Paranoid and Delusional
Disorders
Paranoid Personality Disorder
A. A pervasive distrust and suspiciousness of others such
that their motives are interpreted as malevolent,
beginning by early adulthood and present in a variety of
contexts, as indicated by four (or more) of the following
1. Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates
3. Is reluctant to confide in others because of unwarranted fear
that the information will be used maliciously against him or her
4. Reads hidden demeaning or threatening meanings into benign
remarks or events
Paranoid Personality Disorder
A. A pervasive distrust and suspiciousness of others such that
their motives are interpreted as malevolent, beginning by
early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or
slights)
6. Perceives attacks on his or her character or reputation that are not
apparent to others and is quick to react angrily or to counterattack
7. Has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner
B. Does not occur exclusively during the course of schizophrenia,
a bipolar disorder, or depressive disorder with psychotic
features, or another psychotic disorder and is not attributable
to the physiological effects of another medical condition
Delusional Disorder
Diagnostic Criteria
A. The presence of one (or more) delusions with a
duration of 1 month or longer
B. Criterion A for schizophrenia has never been met
Note: Hallucinations, if present, are not prominent and are
related to the delusional theme (e.g., the sensation of being
infested with insects associated with delusions of
infestation)
C. Apart from the impact of the delusion(s) or its
ramifications, functioning is not markedly impaired,
and behavior is not obviously bizarre or odd
Delusional Disorder
Diagnostic Criteria
D. If manic or major depressive episodes have
occurred, these have been brief relative to
the duration of the delusional periods
E. The disturbance is not attributable to the
physiological effects of a substance or
another medical condition and is not better
explained by another mental disorder, such
as body dysmorphic disorder or obsessivecompulsive disorder
Delusional Disorder
Diagnostic Criteria
• Specify whether:
– Erotomanic type – applies when the central theme of
the delusion is that another person is in love with
the individual
– Grandiose type – applies when the central theme of
the delusion is the conviction of having some great
(but unrecognized) talent or insight or having made
some important discovery
– Jealous type – applies when the central theme of the
individual’s delusion is that his or her spouse or lover
is unfaithful
Delusional Disorder
Diagnostic Criteria
• Specify whether:
– Persecutory type – applies when the central theme of the
delusion involves the individual’s belief that he or she is being
conspired against, cheated, spied on, followed, poisoned or
drugged, maliciously maligned, harassed, or obstructed in the
pursuit of long-term goals
– Somatic type – applies when the central theme of the delusion
involves bodily functions or sensations
– Mixed type – applies when no one delusional theme
predominates
– Unspecified type – applies when the dominant delusional belief
cannot be clearly determined or is not described in the specific
types (e.g., referential delusions without a prominent
persecutory or grandiose component)
Paranoid and Delusional Disorders
• The terms paranoid and delusional are often paired
– They are distinguishable
• There are delusions other than paranoid ones
• Some paranoid ideation does not qualify as delusional
• Each term is mentioned in one DSM-5 diagnostic category
name
– Paranoid personality disorder (PPD)
– Delusional disorder (DD)
• Both terms denote clinical phenomena seen in schizophrenia
and other mental disorders
– e.g. senile dementia in Alzheimer’s, precipated by the use of (or
withdrawal from) certain psychoactive drugs (e.g. amphetamines, etc.)
– Differential diagnosis is extremely important in these cases for
treatment planning
Paranoia
• To be paranoid…
– Generally means to suspect or believe that one (or one’s
group) is being intentionally targeted for harm – especially
betrayal – by some other person(s)
• In this context, even to merely suspect is also to expect
– There is an openness to any information that seems
consistent with the imputed threat
• A paranoid individual may see a nonexistent threat – or notice a
real threat that others miss
• Hostile attributional bias
– An inclination to view others’ behavior as arising from
hostility towards oneself
Paranoia
• “Just because you’re paranoid doesn’t mean
they aren’t after you.”
