major depressive episodes alternate with hypomanic (les severe) episodes rather than full manic episodes
- at least one or more hypomanic episodes, either past or present
- never had a manic episode
- one or more major depressive episodes, either past or present
- facts and statistics
• average age of onset is 19-22 years
• can begin in childhood
• 10-25% of cases progress to Bipolar I disorder
• tends to be chronic
Cyclothymic Disorder
chronic alternation of mood elevation and depression that does not reach the severity of manic or major depressive episodes
- for at least 2 years, numerous periods of hypomanic symptoms and periods of mild depressive symptoms
- tend to be in one mood state or the other for years with relatively few periods of neutral mood
- no major depressive, manic, or mixed episode
- often these individuals are just considered moody
• BUT increased risk of developing the more severe bipolar I or II
o predicts a decreased chance of full inter-episode recovery if precedes the onset of bipolar disorder
Additional Defining Criteria for Bipolar Disorder
all the depression Specifiers apply to bipolar disorder
- specifically catatonic features specifier applies mostly to major depressive episodes, rarely to manic
- psychotic features specifier may apply to manic episodes
• delusions of grandeur
- "mixed features" specifier → major depressive or manic episode that has some symptoms from the opposite polarity
- Rapid Cycling Specifier
Rapid Cycling Specifier
moving quickly in and out of depressive or manic episodes
- experiencing 4 manic or depressive episodes within a year
- severe variety of bipolar disorder
- may have better luck with anticonvulsants and mood stabilizers rather than anti-depressants for treatment
- mostly female
- increases in frequency over time and may reach severity of no breaks between mania and depression (rapid [mood] switching)
• particularly treatment resistant but usually not permanent
• occurs more in those taking anti-depressants
Onset and Duration of bipolar disorders
- bipolar I onset - 15-18, bipolar II onset - 19-22
• can begin in childhood
• younger than for depression
• begins more acutely than depression
- 10-25% with bipolar Ii will progress to full bipolar I disorder
- may be a continuum between mania and depression rather than poles
- rare for bipolar disorder to develop after 40 and when it does, it's chronic
- suicide is all-too common, usually occurring during depressive episodes
- poor prognosis
- cyclothymia is chronic and lifelong
• 1/3-1/2 get full blown bipolar disorder
• mostly female
Prevalence of Mood Disorders
- dysthymia and bipolar disorder are chronic and lifelong
- women are twice as likely to have mood disorders as men but bipolar disorder is equal across genders
- major depressive disorder and dysthymia are significantly lower among blacks than whites but no difference in bipolar disorder
• fair or poor health status is the major predictor of depression in blacks
- native Americans have significantly higher levels of depression
Prevalence in Children, Adolescents, and Older Adults
- less in children than adults, but rises dramatically in adolescence
• children have sex ration of 50:50
• major depression is largely female with puberty triggering this sex imbalance
- stressful life events that trigger major depressive episodes decrease with age
- milder symptoms that do not meet diagnostic criteria seem to be more common among the elderly
- bipolar disorder occurs at the same rates in children and adolescents as in adults
Life Span Developmental Influences on Mood Disorders
- the prevalence of mood disorders varies with age and age and development may almost impact many of the characteristics of mood disorders
• infants of depressed mothers display marked depressive behaviors
- mood disorders are fundamentally similar in children and in adults
• BUT the "look" of depression changes with age
- concerning mania, children under the age of 9 seem to present with more irritability and emotional swings as compared with classic manic states, particularly irritability
• emotional swings may also be characteristic of children
- childhood depression and mania are often diagnosed as ADHD or conduct disorder
• patterns of comorbidity and/or misdiagnosis
- becoming depressed in childhood is dangerous
Age Based Influences on Older Adults
- many elderly especially in nursing homes have depression
• late onset depressions are associated with marked sleep difficulties, illness anxiety disorder, and agitation
• difficult to diagnose in older adults because of physical illness or dementia
- entering menopause increases rates of depression in women with no history
- depression contributes to disease and death in the elderly
• as we become frailer and more alone we become more depressed which increases the causal factors more
• suicide rates are higher in older adults than in any other group
- the gender imbalance in depression lessens considerably after the age of 65
Mood Disorders across cultures
- some cultures have their own idioms for depression
• "heartbroken," weak in spirit
- somatic symptoms of depression are roughly similar across cultures
- in collective cultures, people are more likely to say "our [the group] life has lost its meaning" than "I am depressed"
- native Americans have extremely high rates of depression
Mood Disorders among creative individuals
- mood disorders are very high among creative
- mostly female poets
• maybe because rebellious and independent qualities associated with creativity may be more stressful in a society that puts demands on women to be supportive and affiliative
- creativity is specifically associated with manic episodes not depressive ones
- genetic vulnerability to mood disorders may be independently accompanied by a predisposition to creativity
• mostly in bipolar NOT unipolar depression
equifinality
the same product resulting from different causes
Family studies of mood disorders
prevalence of a given disorder in the first-degree relatives of an individual known to have the disorder (the proband)
- rates in relatives of probands with mood disorders is 2-3x greater than for relatives of controls
Twin studies of mood disorders
examine the frequency with which identical twins have the disorder with fraternal twins
- suggests mood disorders are heritable
- 2-3x more likely for an identical twin to have a mood disorder if the other twin has it
- identical twins are 80% concordant for polarity (uni vs. bipolar)
sex differences in genetic vulnerability to depression
more depressed women twins than males
• environmental events play a larger role in causing depression in men than in women
bipolar disorder confers an increased risk of...
developing some mood disorder but not necessarily bipolar disorder
- suggests bipolar may just be a more severe variant of mood disorder rather than a fundamentally different disorder
genetic contribution of mood disorders for men and women
40% genetic contribution for women but only ~20% contribution for men
Depression and Anxiety: Same genes?
- Close relationship genetically among depression, anxiety, and panic
• Social and psychological factors seems to differentiate anxiety from depression rather than genes
Neurotransmitter Systems and Mood disorders
- low levels of serotonin may cause mood disorders in relation to other neurotransmitters like dopamine and norepinephrine
• serotonin regulates emotional reactions and may control pathways of other hormones
• low levels of serotonin means other hormones do whatever they want
- the balance of the various neurotransmitters and their interaction with systems of self-regulation are more important than the absolute level of any one neurotransmitter
- dopamine may be related to manic episodes, atypical depression, or depression with psychotic features
The endorine system
"stress hypothesis" of the etiology of depression
"stress hypothesis" of the etiology of depression
overactivity in the hypothalamic-pituitary-adrenocortical (HPA) axis which produces stress hormones
- HPA axis begins → in the hypothalamus and runs through the pituitary gland which coordinates the endocrine system
- Neurotransmitter activity in the hypothalamus regulates the release of hormones that affect the HPA axis → neurohormones
- Adrenal gland produces → cortisol, the stress hormone
• Cortisol levels are elevated in depressed patients
- Stress hormones can be harmful to neurons by decreasing a key ingredient that keeps neurons healthy and growing
• Low hippocampal volume may precede and perhaps contribute to the onset of depression
• Exercise increases neurogenesis
Dexamethasone suppression test (DST)
→ thought to be biological test for depression
- Dexamethasone is a glucocorticoid that suppresses cortisol secretion in normal participants but when given to depressed patients there was much less suppression
• Found to also occur in patients with anxiety so not a test
Sleep and Circadian Rhythm
- sleep disturbances are a hallmark for most mood disorders
• depressed people have more REM sleep early which is less restful
- insomnia → a risk factor for both the onset and persistence of depression
• present in many older adults
- bipolar disorder and sleep → insomnia, hypersomnia and decreased REM latency
- negative mood predicted sleep disruption and sleep disruptions resulted in negative mood
- depriving depressed patients of sleep in the second half of the night causes temporary improvement of their symptoms
- abnormal sleep predicts poorer response to treatment
Additional Studies of Brain Structure and Function
- depressed people have greater right-sided anterior activation of their brains particularly of the prefrontal cortex which results in less alpha waves
• might exist before depression and indicate vulnerability
- bipolar patients have increased left-sided anterior activation
Psychological Dimensions of mood disorders
Stressful Life events
• stress and trauma
Stress and Depression
- different people experience different events as stressful
- current moods distort memories
- stressful life events are strongly related to the onset of mood disorders