– Joseph Heller
Paranoia
• The intensity of the paranoia may be linked to various
biases
– Exaggerated assessment of the risk of impending betrayal
– Skewed judgement regarding what constitutes betrayal
– The view that it is especially terrible to be betrayed
– Overreaction to betrayal that one perceives has occurred
• It’s unwarranted to view these facets as a single paranoid
dynamic
– Overreaction to mistreatment may not always be linked to an
exaggerated perception of risk
– It’s possible to overreact to real and to imagined mistreatment
Paranoia
• Perceived Threat
– Paranoia involves sensitivity to danger
– Writers differ in which response to a threat is “the
paranoid one”
• For some it is a fearful, furtive, and avoidant response
• For others it is a hostile and angry response
– Sometimes involving preemptive antagonism
– Each narrows the definition of paranoia in a way
that is not universally shared.
Paranoia
• Perceived threat in PPD
– Paranoia can entail fear and/or hostility
• Seen in Criterion 3 of PPD
– The person may be “reluctant to confide in others because of unwarranted
fear”
• Seen in Criterion 6 of PPD
– The person may be “quick to react angrily”
• Perceived threat in DD
– DSM-IV
• The patient may avoid leaving “his house except late at night…
dressed in clothes quite different from his normal attire”
– DSM-5
• The person may be “resentful and angry and may resort to
violence”
Paranoia
• Overlap between paranoia and social anxiety
– Both involve
• Expectations of negativity from others
• Referential thinking
– Differences
• Socially anxious persons
– Anticipate negative evaluations from others
– Blame others’ negativity on themselves
• Paranoid persons
– Often expect more serious harm
– Blame others’ negativity on their ill will
Paranoia
• Hostility
– Expectations of harm can lead to preemptive attacks
on others
• This can lead to self-fulfilling prophecies :/
– Even when judgements of another’s ill will are
unwarranted, the paranoid individual may engage in
preemptive behaviors that eventually engender real ill
will
– Natsuaki et al. (2009)
• Studied peer relations of adolescents
• Found that those with PPD characteristics initiated more
bullying and other uncooperative behaviors
Paranoia
• Lay stereotypes link psychosis with violence
– Often influenced by cases in the media
– However, a number of systematic studies have shown
a relation between delusions – especially persecutory
– and aggressive behavior
Paranoia
• Hostility
– Laajasalo and Hakkanen (2006)
• Studied patients with schizophrenia who committed
suicide
• Nearly 90% had delusions
– In most cases, these delusions were persecutory
– Risk to family members
• In one group of delusional individuals who had
committed suicide, about two-thirds had killed a family
member
Paranoia
• Perceived Harm
– In PPD, DSM-5 has just one response-to-harm
criterion (criterion 5)
• Patient “persistently bears grudges (i.e. is unforgiving of
insults, injuries, or slights)”
– In DD, DSM-5 notes that the patient with DD “may
engage in litigious or antagonistic behavior”
Paranoia
• Querulous paranoia – when the person is
preoccupied with gaining redress
– May include a toxic mix of
• Obsessive grievance
• Angry confrontation
• Self-righteous disdain for the views of all other persons
• Vexatious litigants or querulants
– May be so persistent and infuriating that they garner
contempt-of-court citations
– Some behave assaultively when pleas are denied
Delusions
• Delusion – a false belief that has emotional
significance to the person, held in defiance of
the evidence at hand
– Delusions qualify as psychosis (i.e. a loss of touch
with reality)
– Delusional states may wax and wane or be stable
• Stable delusional beliefs may be circumscribed,
coherent, and non-bizarre
– In these cases, the individual does not present as psychotic
(though they are)
– Delusional Disorder is likely the more appropriate diagnosis
than Schizophrenia here
Delusions
• Those with DD often do not fit the usual profile
for schizophrenia
– They are often married and self-supporting
– The mean age of onset is usually in the late 30s or
early 40s
• This is quite a bit later than in schizophrenia
• Some view DD as a milder form of schizophrenia
– Nearly 20% of those who initially warranted a DD
diagnosis eventually received a schizophrenia
diagnosis
Delusions
• Two key aspects to delusions
– Emotional significance
– Falsity
Delusions
• Emotional Significance
– Kinderman and Bentall (2007)
• Most delusions “reflect an intense preoccupation with the
individual’s position in the social universe”
– Rhodes and Jakes (2000)
• Most delusions are related to specific personal goals or
motives
– MacDonald (2008)
• “No one develops the delusion that popcorn comes from
barley or that pavement just happens to be made of wornout carpet”
Delusions
• Falsity
– Clinical judgement that is crucial for making
diagnoses, but very problematic
– It’s possible to increase certainty, but tough to
eliminate it…
Delusions
• Examples
– A man’s wife often comes home late from work,
and he believes she is unfaithful
– An Arab immigrant is sure he is being trailed by
the FBI
• The clinician might be skeptical in each case,
but it would be risky to deem the beliefs
categorically false
Delusions
• Examples
– A musically untrained woman asserts that her
compositions will someday be on everyone’s
playlist – if not in this century, then in the next
– An amateur cosmologist asserts that the earth will
explode on February 17, 2946
• Even if the clinician is comfortable with a
diagnosis involving delusions, the claims are
unfalsifiable
Delusions
• Examples
– The depressed person believes himself to be
uniquely evil and loathsome
– The person with body dysmorphic disorder (BDD) is
certain that he is ugly and repulsive
• In both cases, the beliefs relate to inappropriate
standards as opposed to defying truth
– Both patients are embracing unreasonable norms of
virtue or beauty
Attributes of Delusions
• Delusional pathology lies on a continuum
– Partial delusionality
• Overvalued ideation, delusion-like beliefs, strongly held
ideas
– Cognitive distortions and biases are also
somewhere within this continuum (though on the
low end)
– Literature has terms denoting delusions
• Bizarreness, distress, conviction, insight, involvement,
and preoccupation
Attributes of Delusions
• Bizarreness
– Historically indicative of schizophrenia
– Under DSM-5, bizarreness is a specifier that can be
applied to DD delusions
– Sometimes can be blatant
• A woman, born in 1974, claims that she was impregnated by
Elvis prior to his death in 1977 and that she has been carrying
his baby ever since but has postponed the birth out of concern
that the happy event will upset the earth’s gravitational field
– Other times can be less blatant
• Interrater reliability in assessing bizarreness has ranged
from .28 to .85
– Low range gives doubt to the usefulness of this attribute
Attributes of Delusions
• Distress
– Commonly listed as a variable associated with
delusions
• This may reflect the idea that any diagnosis must represent
either a problem for the self or others
– There are exceptions
• Grandiose delusions may not be distressing
– Often involve wealth, power, and/or fame
• Patients who embrace aberrant beliefs may be proud of
their open-mindedness
• Suspicious persons may be proud that they are not being
duped
Attributes of Delusions
• Conviction
– Also known as
•
•
•
•
•
•
•
•
Imperviousness to feedback
Certainty
Commitment
Inflexibility
Fixity
Doxastic strength
Incorrigibility
Firmly sustained
– Rhodes and Jakes (2004)
• Noted that conviction can be self-sustaining
• Delusions having a religious component tend to entail strong conviction
– Sometimes, the less tenable the claim, the stronger evidence of faith it has
Attributes of Delusions
• Insight
– Lack of insight is lack of awareness that one’s belief is in
error
– Often used to differentiate those with persistent delusions
from those having a nonpsychotic disorder
• Example: someone with either DD or social anxiety disorder may
focus on being rejected by or offending others
• DSM-5 differentiates between the two
– “… many with social anxiety disorder have good insight that their beliefs
are out of proportion.”