• context and meaning are often more important than the actual event itself but there are some specific events likely to lead to depression
• breakup of a relationship
• humiliation, loss, and social rejection are the most potent stressful life events likely to lead to depression
- individuals vulnerable to depression may place themselves in high-risk stressful environments such as difficult relationships
- stress triggers depression and depressed individuals create or seek stressful events
Stress and Bipolar Disorders
- negative stressful life events trigger depression but more positive stressful life events seem to trigger mania
• getting into grad school, getting married
- stress seems to initially trigger mania and depression, but as the disorder progresses, these episodes seem to develop a life of their own
- some precipitants of manic episodes seem related to loss of sleep like in the postpartum period or jet lag
-50-80% of people who experience stressful events do NOT develop mood disorders
marital dissatisfaction and depression including bipolar disorders are
strongly related
• for men, depression often causes problems in relationship
• for women, problems in relationships often causes depression
Mood Disorders in Women
• bipolar disorder is evenly divided between genders
• 70% of people with major depression and dysthymia are women
• gender differences in the development of emotional disorders are strongly influenced by perceptions of uncontrollability
- women are subject to culturally induced dependence and passivity which may put them at heightened risk for emotional disorders by increasing their feelings of uncontrollability and helplessness
• women tend to ruminate more than men about their situation and blame themselves for being depressed
• women experience more discrimination, poverty, sexual harassment, and abuse than men, learning less and accumulating less power
Social Support
risk of depression for people who live alone is almost 80% higher than for people who live with others
• social support is very important in preventing depression
An Integrative Theory of mood disorders
depression and anxiety may often share a common, genetically determined biological vulnerability → an overactive neurobiological response to stressful life events
- psychological processes of inadequate coping and depressive cognitive style
- stressful life events trigger the onset of depression in most cases in these vulnerable individuals, particularly initial episodes
- interpersonal relationships or cognitive style may protect us from the effects of stress and therefore from developing mood disorders
most cases of depression go
untreated because neither health car professionals nor patients recognize and correctly identify or diagnose depression
Medications
- antidepressants
- lithium
antidepressants
• SSRIs, mixed reuptake inhibitor, tricyclic antidepressants, monoamine oxidase (MAO) inhibitors)
• Few differences among antidepressants
• Relatively ineffective for mild to moderate depression; only really advantageous in severely depressed patients
• Worth being persistent with (aka try a 2nd drug if 1st doesn't work) because the second may work
• Drug treatments effective with adults are not necessarily effective with children
• Traditional antidepressant drug treatments are usually effective with the elderly but administering them takes considerable skill because of age specific side effects
• A more important goal than recovery is often to delay the next depressive episode or even prevent it entirely
• Drug treatment usually goes well beyond termination of a depressive episode then in withdraw to prevent relapse
lithium
mood stabilizing drug
- common salt
- primary treatment for bipolar disorders because it prevents and treats manic episodes whereas normal anti-depressants can induce manic episodes
- unsure of mechanism of action
- narrow therapeutic window
• too little → ineffective
• too much → toxic, lethal, lowers thyroid functioning
• 50% efficacy rate
- valproate
- people with bipolar disorder are especially susceptible to relapse because wanting the high of mania often makes them not take drugs correctly
valproate
recently overtaken lithium as most popular mood stabilizer that is equally effective but it and other mood stabilizing drugs are less effective than lithium at preventing suicide
Electroconvulsive therapy (ECT)
now a safe and reasonably effective treatment for those cases of severe depression that do not improve with other treatments
- patients are anesthetized and given muscle-relaxing drugs
- electric shock is administered directly through the brain for less than a second producing a seizure and a series of brief convulsions that usually lasts for several minutes
- done once everyday for 6-10 days
- side effects include short term memory loss and confusion
• long term memory loss in some
- works in 50% of those not responding to medication
- continued treatment with medication or psychotherapy is necessary but relapse is still high
Transcranial Magnetic stimulation
• placing a magnetic coil over the individual's head to generate a precisely localized electromagnetic pulse
• not anesthesia required; side effects usually just headaches
• ECT though is clearly more effective
• Slight advantage for combining with medication
Vagus nerve stimulation
though to influence neurotransmitter production in the brain stem and limbic system
• results are weak; rarely used
Deep brain stimulation via surgically implanted device controlled by pacemaker type thing
shows some promise
Theories of Depression
- cognitive
- behavioral
- psychoanalytic
• above three all hone in on one central concept → people experience depression when they experience loss
- biological
Beck's Cognitive Theory of Depression
- four major symptom categories of depression
• emotional
• cognitive
• motivational
• physical and vegetative
- core of depression is distorted cognitions, although emotions might be more obvious
- logical errors contributing to development of depression
Beck's Cognitive Theory of Depression - logical errors contributing to development of depression
• arbitrary inference
• selective abstraction
• overgeneralization
• negative schemas
• magnification and minimization
• personalization
• dichotomous thinking
Beck's Cognitive Theory of Depression - logical errors
arbitrary inference
drawing a (negative) conclusion in the absence of evidence to support the conclusion; emphasizing the negative rather than the positive
Beck's Cognitive Theory of Depression - logical errors
selective abstraction
focusing on a (negative) detail taken out of context, and interpreting the experience based on this one fragment of information
Beck's Cognitive Theory of Depression - logical errors
overgeneralization
drawing a general conclusion based on one or more specific (negative) incidents
Beck's Cognitive Theory of Depression - logical errors
negative schemas
an enduring negative cognitive belief system about some aspect of life
Beck's Cognitive Theory of Depression - logical errors
magnification and minimization
errors in evaluating the significance or magnitude of an event
• negative events magnified
• positive events minimized
Beck's Cognitive Theory of Depression - logical errors
personalization
relating external events to oneself when there is insufficient basis for the conclusion
Beck's Cognitive Theory of Depression - logical errors
dichotomous thinking
placing experiences into one of two opposite categories, in oversimplified way
- all-or-nothing, right or wrong thinking; no continuum
• must be perfect to be right; anything else is a failure
Beck's Cognitive Theory of Depression - Major Areas Affected by Logical Errors
negative "cognitive triad"
• negative view of self
• negative view of world
• negative view of future → important predictor of suicide (hopelessness)
Types of Thoughts Involved in Depression
Automatic thoughts
Basic beliefs
Automatic thoughts
beliefs about the moment-to-movement occurrences in life
- Attributions
- Expectancies
attributions
explanations for events
• "this person skipped the seat beside me because I am such a loser"
expectancies
→ predictions about the future
• "I gave a stupid answer to the question he asked in class; he'll never write me a decent letter of recommendation; I'll never get into graduate school; I'll probably end up homeless; I should just end it all right now."
Basic beliefs
usually develop in childhood based on experiences
- Assumptions
- Schemas
assumptions
beliefs about the nature of the world on a basic level
• "People really can't be trusted. They only care about themselves when it gets tough."
schemas
→ basic beliefs about the nature of oneself
• "No one could love me; I'm such a loser."
The Development of Depression
• person has vulnerabilities due to negative schemas and assumptions
• negative life situation (extreme stress, loss or thwarting of goals, etc.) triggers schemas
• activation of schemas leads to distorted automatic thoughts through logical errors
• schemas also activate negative emotions related to cognitive schemas
• negative emotions further energize schemas
Treatment Implications for Cognitive Therapy
- behavioral activation → making people do things even when they're not motivated rather than allowing them to isolate themselves and further withdraw
- alter automatic thoughts
• carefully examine thought processes while depressed to recognize "depressive" errors in thinking
• correct cognitive errors
• substitute more adaptive thoughts
• correct negative cognitive schemas
- alter basic beliefs and underlying schemas to be more positive/realistic
Cognitive-Behavioral Analysis System of Psychotherapy
integrates cognitive, behavioral, and interpersonal strategies and focuses on problem solving skills particularly in the context of relationships
Mindfulness-based cognitive therapy
integrates meditation with cognitive therapy
Behavioral Theories of Depression
- almost all behavioral theories involve some aspect of loss of reinforcement
• Loss of reinforcement
• Loss of reinforcer effectiveness (Costello)
• Loss of control over reinforcers (Seligman's learned helplessness theory)
Loss of reinforcement
due to changes in role, loss of relationship, move to new location, etc.
Loss of reinforcer effectiveness (Costello)
Reinforcers are "chained together" and when lose one, others lose their effectiveness as well
Learned Helplessness: Seligman
- helplessness depressions result from a loss of control over reinforcers
• people become depressed when they cannot control what happens to them
• people become anxious and depressed when they decide that they have no control over the stress in their lives
- the probability of reinforcement give a response = probability of reinforcement given no response
• responding does not matter or affect the outcome
Implications of Helplessness Theory
- Depression can occur when the person experiences positive pleasurable events, if the person does not control them:
- Gender implications
• Powerful male → people agree with and are nice to simply because yields power
• Attractive female → given many opportunities because of attractiveness which do not feel earned
Loss of control: laboratory procedures
- dogs given inescapable shock (not signaled) or can escape from shock
- later all dogs can escape or avoid shock (impending shock is signaled)
- dogs with inescapable learning
• don't avoid shock when they can
• if they do avoid shock, don't seem to learn from it
Reformulated Helplessness Theory: Abramson, Seligman, & Teasdale (1978)
- when a person experiences a loss of control during negative or positive events, the person interprets the situations:
• why did they occur?
• Attributions → causal explanations for events
Attributional Dimensions in Helplessness Theory
• Internal/external
• Global/specific
• Stable/unstable
Attributional Dimensions in Helplessness Theory
• Internal/external
Degree to which the event is caused by something within oneself or outside world
Attributional Dimensions in Helplessness Theory
• Global/specific
Degree to which the cause will influence many events or a very few events
Attributional Dimensions in Helplessness Theory
• Stable/unstable
Degree to which the cause will be present in the future or for only a limited time
attributional style of depressed people
Make internal, global, stable attributions about bad things and external, specific unstable attributions about good things
attributional style of healthier people
Make external, specific, unstable attributions about bad things
negative attributional styles
• Meaningful negative events early in childhood may lead to negative Attributional styles making these children more vulnerable to future depressive episodes
• Negative Attributional styles may be increase vulnerability for depression and/or anxiety
types of helpless depressions
• Personal Helplessness
• Universal helplessness
• Development of hopelessness is crucial in development of depression, as compared to anxiety
Personal Helplessness
internal attributions
- Poor self-esteem
- Sad mood
- Lack of motivation
Universal helplessness
external attributions
- Good self-esteem
- Sad mood
- Lack of motivation
Treatment Implications
- Arrange environment and experiences such that person has control
• Gender
• Minorities
• Disadvantaged in other ways
- Alter cognitions such that person does not make internal, stable, global attributions inappropriately
- increased activity alone can improve self-concept and lift depression
- preventing avoidance of social and environmental cues that produce negative affect or depression and result in avoidance and inactivity
- exercise
• exercise may increase neurogenesis in the hippocampus which is associated with resilience to depression
Interpersonal Psychotherapy
focuses on resolving problems in existing relationships and learning to form important new interpersonal relationships
- Identify life stressors that seem to precipitate the depression
-- Dealing with interpersonal role disputes
--- Stages of dispute
---- Negotiation stage
---- Impasse stage
---- Resolution stage
-- Adjusting to the loss of a relationship
-- Acquiring new relationships
-- Identifying and corecting deficits in social skills
CBT and IPT outcomes
- comparable to medications during active treatment phase
- better than medications with long term follow-up
- more effective than:
• placebo
• brief psychodynamic treatment
- great for postpartum depression and adolescents
Freud's Theory of Depression: The Object Loss Theory
- Mourning & Melancholia → Freud's writing on depression
- compared depression to normal process of grieving when object is lost
- The Mourning Process → mourning = how you let objects go; usually not all at once so you're not overwhelmed
The Mourning Process Step 1
Introjection (take person who you've lost and bring them inside of you) of, and Identification (make the lost person a part of you) with, the lost object
- This allows the person to control the speed with which he/she "lets go" of lost object
- Otherwise, ego becomes overwhelmed with loss
- Examples
• ET → ET points to Elliot's head/heart and says "I'll be right here"
• Dressing or behaving like lost object
• Keeping rooms the same or creating shrines → allows people to avoid facing the loss
The Mourning Process Step 2
letting go or "loosening of the tie with the introjected object"
- Often occurs slowly, a bit at a time in order not to be overwhelmed
- Re-experience good and bad memories, positive and negative emotions
factors that interfere with letting go
- lost object was not loved on mature level rather the provider of "narcissistic supplies"
• providers of "narcissistic supplies" → provide positive feedback to person which makes the person care not about the person but the feedback because they increase their self-esteem
- mourning person is orally fixated and needs to be taken care of by lost object
• cannot let object go because they took care of you; now you feel you can't take care of yourself
Factor that leads to negative or ambivalent introject
- Previous relationship with lost object was ambivalent → have both good and bad feelings at once
- If you introject this person you begin to → hate yourself
Angry with lost object but introjected and identified with object so
you have negative feelings toward self
The Development of Depression Freud
- the "pathognomonic introjection" (necessary and sufficient)
- depression involves a continued struggle with a highly cathected, ambivalently held lost object
• anger held toward lost object that was introjected causes person to hate self
- the ego of the mourner and lost object are equated
• negative feelings toward lost object turned on self
• superego treats ego (punishing in some way person would have like to have treated lost object
• "No one contemplates suicide who first has not contemplated homicide"
• Depression involves anger turned inward
Family studies of depression
- Rate is high in relatives of probands (proband = person with disorder)
- Relatives of bipolar probands - risk for unipolar depression increases most and bipolar depression also increases but less than for unipolar depression
- May be environment of being around depressed people
adoption studies of depression
take young children from depressed parents and put them in environment with no history of depression
- Data are mixed
twin studies of depression
- Concordance rates are high in identical twins
- Severe cases have a stronger genetic contribution
- Heritability rates are higher for females
- Vulnerability for unipolar or bipolar disorder
• Appear to be inherited separately
Biochemical Bases of Depression
- Monoamine theory (catecholamine) → neurotransmitters
• Serotonin (5-HT)
• Norepinephrine (NE)
• Dopamine
- All share a terminal single amine (NH2)
- Focus on serotonin and norepinephrine
Classes of Antidepressants
• Tricyclics
• Selective serotonin reuptake inhibitors (SSRI)
• Mixed reuptake inhibitors
• Monoamine oxidase inhibitors (MAOI)
• St. John's wort
Tricyclics
- Block reuptake of 5-HT or NE
- Historic depression drug
- A lot of side effects but many side effects disappear over time
- Lethal if taken in excess
Selective serotonin reuptake inhibitors (SSRI)
- Blocks presynaptic reuptake of 5-HT temporarily increasing levels at the receptor site
- Levels of serotonin are eventually increased
- Fluoxetine (Prozac)
Mixed reuptake inhibitors
- Blocks reuptake of 5-HT and NE
- Venlafaxine (Effexor)
Monoamine oxidase inhibitors (MAOI)
- Blocks the enzyme MAO that breaks down such neurotransmitters as NE and 5-HT
- Usually only prescribed when other antidepressants are ineffective because of severe interactions with some foods and drugs
St. John's wort
UK uses in a preliminary way but major US study found no benefits from St. John's wort compared with placebo
Antidepressants: often don't know...
often don't know which antidepressant people will respond to, if they'll even respond to one at all
Neurotransmitter Theories of Mood Disorders
• Serotonin Theory
• Norepinephrine Theory
• Two disease theory
• Permissive Theory
• Balance Theory
• Depression is due to too rapid reuptake
• Depression is due to undersensitivity of postsynaptic receptors
Serotonin Theory
- Low serotonin → depression
- High serotonin → manic episode
Norepinephrine Theory
- Low NE → depression
- High NE → manic episode
Two disease theory
- NE type → low NE, 5-HT normal
- 5-HT type → low 5-HT, normal NE
Permissive Theory
- When serotonin is low, transmitters such as NE become dysregulated or drop and contribute to depression
- Dopamine might be high in manic episodes
Prevention
- preventing in children and adolescents
• universal programs → applied to everyone
• selected interventions → target individuals at risk for depression
• indicated interventions → target individuals showing mild symptoms
- programs power is lessened if the child lives with a depressed parent
• parents should be treated as child is prevented
Combining Treatments for Depression
- for persistent depression, possible benefits of drugs and psychotherapy above individual treatments
• 48% benefit from meds or CBT
• 73% benefit from combined
Preventing Relapse of Depression
- everyone received treatment for 12 months then were followed for 1 year after treatment
• survival = did not go back into disorder
- during treatment....
• Placebos don't do much
• Medications have 50% survival rate
• CBT has about 65% survival rate
- after 12 months of treatment and 12 months of no treatment...