• However, in obsessive-compulsive and related disorders, lack of
true insight does not always qualify the individual for a DD
diagnosis
Attributes of Delusions
• Involvement
– Emotional involvement is very similar to distress
– Behavioral involvement
• The presence of delusion-related actions, or the
pressure to act upon beliefs
• Most noteworthy when it is discrepant with insight
– In these cases, the individual will acknowledge that their
belief isn’t true, but will still act as if it were true
Attributes of Delusions
• Preoccupation
– This is the extent to which the ideation consumes
the individual’s mental life
• Described as obsessive, pervasive, recurring, persistent,
perseverative, ruminative, and intrusive
– DSM-5 draws a barrier between DD diagnoses and
OCSD diagnoses
• If someone qualifies for OCD, they can’t qualify for DD,
even if insight is absent
Delusional Themes
• Erotomanic
– In lay usage, it refers to rampant sexual desire
and/or behavior
– Here, it refers to the belief that a specific other
person – usually someone implausibly grand and
distant – is in love with them
– Traditional name is de Clerambault syndrome
– May account for only a small fraction of DD cases
Delusional Themes
• Jealous
– Refers to the belief that one’s partner is unfaithful
• As in a “jealous lover”
– Two variants of the clinical problem
• Suspicious jealousy – an excessive pre-occupation with the
possibility of betrayal
• Reactive jealousy – an excessive response to real or imagined
betrayal
– Variants of jealousy are also seen elsewhere, so differential
diagnosis is, again, important
• Obsessive-compulsive and related disorders
• Borderline personality disorder
Delusional Themes
• Persecutory
– Includes
• Beliefs that someone is interfering with what one is
aspiring for
• Beliefs that someone is working to bring about what
one dreads
– Phenomenon encompass humiliation, exploitation,
victimization, rejection, exclusion, betrayal, etc.
– These are likely the most common of all
schizophrenia symptoms
Delusional Themes
• Somatic
– Delusions involving one’s body are noted under four DSM5 diagnoses
• Schizophrenia, depression, DD-somatic, and BDD
– Delusional disorder is uncommon, but somatic cases make
up a substantial subset of patients within that diagnosis
Substance-Related and Addictive
Disorders
Must Read
Barney’s Change
Alcohol Use Disorder
Diagnostic Criteria
A. A problematic pattern of alcohol use leading to clinically
significant impairment or distress, as manifested by at
least two of the following, occurring within a 12-month
period:
1. Alcohol is often taken in larger amounts or over a longer period
than was intended
2. There is a persistent desire or unsuccessful efforts to cut down
or control alcohol use
3. A great deal of time is spent in activities necessary to obtain
alcohol, use alcohol, or recover from its effects
4. Craving, or a strong desire or urge to use alcohol
5. Recurrent alcohol use resulting in a failure to fulfill major role
obligations at work, school, or home
Alcohol Use Disorder
Diagnostic Criteria
A. A problematic pattern of alcohol use leading to clinically
significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period:
6. Continued alcohol use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of alcohol
7. Important social, occupational, or recreational activities are
given up or reduced because of alcohol use
8. Recurrent alcohol use in situations in which it is physically
hazardous
9. Alcohol use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by alcohol
Alcohol Use Disorder
Diagnostic Criteria
A. A problematic pattern of alcohol use leading to
clinically significant impairment or distress, as
manifested by at least two of the following, occurring
within a 12-month period:
10. Tolerance, as defined by either of the following:
a) A need for markedly increased amounts of alcohol to achieve
intoxication or desired effect
b) Markedly diminished effect with continued use of the same
amount of alcohol
11. Withdrawal, as manifested by either of the following:
a) The characteristic withdrawal syndrome for alcohol
b) Alcohol (or a closely related substance, such as a benzodiazepine) is
taken to relieve or avoid withdrawal symptoms
Substance Use Disorders (SUDs)
• Among the most common psychiatric
conditions in the United States
– Over 8% of individuals aged 12 or older meet
criteria within the past year.
• Of those, 13% met criteria for both alcohol and another
SUD
Substance Use Disorders (SUDs)
• Nationally Representative Epidemiology Study
– Rates of alcohol use disorders
• In 2011 – 6.5%
• In 2002 through 2010 (range = 7.1% – 7.7%)
– Rates of substance use disorders
• In 2011 – 2.5%
• In 2002 though 2010 (range = 2.5% – 3.0%)
Behavioral Addictions
• Behavioral addictions
– Similar to SUDS in their neurological impact and
pathways
• Specifically true for pathological gambling
– Pathological gambling
• Lifetime prevalence is less than 1%
• Of those who meet criteria for pathological gambling
– 73% met lifetime criteria for an alcohol use disorder
» 25% alcohol abuse
» 48% alcohol dependence
– 38% met lifetime criteria for a SUD
» 27% substance abuse
» 11% substance dependence
Evolution of the Diagnosis
• DSM-I (1953)
– SUDs were grouped under sociopathic personality
disturbances
• Also included here were
– Paraphilias (then known as “sexual deviations”)
– Antisocial personality disorder (then known as “antisocial and
dissocial reactions”)
• This was reflective of the social climate, which
conceptualized those with SUDs as social deviants
Evolution of the Diagnosis
• DSM-II
– Saw only small changes to the SUD diagnosis
• Kept its consistency with personality disorders and
sexual deviations
• Removed the sociopathic categorization
Evolution of the Diagnosis
• DSM-III
– Included tobacco/nicotine dependence for the first time
• DSM-III-R
– Diagnoses were refined based on empirically bound
criteria
• SUDs were separated from personality disorders and
paraphilias
– Included the distinction between abuse and dependence
• Concept of physiological dependence (i.e., withdrawal and
tolerance) was added
Evolution of the Diagnosis
• DSM-IV
– Did not make substantial changes
– Allowed for listing specifiers
• i.e., with or without physiological dependence
• These appeared to be more relevant for some
substances (e.g., alcohol and opiates) than others (e.g.,
hallucinogens, inhalants)
– Social consequences were moved from the
dependence criteria to the abuse criteria
DSM-5
• Several empirically supported changes to the
substance-related disorders diagnostic criteria
– Research suggested that
• The abuse category was less reliable than the dependence category
• The abuse and dependence categories were not necessarily
hierarchical
– Thus, the abuse and dependence categories were removed
• In DSM-5, there is now a single substance use disorder
category with specifiers based on an unweighted
symptom count
– Mild severity specifier – two to three symptoms
– Moderate severity specifier – four to five symptoms
– Severe severity specifier – six or more symptoms
DSM-5
• Gambling Disorder
– Only non-substance-related addiction to be included in the
DSM-5 SUDs category
• Diagnostic criteria largely overlap with SUDs
– Previously included as an impulse control disorder
• Research suggests commonalities between gambling disorders and
SUDs
– Reclassification could potentially improve prevention and intervention
Gambling Disorder
Diagnostic Criteria
A. Persistent and recurrent problematic gambling behavior
leading to clinically significant impairment or distress, as
indicated by the individual exhibiting four (or more) of the
following in a 12-month period
1. Needs to gamble with increasing amounts of money in order to
achieve the desired excitement
2. Is restless or irritable when attempting to cut down or stop
gambling
3. Has made repeated unsuccessful efforts to control, cut back, or stop
gambling
4. Is often preoccupied with gambling (e.g., having persistent thoughts
of reliving past gambling experiences, handicapping or planning the
next venture, thinking of ways to get money with which to gamble).