• Placebos have 5% survival rate
• Medications have ~20-25% survival rate (80% relapse)
• Cognitive there have about 50% survival rate 50% relapse
Psychological Treatments for Bipolar Disorder
- management of interpersonal problems
- increase medication compliance
- interpersonal and social rhythm therapy
• manage circadian rhythms which bipolar individuals are very susceptible to
• longer between manic or depressive episodes
- family-focused treatment
• family tension is associated with relapse in bipolar disorder
• less relapse with treatment and longer in between them
Suicide statistics
- population specific
• Caucasians
• Native Americans
- increasing rates
• adolescents
• elderly
- 11th leading cause of death in the US
Suicide in china
- in all countries except china, men are 4x more likely to commit suicide than females because they generally choose far more violent methods of suicide such as guns and hanging whereas women choose less violent methods like drug overdoses
• in china more women than men commit suicide particularly in rural settings
• Chinese suicide rates may be the highest in the world due to an absence of stigma, meaning suicide is seen as a reasonable solution to problems in Chinese literature
indices of suicidal behavior
• suicidal ideation
• suicidal plans
• suicidal attempts
suicidal ideation
thinking seriously about suicide
suicidal plans
the formulation of a specific method for killing oneself
suicidal attempts
the person survives
- females attempt suicide 3x more than males but males still commit suicide 4x more
types of suicide
• altruistic
• egoistic
• anomic
• fatalistic
altruistic
formalized suicides that were approved of such as hara-kiri in Japan
egoistic
→ suicide caused by loss of social support
anomic
→ suicide resulting from marked disruption such as the loss of a high-prestige job
fatalistic
→ suicide resulting from a loss of control over one's own destiny
Freud believed that suicide (and depression) indicated
unconscious hostility directed inward to the self rather than outward to the person or situation causing the anger
Risk Factors for suicide
- family history of suicide
- neurobiology
• low levels of serotonin
- preexisting disorder
• usually mood, substance us, or impulse control disorders
• hopelessness strongly predicts suicide
- alcohol
• 25-50% of suicides
- stressful life event
• physical/sexual abuse
• natural disasters
• extreme catastrophes
- shameful/humiliating stressor
- suicide publicity and media coverage
• clusters of suicides predominate among teenagers
• suicides are often romanticized by the media
treatment for suicide
- prediction of suicide is still an uncertain act
- sometimes suicidal thoughts are implicit or out of awareness so they can be hard for people to realize/tell therapists about
• implicit associations between the words suicide and self made suicide 6x more likely in the next 6 months
- check for possible recent humiliations and determine whether any of the factors are present that might indicate a high probability of suicide
- no-suicide contract
- programs for at-risk individuals
- CBT can be helpful in decreasing suicide risk
importance of assessment
• suicidal desire → ideation, hopelessness, burdensomeness, feeling tapped
• suicidal capability → past attempts, high anxiety and/or rage, available means
• suicidal intent → plan, expressed intent to die, preparatory behavior
- immediate action is required if all three are present
no-suicide contract
- promise not to do anything remotely connected with suicide
- if refused, then hospitalization occurs
• complete or partial
programs for at-risk individuals
• make services available to students when one has committed suicide
• limit access to lethal weapons
• helplines
personality disorders
• a persistent pattern of emotions, cognitions, and behavior that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships
• pervasive and inflexible across social and personal contexts
• leads to distress or impairment
• onset in adolescence or early adulthood and tends to be stable over time
statistics and development personality disorders
prevalence = 6%, may be closer to 10%
origins and course
- begin in childhood
- chronic course
• can remit but is replaced by other personality disorder
- high comorbidity
Ted Bundy: Serial Killer
antisocial personality disorder
- honor student in Psychology, U. of Washington
- "He conducts himself more like a young professional than a student. I would place him in the top one percent of the undergraduates with whom I have interacted."
- Bundy, "I'm the most cold-hearted son of a bitch you'll ever meet. I don't feel guilt for anything."
Cluster B: Antisocial clinical description
- noncompliance with social norms → don't follow law/rules
• according to Freud, missing superego
- "social predators"
• violate rights of others
• irresponsible
• impulsive → emotion driven
• deceitful → don't feel guilt
- very good behaviorists → say what they'll get rewarded for and won't say what will get them punished
- lack a conscience, empathy, and remorse
- substance abuse is common
- often preceded by conduct disorder in youth
- aka moral insanity, egopathy, sociopathy, psychopathy
nature of psychopathology
Cleckley/Hare criteria (20 item checklist assessment tool) which focuses primarily on personality traits
• glibness/superficial charm
• grandiose sense of self-worth
• pathological lying
• conning/manipulative
• lack of remorse
• callous/lack of empathy
Antisocial Personality Disorder and Criminality
some psychopaths/APDs are criminal and antisocial while others are not criminal or aggressive
- may be due to IQ
• high IQ may protect some people from developing more serious problems or from getting caught

some psychopaths function well in certain segments of society → politics, business, entertainment
- not the focus of much research because hard to identify this subclinical population
Conduct Disorder
diagnosis for children who engage in behaviors that violate society's norms
- childhood onset type → the onset of at least one criterion characteristic of CD prior to age 10
- adolescent onset type → the absence of any criteria characteristic of CD prior to age 10 years
- "with a callous-unemotional presentation" subtype → presenting with personality characteristics similar to an adult psychopath
- most often see in boys
- developmental nature
• many adults with APD has conduct disorder
Types of Antisocial Personality Proposed by Millon
- Antisocial sociopath
- Exploitive sociopath
- Impulsive sociopath
Antisocial sociopath
• Mistrustful, anticipates betrayal
• Cold-blooded, ruthless, dog-eat-dog world
• Rejection of tender emotions because people treat each other badly
• Angry people because they have been treated badly/don't like how they've been treated in the world
- Grew up in an abusive environment, tough neighborhood so they want to throw it back at the world
• Frequent, destructive behavior towards others without guilt or remorse
Exploitive sociopath
• very self-centered, narcissistic
- behavior driven by narcissism → you don't have to live by the rules of others; "I'm special"
• strong social skills
- make it easy to trick/pull one over on people
• air of dignity and confidence
• skilled at deceiving others
• frequent lying, swindling, sexual excesses, fraud
• lack of hostile vindictiveness
• maybe grew up...
- spoiled, wealthy, told special, etc.
Impulsive sociopath
• strong need for excitement and stimulation
- perhaps because cortical arousal is too low
• seeks novelty, danger, and thrills
• desires attention and approval
• brief, intense relationships because once the novelty effect wears off they get bored
• no sense of loyalty, responsibility, commitment
• lack of concern for impact on other people
Antisocial Personality Disorder: theory
- the sociocultural perspective
injustices built into our society contribute dramatically to the development of criminal behavior
Antisocial Personality Disorder: theory
- the behavioral perspective
• modeling by family
• inconsistent and lenient discipline by parents
• reinforcement by peers
Antisocial Personality Disorder: theory
- the cognitive perspective
• focuses on social information processing
- interpret ambiguous, vague cues from other people that most would say was nothing as negative
• cognitively distort evil intent of other people
Antisocial Personality Disorder: theory
- the biological perspective
• genetic factors
- offspring adopted from felons had higher rates of arrest, conviction, APD especially when kept in interim orphanages longer
- may only be important in the presence of certain environmental influences
• physiological abnormalities
Antisocial Personality Disorder: theory
- the psychodynamic perspective
• lack of parental love during infancy leads to lack of basic trust and person becomes detached
• lack of development of superego, right/wrong
Antisocial Personality Disorder: theory
- Arousal theories
• underarousal hypothesis
• fearlessness hypothesis
• 3 major brain systems influence learning and emotional behavior
underarousal hypothesis
psychopaths have abnormally low levels of cortical arousal
- inverted U-shape between arousal and performance (low and high arousal have negative affect and perform poorly)
- abnormally low levels of cortical arousal are the primary cause of antisocial and risk-taking behaviors; they seek stimulation to boost chronically low levels of arousal
fearlessness hypothesis
psychopaths have a higher threshold for experiencing fear than most other individuals
- things that greatly frighten the rest of us have little effect on the psychopath
3 major brain systems influence learning and emotional behavior
- the behavioral inhibition system
- the reward system
- the fight/flight system
the behavioral inhibition system
responsible for our ability to stop or slow down when we are faced with impending punishment, nonreward, or novel situations
• psychopaths may have weaker BIS meaning less fear
the reward system
responsible for how we behave; associated with hope and relief
• psychopaths may have more prominent rewards
Psychological and Social Dimensions of APD
- once psychopaths set their sights on a reward goal, they are less likely than nonpsychopaths to be deterred despite signs the goal is no longer achievable
• reckless and daring behavior
- aggression in children with antisocial personality disorder may escalate partly as a result of their interactions with their parents
• parents often give in to children's problem behavior resulting in continuing problem behavior
- shared environmental factors may increase APD
Developmental Influences in APD
- antisocial behaviors change with age
- antisocial behaviors begin to decline rather markedly around the age of 40
An Integrative Model of APD
- genetics may lead to differences in neurotransmitters and neurohormone (dopamine and serotonin) function that influences aggressiveness, as well as differences in neurohormone (cortisol) function that affects the way people deal with stress
- gene-environment interaction of fear conditioning in children
• we learn to fear things that can harm us
• psychopaths may not learn to fear things that can harm them
o perhaps due to deficits in amygdala functioning
- interaction style that encourages APD in children
Conscience Development: Solomon
- analog research → studying something like the phenomenon
- conscience
• resistance to temptation → resist negative reactions, do things like return lost wallets rather than giving into the temptation of keeping it
• guilt
The Case of the Wayward Beagle
beagles taught not to eat canned dog food, only dry dog food; hit on snout with newspaper after:
- 0, 5, or 15 seconds after eating canned food
dogs presented canned and dry dog food without anyone present
- who breaks the taboo and eats the dog food first
• 15 second delay breaks the taboo first
• 5 second delay breaks the taboo second
• 0 second delay breaks the taboo third
Experiencing
once the dogs broke the taboo and began to eat, which dogs showed distress (e.g. whining, tail between legs, hiding in corner) and which were happy?