Gambling Disorder
Diagnostic Criteria
A. Persistent and recurrent problematic gambling behavior leading
to clinically significant impairment or distress, as indicated by the
individual exhibiting four (or more) of the following in a 12month period
5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious,
depressed)
6. After losing money gambling, often returns another day to get even
(“chasing” one’s losses)
7. Lies to conceal the extent of involvement with gambling
8. Has jeopardized or lost a significant relationship, job, or educational or
career opportunity because of gambling
9. Relies on others to provide money to relieve desperate financial
situations caused by gambling
B. The gambling behavior is not better explained by a manic episode
DSM-5
• Internet and sex addictions
– Were considered…
– However, the DSM-5 work groups did not believe
there was enough empirical evidence for them to
be included
Clinical Subtyping for SUDs
• There has been ongoing concern about the
heterogeneity with the SUD diagnoses
– This has resulted in the proposal of a variety of
clinical typologies in order to increase specificity
Clinical Subtyping for SUDs
• Cloninger’s neurobiological model (1981)
– Based on data from an all-male sample of Swedish adoptees
– Differentiates between two genetically driven subtypes; Type
1 and Type 2
• Type 1
– Later onset of alcohol-related problems (after age 25)
– More psychological (as opposed to physiological) dependence
– Experience guilt associated with their use
• Type 2
–
–
–
–
Earlier onset of alcohol-related problems
Have more extensive behavioral problems associated with their use
More severe
Associated with a positive family history for alcoholism
– Sample consisted of all males, though there has been
reasonable replication in females
Clinical Subtyping for SUDs
• Babor et al. (1992)
– Type A and Type B alcoholics
• Based on 17 different characteristics of alcoholics
– Covers genetic, biological, psychological, and sociocultural aspects
• Type A
– Similar to Cloninger’s Type 1
» Later onset of alcohol dependence
» Fewer problems in childhood
» Less psychopathology
• Type B
– Similar to Cloninger’s Type 2
» Earlier onset of alcohol dependence
» Severe problems in childhood (particularly conduct disorder)
» Greater levels of psychopathology
» More severe
• More chronic consequences of use
• Poor treatment outcomes
Clinical Subtyping for SUDs
• Moss, Chen, and Yi (2007)
– Identified five clusters using data from a large
nationally representative sample
• Young adult subtype
–
–
–
–
Young age (M = 24.5 years)
Early onset of dependence (M = 19.5 years)
Low probability of ASPD
Moderate probability of family history of alcohol dependence
• Functional subtype
–
–
–
–
–
Older age (M = 41 years)
Later initiation of drinking (M = 18.5 years)
Later onset of dependence (M = 37 years)
Low probability of ASPD
Moderate probability of family history
Clinical Subtyping for SUDs
• Moss, Chen, and Yi (2007)
– Identified five clusters using data from a large nationally
representative sample
• Intermediate familial subtype
–
–
–
–
–
Older age (M = 37 years)
Initiation of drinking (M = 17 years)
Onset of dependence (M = 32 years)
Moderately elevated probability of ASPD
Elevated probability of family history
• Young antisocial subtype
–
–
–
–
–
Young age (M = 26.4 years)
Initiation of drinking (M = 15.5 years)
Onset of dependence (M = 18.4 years)
Highest probability of ASPD
Elevated probability of family history
Clinical Subtyping for SUDs
• Moss, Chen, and Yi (2007)
– Identified five clusters using data from a large
nationally representative sample
• Chronic severe subtype
–
–
–
–
–
Older age (M = 37.8 years)
Initiation of drinking (M = 16 years)
Onset of dependence (M = 29 years)
Elevated probability of ASPD
Highest probability of family history
Risk Factors for Addictive Disorders
Family History
• Familial link has been widely established in the
research literature
– Several studies have found a potentially stronger
heritability for illicit drug use than for alcohol
• Merikangas et al. (1998)
– Found an “8-fold increased risk of drug disorders among
relatives of probands with drug disorders across a wide range
of specific substances, including opiates, cocaine, cannabis,
and sedatives, compared with that of relatives of controls.”
– Familial link could be a result of genetic factors,
environmental factors, or both
Risk Factors for Addictive Disorders
Levels of Response to Alcohol
• Level of response to alcohol
– A heritable mechanism influencing one’s
propensity to develop an alcohol disorder
• How might you evaluate this?
– Participants are given a challenge dose of alcohol
– Researchers then assess two correlated indicators
of intoxication
• Body sway
• Subjective perception of alcohol effects
Risk Factors for Addictive Disorders
Levels of Response to Alcohol
• Lower response to alcohol (i.e., the need for a higher
number of drinks for an effect) has been associated with
– Family history of alcoholism
– Development of tolerance (the need for increased amounts to
achieve the desired effect or a diminished effect in response
to the same amounts) to alcohol
– A fourfold greater likelihood of future alcohol dependence
• Also, a unique predictor of alcohol use disorders above
and beyond a variety of other risk factors
• A robust predictor of alcohol use disorders in both
young and middle-aged groups
Risk Factors for Addictive Disorders
Alcohol and Drug Expectancies
• Expectancies – beliefs about the anticipated
effects of alcohol or other substance use
– Individuals’ beliefs of the effects of substance use
on social, affective, cognitive, and motor
functioning
– Typically assessed using self-report questionnaires
– Learned from
• Family, peer, and media influences
• Prior personal use of a given substance
Risk Factors for Addictive Disorders
Alcohol and Drug Expectancies
• Alcohol expectancies have been shown to predict
initiation, progression, problem use, and posttreatment
relapse
– Elevated risk is associated with expectations that alcohol use
will have positive effects
• Marijuana expectancies are shown to have similar
effects to alcohol expectances
– Domains are also common (e.g., social and sexual facilitation,
tension reduction, and cognitive and behavioral impairment).
• Cocaine expectancies include unique domains
– e.g., anxiety and increased energy or arousal
Risk Factors for Addictive Disorders
Alcohol and Drug Expectancies
• Expectancies can be modifiable
– Unlike many risk factors…
• Interventions
– Utilize information about individual’s expectancies
• e.g. expectations of tension reduction or social facilitation
– Challenge expectations
– Develop alternative skills for achieving the desired effects
Risk Factors for Addictive Disorders
Cognitive Distortions and Gambling
• If a coin flip has landed
on “heads” five times in
a row, what are the
odds that it will land on
“tails” the following
flip?
Risk Factors for Addictive Disorders
Cognitive Distortions and Gambling
• If a coin flip has landed
on “heads” five times in
a row, what are the
odds that it will land on
“tails” the following
flip?
Risk Factors for Addictive Disorders
Cognitive Distortions and Gambling
• The Gambler’s Fallacy
– The belief that, despite the random nature of a
process, a certain outcome can be expected
– This cognitive bias is viewed as one of the causes
of “chasing losses”
• “Chasing losses” is a common symptom of pathological
gambling and a criterion for DSM-5 gambling disorder
Risk Factors for Addictive Disorders
Cognitive Distortions and Gambling
• Other cognitive distortions
– Overconfidence about one’s ability
• Found to be related to pathological gambling across multiple studies
– Illusory correlations (e.g., superstitions)
• Pathological gamblers often believe that their personal luck will impact the
outcome of gambling
– Interpretive control
• Heavy gamblers are more likely to remember their wins rather than their losses
– Illusion of control
• Pathological gamblers, compared to controls, are less able to distinguish
between situations in whey they do and do not have control
• Found to be highly related to pathological gambling
• These distortions are not specific to gambling
– Play a role in its initiation and continuation
Risk Factors for Addictive Disorders
Peer Influences
• Influence of peers on substance use during
adolescence is clear from decades of research
– Not all peer influences are equal
• Peers perceived as more similar exert a greater impact
Risk Factors for Addictive Disorders
Peer Influences
• Risk factors for adolescent substance involvement
– Greater peer involvement with substances
– Higher perceptions of peer use
– Greater perceived peer acceptance of substance use
Gender Differences in Addictive Disorders
• Men and women share commonalities, but important
differences exist
– Men consume greater quantities
– Men abuse substances at higher rates
• However, this gap is narrowing for both alcohol and illicit
drugs
– Telescoping
• Accelerated development of alcohol problems and dependence in women