- 5 & 15 second group showed distress
• taught you might eat for a while and then bad things happen so they have distress
- NO distress from 0 second delay group
• Never had experience of eating then punishment occurring
Biological Bases of APD
Twin studies
Monozygotic highest concordance rates, then dizygotic twins of same gender, then opposite gender twins
Biological Bases of APD
Adoption studies
- Select adoptees, some of whom grow up to be "criminals" and others who do not
- Calculate criminal status of biological and adoptive fathers
Adoption and APD: Hutchings and Mednick (1973)
Which pairing of biological and adoptive parents is most likely to result in criminal adoptees?
- Both fathers criminal → 36% of adoptees become criminal
- Biological father criminal/ adoptive father not → 21% of adoptees become criminal
- Adoptive father criminal/ biological father not → 11% of adoptees become criminal
- Neither father criminal → 10% of adoptees become criminal
• shows that biology plays a big role
Physiological Abnormalities in APD: EEG studies
show high level of abnormal EEG patterns
- Cortical immaturity hypothesis (delayed development of cortex)
• Generalized slow wave activity indicative of infants and young children
• If delays in development of cortex, does it finally mature and less antisocial behavior?
Physiological Abnormalities in APD: Specific EEG abnormalities
• Increased prefrontal lobe activity (area of brain that controls impulsive behavior)
• Slow-wave activity in temporal lobe and limbic system (control memory and emotion, learning to avoid punishment)
Physiological Abnormalities in APD
Lower state of cortical excitability and less responsive to sensory input
Antisocial Personality Disorder: Treatment
- unlikely to seek on own and if do seek, poor treatment outcomes
- high recidivism → repeating behavior despite jail, etc.
- incarceration to prevent future antisocial acts
- early intervention
- prevention → best approach rather than treatment
• parent training
• rewards for pro-social behaviors
• skills training
• improve social competence
Cluster B: Narcissistic clinical description
- Exaggerated and unreasonable sense of self-importance
• Grandiosity → fantasies of greatness
- Require attention
- Lack sensitivity and compassion
- Sensitive to criticism
- Envious
- Arrogant
- use or exploit others for their own interests and show little empathy
- often depressed because they fail to live up to their own expectations
Causes of narcissistic personality disorder
- Deficits in early childhood learning
• Altruism
• Empathy
- Sociological view
• Increased individual focus
• "Me generation"
treatment of narcissistic personality disorder
- focuses on:
• Grandiosity
• Lack of empathy
• Hypersensitivity to evaluation
• Co-occurring depression
• Little empirical support
Perspectives on Substance-Related and Addictive Disorders
- 9% of general population suspected to use illegal drugs
- people can use drugs and not abuse them but we don't know who will become addicted
- dependence can present without abuse
• prescription drugs prescribed after surgery
substance
chemical compounds that are ingested to alter mood or behavior
• psychoactive substances → alter mood, behavior, or both
• safe drugs (alcohol, nicotine, caffeine) also affect mood and behavior, can be addictive and account for more health problems and morality than all illegal drugs combined
substance use
the ingestion of psychoactive substances in moderate amounts that does not significantly interfere with social, educational, or occupational functioning
• occasionally drinking coffee, drinking, or smoking
substance intoxication
physiological reaction to ingested substance
substance abuse
defined in terms of how significantly the substance interferes with the users life
substance dependence
addiction;
- physiologically dependent on the drug or drugs, requires increasingly great amounts of the drug to experience the same effect (tolerance) and will respond physically in a negative way when the substance is no longer ingested (withdrawal)
• withdrawal differs between drugs
- repeated use of a drug, a desperate need to ingest more of the substance, and the likelihood that use will resume after a period of abstinence are behaviors that define the extent of drug dependence
substance-related disorders are described by
level of severity
• mild
• moderate
• severe
Diagnostic Issues with substance use disorders
- drug and alcohol abuse previously considered "sociopathic personality disturbances" or moral weaknesses but regarded as biological disease since 1980s
- symptoms of other disorders can complicate the substance abuse picture significantly
• ¾ of people in addiction treatment centers have additional psychiatric disorders
o often mood or anxiety disorders
- if symptoms seen in schizophrenia or in extreme states of anxiety appear during intoxication or within 6 weeks of withdrawal from drugs, they are NOT considered signs of a separate psychiatric disorder
depressants
- decrease CNS activity
- reduce our levels of physiological arousal and help us relax
- alcohol; sedative, hypnotic, anxiolytic drugs
- among drugs mostly likely to produce symptoms of physical dependence, tolerance, and withdrawal
Alcohol-Related Disorders
alcohol has a long history and is produced when certain yeasts react with sugar and water and fermentation takes place
clinical description of alcohol-related disorders
- feel stimulated at first, but CNS is actually depressed
- feeling of well-being, reduced inhibitions, become more outgoing
• literally because inhibiting sections of brain are slowed/depressed
- continued drinking causes impeded ability to function properly
• motor coordination impaired
• reaction time slowed
• confusion
• ability to make judgments impaired
• vision and hearing negatively affected
path of alcohol
- consumed, down esophagus, into stomach, mostly absorbed into the blood in the small intestine where it then is circulated throughout the bloodstream contacting every major organ
• vaporized and exhaled in lungs → breathalyzer test
- them passes through liver and broken down or metabolized into carbon dioxide and water by enzymes
alcohol influences a number of neuroreceptor systems making it hard to study
- GABA system
- Glutamate system
- Serotonin system
alcohol and GABA
• GABA is inhibitory neurotransmitter, interferes with firing of neuron by allowing chloride ions to enter cell making it less sensitive to neurotransmitter effects
• Alcohol reinforces chloride movement making firing more difficult
alcohol and glutamate
• Excitatory and related to memory
• Blackouts may result form interaction of alcohol with glutamate system
alcohol and serotonin
• May be responsible for alcohol cravings
Withdrawal from alcohol
hand tremors, nausea, vomiting, anxiety, hallucinations, agitation, insomnia, delirium tremens
- Delirium tremens → frightening hallucinations and body tremors
Long term excessive drinking
liver disease, pancreatitis, cardiovascular disorders, brain damage
Two types of organic brain syndromes may result from long-term heavy alcohol use
- Dementia
- Wernicke-Korsakoff Syndrom
dementia
→ general loss of intellectual abilities
Wernicke-Korsakoff Syndrom
results in confusion, loss of muscle coordination, and unintelligible speech
• Caused by thiamine deficiency because thiamine is metabolized poorly by heavy drinkers
Mild to moderate intake of alcohol (especially wine) may actually
serve a protective role in cognitive decline as we age
Fetal Alcohol Syndrome
a combination of problems that can occur in a child whose mother drank while she was pregnant
• Fetal growth retardation, cognitive deficits, behavior problems, learning difficulties
• Characteristic facial features
Alcohol Dehydrogenase
an enzyme that helps metabolize alcohol
- 3 types
• beta-3 ADH more common in FAS kids as well as African Americans suggesting certain racial groups may be more susceptible to FAS
Statistic on Use and Abuse of Alcohol
- most adults in the US say their light to not drinkers
- but ~half of all Americans over 12 report being current drinkers
- considerable differences among racial groups/backgrounds
• whites have highest frequency of drinking, Asians lowest
- 22.6% of American report binge drinking (5+ drinks in one occasion) in the past month
• Asians have least, Native Americans have most
• Also more prevalent among college students, esp. male
- Correlation between # drinks/week and GPA
- Estimates 3 million adults are alcohol dependent (in the US?)
• Rates vary WIDELY outside of US due to cultural differences
Progression of alcoholism
- 20% of people with severe alcohol dependence have spontaneous remission
- Jellinek's FAULTY model for progression of alcoholism
- The course of alcohol dependence may be progressive for most people, whereas the course of alcohol abuse may be more variable
- One's response to the sedative effects of the substance affects later use
• Those individuals who tend not to develop the slurred speech, staggering and other sedative effects of alcohol use are more likely to abuse it in the future
Jellinek's FAULTY model for progression of alcoholism
- Prealcoholic stage
- Prodromal stage
- Crucial stage
- Chronic stage
Prealcoholic stage
→ drinking occasionally with few serious consequences
Prodromal stage
→ drinking heavily but with few outward signs of a problem
Crucial stage
→ loss of control with occasional binges
Chronic stage
→ the primary daily activities involve getting and drinking alcohol
Alcohol use is linked to violent behavior
- Alcohol does make participants more aggressive but there are a number of interrelated factors causing this
- May increase a person's likelihood of engaging impulsive acts impairing the ability to consider the consequences of acting impulsively
sedative
calming
hypnotic
sleep-inducing
anxiolytic
anxiety-reducing
Sedative-, Hypnotic-, or Anxiolytic drugs include
• barbiturates
• benzodiazepines
barbiturates
family of sedative drugs first synthesized in Germany in 1882 prescribed to help people sleep and replace drugs like alcohol and opium
- widely prescribed in 30s and 40s but became most abused drug by 50s
benzodiazepines
used since the 60s primarily to reduce anxiety, calm individuals, induce sleep, muscle relaxants, anticonvulsants
- considered much safer than barbiturates, with less risk of abuse and dependence
- Rohypnol → date rape drug
• Same effect as alcohol without the odor
barbiturates at low doses
relax the muscles and can produce a mild feeling of well-being
barbiturates at larger doses
results similar to those of heavy drinking
barbiturates at extremely high doses
diaphragm muscles can relax so much that they cause death
benzodiazepines when used recreationally first cause
pleasant high and reduction of inhibition like alcohol
benzodiazepines with continued use
tolerance and dependence can develop
• withdrawal similar to alcohol → anxiety, insomnia, tremors, delirium
sedative-, hypnotic-, anxiolytic-related disorder symptoms include
maladaptive behavioral changes such as inappropriate sexual or aggressive behavior, variable moods, impaired judgment, impaired social or occupational functioning, slurred speech, motor coordination problems, and unsteady gait
sedative-, hypnotic-, anxiolytic drugs affect the brain by influencing
the GABA neurotransmitter system
- as such, these drugs have a synergistic effect with alcohol
Statistics sedative-, hypnotic-, anxiolytic-related disorder
• barbiturate use has declined and benzodiazepine use has increased since 1960
• abuse tends to occur in female Caucasians over age 35
stimulants
- most commonly consumed psychoactive drugs in the US
• caffeine, nicotine, amphetamines, cocaine
Amphetamines at low doses
at low doses → induce feelings of elation and vigor and reduce fatigue
• crash → depressed or tired
amphetamines
created in 1887 and used as a treatment for asthma and nasal decongestant and narcolepsy and ADHD
• also used for weight loss as they reduce appetite
• 31% of college students have used to improve studying
- Great risk for dependency and long-term difficulties
intoxication in amphetamine use disorders
euphoria or affective blunting, changes in sociability, interpersonal sensitivity, anxiety, tension, anger, stereotyped behaviors, impaired judgment, and impaired social or occupational functioning
• physiological changes also occur
MDMA
Germany, 1912; originally an appetite suppressant, now a club drug (ecstasy, molly)
- Happiness, love, intensified emotions/sensations
- Repeated use may cause lasting memory problems
Chrystal meth
purified amphetamine ingested normally through smoking
- Marked aggressive tendencies, stays in system longer than cocaine making it dangerous
- Originally in gay community, now spread
amphetamines stimulate...
stimulate the CNS by enhancing activity of NE and DA
- help release of the neurotransmitters and block their reuptake making more available in the system
• too much can lead to hallucinations and delusions
• may be theory for schizophrenia
Cocaine
- became the stimulant of choice in the 70s
- derived from leaves of coca plant
- came to US in late 19th century and was sold in coca-leaf cigarettes, cigars, inhalants, crystals and Coca-Cola up until 1903
cocaine one small amounts
increases alertness, produces euphoria, increases blood pressure and pulse, causes insomnia and loss of appetite
cocaine-induced paranoia
common among persons with cocaine use disorder
cocaine and the heart
makes heart beat more rapidly and irregularly and can have fatal consequences for some
cocaine/crack and babies
more irritable than normal babies, with long bouts of high pitched crying
- may NOT have permanent brain damage though, damage may be less - decreased birth weight and head circumference
- increased risk for later behavior problems
- mothers often use others substances, worsening child's health
- kids often raised in disrupted home environments
cocaine statistics
• 5% of adults use cocaine at some point in their lives
• white males, black males, white females, black females in order form most to least use
• 0.2% of people have tried crack
cocaine effect
causes "up" effect through DA system
• blocks reuptake of DA so that DA repeatedly stimulates neurons
• dependence for cocaine is different than other drugs
people find only that they have a growing inability to resist taking more
- with continued use...
• sleep is disrupted
• tolerance causes need for higher doses
• paranoia and other negative symptoms may occur
• social isolation may occur
• potential premature aging of the brain
- withdrawal → feelings of apathy and boredom
Tobaccos related disorders
- nicotine gives tobacco its pleasurable effects
- 20% of Americans smoke
nicotine withdrawal symptoms
• depressed mood
• insomnia
• irritability
• anxiety
• difficulty concentrating
• restlessness
• increased appetite and weight gain
nicotine in small doses
stimulates the CNS, relieving stress and improving mood but...
• also causes high blood pressure, increased risk of heart disease and cancer
nicotine in high doses
blur vision, cause confusion, lead to convulsions, cause death
nicotine entering the blood
nicotine is inhaled into the lungs where it enter the blood-stream
• reaches brain 7-19 seconds after inhaled
• stimulates nicotinic acetylcholine receptors in the midbrain reticular formation and limbic system (site of the DA/pleasure pathway)
- maternal-smoking predicts
later substance abuse but may be more environmental than biological
smoking linked with
signs of negative affect (depression, anxiety, anger)
• severe depression occurs more often in people with nicotine dependence (situations increase risk for one another)
Caffeine Related Disorders
- caffeine is most common psychoactive substance used by 90% of Americans
• "gentle stimulant"
- in small doses → elevates mood and decreases fatigue
- in larger doses → makes you feel jittery and causes insomnia
• takes 6 hours to leave our body so can disrupt sleep easily
- people react variously to caffeine
- 1 cup of coffee per day does not harm the developing fetus
- Caffeine use disorder → problematic caffeine use that causes significant impairment and distress
- regular caffeine use can cause tolerance and dependence
- seems to affect the brain through the neuromodulator adenosine and lesser through DA
• caffeine blocks adenosine reuptake
Opioids
- opiate → natural chemicals in the opium poppy that have a narcotic effect
• relieve pain and induce sleep
- natural opiates → morphine, laudanum
- synthetic variations → heroin, methadone, hydrocodone, oxycodone
- opiate-like brain substances → enkephalins, beta-endorphins, dynorphins
- opiates induce → euphoria, drowsiness, and slowed breathing; pain relief
• high doses → death if respiration is completely depressed
- withdrawal is highly unpleasant → yawning, nausea, vomiting, chills, muscle aches, diarrhea, insomnia
• lasts 1-3 days; withdrawal complete in 1 week
- most commonly abused opiate → heroin
• prescription pills have also become much more common
- also at risk for HIV/AIDS when using because often injected
- high caused by body's natural opioid system
• natural opiates mimic brain opiate-like substances providing narcotic effect
cannabis (marijuana)
drug of choice in 60s and early 70s
• Still most routinely used illegal substance with 5-15% of people in Western countries reporting regular use
• Marijuana/Weed → name given to dried parts of the cannabis or hemp plants
cannabis users often experience
• altered perceptions of the world
• mood swings
• heightened sensory experiences
• seeing vivid colors
• appreciating the subtleties of music
• finding things more funny/entertaining
• time standing still/dreamlike state
cannabis use
- first time users may have no reaction
- people can "turn off" the high if they are sufficiently motivated
- larger doses may cause → paranoia, hallucinations, dizziness
- frequent use may cause impairments of
• memory, concentration
• relationship with others
• employment
synthetic marijuana
K2, Spice; marketed as "herbal incense"
- can be purchased legally in some places but can cause harmful reactions
• hallucinations, seizures, heart rhythm problems
chronic and heavy users of marijuana
• some report tolerance to euphoric high
• some report reverse tolerance, meaning they get more pleasure after repeated use
major signs of withdrawal do not occur with cannabis
irritability, restlessness, appetite loss, nausea, difficulty sleeping
Cannabis in medicine
- evidence to be used to treat
• chemotherapy induced nausea and vomiting
• HIV associated anorexia
• Neuropathic pain in MS
• Cancer pain
• Seizure disorders
- Smoking may be bad because of carcinogens BUT one long term study suggests that occasional use does not appear to have a negative effect on lung functioning
marijuana intake and chemicals
- intake through smoking marijuana cigarettes or hashish
- marijuana contains more than 80 cannabinoids which alter mood and behavior
• THC (tetrahydrocannabinoids) is most common
Brain makes own THC
→ anandamide and several other natural brain chemicals
LSD (d-lysergic acid diethylamide)
synthetically produced and most common hallucinogenic drug that also naturally occurs in the derivatives of the ergot grain fungus
• first produced illegally for recreational use in the 60s
number of other hallucinogens, some occurring naturally
• psilocybin → found in certain species of mushrooms
• lysergic acid amide → found in the seeds of the morning glory plant
• dimethyltryptamine → found in the bark of the Virola tree
• mescaline → found in the peyote cactus plant
• phencyclidine (PCP) → snorted, smoked, or injected intravenously causing impulsivity and aggression
diagnostic criteria for hallucinogen intoxication
perceptual changes (intensification of perceptions), depersonalization, hallucinations
• physical symptoms → pupillary dilations, rapid heartbeat, sweating, blurred vision
• often described as a mystical experience
tolerance develops quickly to hallucinogens
hallucinogen use disorder
• drugs lose their effectiveness if taken repeatedly over a period of days
• sensitivity returns after about a week of abstinence
• no withdrawal symptoms are reported
hallucinogens have
possibility of psychotic reaction and "bad trips"
• dangerous behavior though is not increased more than being drunk, etc.
LSD, psilocybin, lysergic acid amide, and DMT are chemically similar to
serotonin
mescaline resembles
NE
other hallucinogens resemble
acetylcholine
Inhalants
ariety of substances found in volatile solvents that are breathed into the lungs directlu
• spry paint, hair spray, paint thinner, gasoline, amyl nitrate, nitrous oxide, nail polish remover, sharpies, etc.
• typically used by Caucasian males in rural or small towns with higher levels of anxiety, depression, impulsivity and fearlessness
• rapidly absorbed into bloodstream
• high resembles alcohol intoxication and usually includes dizziness, slurred speech, incoordination, euphoria, lethargy
• tolerance and withdrawal occur
• physical damage → sudden sniffing death (cardiac arrest) if startled
Anabolic-androgenic steroids
synthesized form of the hormone testosterone
• illicit use orally or by injection by those wishing to improve their physical abilities by increasing muscle bulk
• 2-6% of males will use illegally at some point in their life
• does NOT produce a desirable high but in instead used to enhance performance and body size
• dependence involves desire to maintain gains rather than need to re-experience emotional/physical state
• long term use can cause mood disturbances
Dissociative anesthetics
cause drowsiness, pain relief, feeling of being out of one's body
• "designer drugs"
• MDMA → heighten auditory and visual perception, taste and touch
• Ketamine
• GHB
• All can result in tolerance and dependence
Ketamine
→ dissociative anesthetic that produces a sense of detachment along with a reduced awareness of pain
GHB
→ CNS depressant marketed in health food stores in the 80s to stimulate muscle growth
- Low doses → relaxation and increased tendency to verbalize
- Higher doses/mixed with alcohol/other drugs → seizures, severe respiratory depression, coma
- Date rape drug
Familial and Genetic Influence of substance-related disorders
- drug abuse has genetic influences; some people are genetically vulnerable to drug abuse
- genetic factors affect how people experience certain drugs
• certain genes are associated with greater likelihood of heroin addiction in Hispanic and African American populations
- genetic factors may also help predict which treatments may be effective in reducing these problems
Neurobiological Influences of substance-related disorders
- people are positively reinforced for using drugs because drugs affect the brain's pleasure pathway the way food or sex does
- amphetamines and cocaine act directly on the DA system whereas other drugs increase DA in roundabout ways or affect other reward systems like 5HT or NE
- sons of alcoholics may be more sensitive to alcohol when first ingested but then become less sensitive to later drinks and they tend to drink more heavily and more often
Psychological Dimensions of substance abuse disorder
- Positive Reinforcement
- Negative reinforcement
positive reinforcement
- psychoactive substances are pleasurable so people continue to take them trying to recapture the pleasure
- social contexts for drugs may encourage its use
- positive reinforcement in the use and the situations surrounding the use of drugs contributes to whether or not people decide to try to continue using drugs
Negative Reinforcement
- drugs help reduce unpleasant feelings, reinforcing use
- substance use becomes a way for users to cope with the unpleasant feelings that go along with life circumstances
- having a parent with alcohol dependence and/or unpleasant feelings made adolescents more likely to use drugs
- many people may use drugs to self-medicate so treating the real underlying problem (i.e. giving coke users trying to focus their attention because of ADHD methylphenidate) may reduce usage
- Opponent Process Theory
Opponent Process Theory
an increase in positive feelings with be followed shortly by an increase in negative feelings; similarly, an increase in negative feelings will be followed by an period of positive feelings
- strengthened with use (tolerance); weakened with disuse
• when more drug is needed to achieve the high, the negative feelings afterward intensify (worsened withdrawal)
• at this point, motivation for taking drug shifts from seeking a high to avoiding a low
Cognitive Dimensions
the influence of how we think about drug use has been labeled an expectancy effect
- expectancies develop before people actually use drugs
• adolescents may begin drinking or using drugs partly because they believe these substances will have positive effects
- expectancies change as people have more experience with drugs
- cravings
cravings
once people stop taking drugs after prolonged or repeated use, cravings can interfere with efforts to remain off the drugs
- cravings triggered by
• availability of the drug
• contact with things associated with drug taking
• specific moods
• having a small dose of the drug
Social Dimensions
- exposure to psychoactive substances in a necessary perquisite for their use and possible abuse
- drug addicted parents spend less time monitoring their children than parents without drug problems and this is an important contribution to early adolescent substance use
• self-perpetrating pattern
- moral weakness model of chemical dependence
- disease model of dependence
moral weakness model of chemical dependence
drug use is seen as a failure of self control in the face of temptation
• psychosocial perspective
• drug users lack the character or moral fiber to resist the lure of drugs
• leads to punishing those afflicted
disease model of dependence
drug dependence is caused by an underlying physiological disorder
• biological perspective
• includes seeking treatment for a medical disorder
• idea that the disease is uncontrollable can be counterproductive
Cultural Dimensions of substance abuse disorder
- acculturation → the extent to which and how well people adapt to new cultures
• source of strength or stress
- different cultural factors can affect drug use and treatment in either a positive or negative way
- different cultures have different acceptable psychoactive drugs
- people of Asian descent are more likely to have the ALDH2 gene which produces a severe "flushing" of the face after drinking alcohol
- cultural factors not only influence the rates of substance abuse but also determine how it manifests
An Integrative Model of substance abuse disorder
- access to a drug is a necessary but not sufficient condition for abuse or dependence
- whether people use a drug also depends on social and cultural expectations
- major stressors aggravate many disorders
- genetic influences may be of several types
• great sensitivity to the effects of certain drugs
• ability to metabolize quicker and tolerate more
- psychiatric disorders may put someone at risk for substance abuse
• antisocial personality disorder
• mood disorders
• anxiety
- the brain reorganizes itself in drug addicts contributing to continued use and relapse
- once a drug has been used repeatedly, biology and cognition conspire to create dependence
• conditioning
Principles of Effective Treatment
single treatment is appropriate for all individuals
• treatment needs to be readily available
• effective treatment attends to multiple needs of the individual not just his or her drug use
• an individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs
• remaining in treatment for an adequate period of time is critical for treatment effectiveness (3 months or longer
• counseling and other behavioral therapies are critical components of effective treatment for addiction
• medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies
• addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way
• medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use
• treatment does not need to be voluntary to be effective
• possible drug use during treatment must be monitored continuously
• treatment programs should provide assessment for HIV/AIDS, hep B and C, TB, and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection
• Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment
Biological Treatments of substance abuse disorder
Agonist Substitution
Antagonist Treatments
Aversive Treatment
Agonist Substitution
providing the person with a safe drug that has a chemical makeup similar to the addictive drug
- methadone
- buprenorphine
methadone
opiate agonist often given as a heroin substitute
• initially provides the same analgesic and sedative effects as heroin but not the quick high; effects lost once tolerance is developed
• heroin and methadone have cross tolerance → meaning they act on the same neurotransmitter receptors so a heroin addict may become addicted to methadone instead
• methadone combined with counseling may reduce heroin use and decrease criminal activity
buprenorphine
blocks the effects of opiates and seems to encourage better compliance than would a nonopiate or opiate antagonist
cigarette smoking is treated by...
• nicotine substitution → gum, patch, inhaler, nasal spray which lack carcinogens in smaller and smaller doses to lessen withdrawal
• bupropion → curbs nicotine cravings without being an agonist for nicotine
Antagonist Treatments
block or counteract the effects of psychoactive drugs
- naltrexone
- acamprosate
naltrexone
opiate-antagonist drug; produces immediate withdrawal symptoms in someone dependent on opiates
• must be given only once a person is free from withdrawal symptoms
• person must be highly motivated to continue treatment
• works better if person is also in therapy
acamprosate
decrease cravings in people dependent on alcohol
• works better if person is also in therapy
• person must be highly motivated
Aversive Treatment
drugs that make ingesting the abused substances extremely unpleasant
- disulfiram (Antabuse)
- silver nitrate in nicotine gum
- all aversive treatments require extreme motivation
disulfiram (Antabuse)
used with alcoholism; prevents the breakdown of acetaldehyde, a by-product of alcohol, which causes a buildup resulting in illness
• causes nausea, vomiting, elevated heart rate, and respiration if alcohol is consumed
• ideally taken in the morning before alcohol cravings occur
• noncompliance is a major concern
silver nitrate in nicotine gum
makes it taste bad, but not particularly effective
Other Biological Approaches
- medication is often prescribed to help people deal with the often-disturbing symptoms of withdrawal
• clonidine → given to people withdrawing from opiates to treat hypertension
• benzodiazepines → given to people withdrawing from alcohol and other drugs to minimize discomfort
Psychosocial Treatments for substance abuse disorders
- biological treatments are not usually ever successful alone
- need for social support or therapeutic intervention
- many types of treatments have not been psychologically evaluated and while they may be effective, the idea that people are using these services of unknown value is cause for concern
Inpatient Facilities for substance abuse disorders
- first one in 1935 in Lexington, Kentucky
- most are now privately run and help people get through the initial withdrawal period and provide supportive therapy so they can go back to their communities
- can be very expensive
- may be no difference between intensive residential setting programs and cheaper quality outpatient care in the outcomes for alcoholic patients or for drug treatment in general
Alcoholics Anonymous and Its Variations
most popular model for treatment of substance abuse
12 steps program first developed by AA established in 1935 by two alcoholic professionals
- foundation → the notion that alcoholism is a disease and alcoholics must acknowledge their addiction to alcohol and its destructive power over them
• addiction is stronger than any individual so they must look to a higher power to help them overcome their shortcomings
- AA is independent from the established medical community and free from the stigmatization of alcoholism
- Focus on social support through group meetings
People and AA and its variations
- 9% of the adult population in the US has attended an AA meeting
- many people credit AA, NA, CA with saving their lives
- people who regularly participate in AA activities - or similarly supportive approaches - and follow the guidelines carefully are more likely to have positive outcomes
Controlled Use of substances
- one AA tenet is total abstinence
- some researchers though believe a portion of substance users may be capable of becoming social users without resuming their abuse of drugs
- controlled drinking is very controversial
• controlled drinking may be a viable alternative to abstinence for some alcohol abusers (controlled drinking group was functioning well 85% of the time vs. 42% in abstinence) although it isn't a cure
o popular treatment in UK but not so much in US
Component Treatment
biological treatments are increased when psychological therapy is added
- aversion therapy (conditioning model) → substance use is paired with something extremely unpleasant like a brief shock or nausea
• counteract positive associations with substance use with negative associations
• can make negative associations by imagining unpleasant scenes in a technique called covert sensitization
contingency management
clinician and client together select the behaviors that the client needs to change and decide on the reinforcers that will reward reaching certain goals, perhaps money or small retail items like CDS
community reinforcement approach
several facets of the drug problem are addressed to help identify and correct aspects of the person's life that might contribute to substance use or interfere with efforts to abstain
• abuser improves relationships with other important people
• clients are taught how to identify the antecedents and consequences that influence their drug taking
• clients are given assistance with employment, education, finances, or other social service areas that may help reduce their stress
• new recreational options help the person replace substance use with new activities
motivational enhancement therapy (MET)
intervention approach that directly addresses the lack of personal awareness that one has a problem and an unwillingness to change
- based on work of Miller and Rollnick→ proposed that behavior changes in adults is more likely with empathetic and optimistic counseling and a focus on a personal connection with the clients core values
• by reminding the client about what they cherish, MET intends to improve the individual's belief that nay changes made will have positive outcomes and the individual is therefore more likely to make the recommended changes
CBT and substance use
- person's reactions to cues that lead to substance use and thoughts and behaviors to resist use
- relapse prevention → looks at the learned aspects of dependence and see relapse as a failure of cognitive and behavioral coping skills
• helping people remove any ambivalence about stopping their drug use by examining their beliefs about the positive aspects of the drug and confronting the negative consequences of its use
• high risk situations are identified and strategies are developed to help deal with them
prevention of substance abuse
- shifted from education-based approaches to more wide-ranging approaches, including changes in the laws regarding drug possession and use and community-based interventions
• DARE program encourages a "no drug use" message through fear of consequences, rewards for commitments not to use drugs, and strategies for refusing drugs
o This type of program may not have its intended effects
• More comprehensive programs involving skills training to avoid social and environmental pressures can be effective among some
- most powerful strategy may be cultural change
gambling disorder
- affects 1.9% of Americans in their lifetime
- criteria includes same pattern of urges in substance-related disorder
- need to gamble more money over time
- withdrawal symptoms such as restlessness and irritability when attempting to stop
- biological origins
• less impulse regulation when given environmental cues
• abnormalities in the dopamine and serotonin systems
gambling disorder treatment
• difficult because of problem denial, impulsivity, continuing optimism
• pathological gamblers experience cravings
• 70-90% of Gamblers Anonymous drop out
• desire to quit must be present before intervention
Impulse-Control Disorders
- a lot of disorders begin with an irresistible impulse
Intermittent Explosive Disorder
a disorder characterized by episodes in which a person acts on aggressive impulses that result in serious assaults or destruction of property
- lifetime prevalence of 5-7%
- controversial because may be used as a legal defense for all violent crimes
- influence of neurotransmitters such as 5HT and NE and testosterone levels along with their interaction with psychosocial influences
- CBT and approaches modeled after drug treatments appear most effective for these individuals
Kleptomania
a recurrent failure to resist urges to steal things that are not needed for personal use or their monetary value
- rare
- person begins to feel tension just before stealing which is followed by feelings of pleasure or relief while the theft is committed
- high impulsivity → inability to judge immediate gratification compared with long-term negative consequences
- often report amnesia about the act of shoplifting
- damage in areas of the brain associated with poor decision making
- high comorbidity with mood disorders and to a lesser extent substance abuse and dependence
- few reports of treatment exist
• behavioral or anti-depressants
• naltrexone somewhat effective
Pyromania
an impulse-control disorder that involves having a irresistible urge to set fires
- person feels tension or arousal before setting a fire and a sense of gratification or relief when the fire burns
- diagnosed in only 3% of arsonists; rare
- generally CBT treatment
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