when compared to men
– Findings of accelerated progression for women are limited for
other substances, but have been documented for cannabis and
opiates
Gender Differences in Addictive Disorders
• Women are more vulnerable to many physiological
consequences of alcohol use and abuse
– Women have higher blood alcohol concentrations after
consuming the same amount of alcohol as men
• Due to
– Differences in the metabolism of alcohol in both the stomach and liver
– Differences in body water
• This has led to lower standards for the definition of moderate and
heavy drinking for women compared to men
– Women develop liver disease more quickly than men and
have higher rates of liver-related mortality
– Increased risk of breast cancer has been associated with
moderate to heavy alcohol consumption in numerous studies
Gender Differences in Addictive Disorders
• Teratogenic effects of alcohol
– Fetal alcohol syndrome (FAS)
• Among children born to women consuming significant
amounts of alcohol during pregnancy
• Involves physical (facial dysmorphology and small stature)
and neuropsychological (mental retardation and attention
impairment) effects that continue throughout life
– Fetal alcohol effects (FAE)
• Less severe fetal alcohol effects also occur with lower
levels of alcohol consumption
Gender Differences in Addictive Disorders
• Teratogenic effects of other substances
– Use of cocaine during pregnancy
• Associated with slow fetal growth, low birth weight, early
labor, spontaneous abortion, and sudden infant death
syndrome
– Infants born to mothers who are opiate dependent
•
•
•
•
•
Are addicted and require treatment for withdrawal
Are more likely to be premature
Experience respiratory illness
May be underweight
Have an increased mortality risk
Gender Differences in Addictive Disorders
• Gender differences in gambling behaviors and related
problems
– Male adolescents report more gambling and experience a
greater number of gambling-related problems than female
adolescents
• Men and women are equally likely to have gambled in the past
year
– Men gamble more frequently and have greater wins and losses
– Female pathological gamblers appear to be at greater risk
for mood and anxiety disorders
• Depression, dysthymia, and panic disorder
– Male pathological gamblers appear go be at greater risk for
SUDs
I’m just going to leave this here…
• Tobacco hornworm (Manduca sexta)
Research and Causation
What Is a Cause?
• That is, how do we know that one thing
causes another?
What Is a Cause?
• That is, how do we know that one thing
causes another?
• Turns out, there is no easy answer to this
question
– Philosophers, scientists, and economists have
been arguing for centuries over what constitutes
causality
• No reason to believe any of these fields has a great
answer to the question
Aristotle
• Posterior Analytics (350
B.C.E.)
– Presented the notion
that we do not have
knowledge of something
until we know its cause
– This notion seems
central to human
psychology…
The Why Game
• Mom: I’m going to the grocery store
– Child: Why?
– Mom: Because I need to get bananas
• Child: Why?
• Mom: Because I like bananas in my cereal
– Child: Why?
– Mom: …
• The desire to know the why of things seems basic
– Aristotle simply formalized this notion by saying that we
aren’t satisfied with our knowledge of a subject until we
know the “why” behind it
David Hume
• Hume was obsessed with the notion of
“experience” and how it generates
knowledge
– Noted: if we always observe B occurring after
A, we will automatically think that A causes B
due to their contiguity
– Of course, he notes that this is our
perception
• Doesn’t actually mean that A causes B
• Stated
– How we perceive causality will be based on
temporality and contiguity
– We a naturally inclined to attribute the
experience of constant contiguity to causality
John Stuart Mill: Five Methods of Induction
• 1. Direct Method of Agreement
– If something is a necessary cause, it
must always be present when we
observe the effect
– Example
• If we always observe that the varicella
zoster virus causes chickenpox
symptoms, then varicella zoster must be
a necessary cause of chickenpox
• We can’t observe any cases of
chickenpox symptoms where the
varicella zoster virus isn’t present
John Stuart Mill: Five Methods of Induction
• 2. Method of Difference
– If..
• Two situations are exactly the same in every aspect except one,…
• And the effect occurs in one but not the other situation,…
• Then the one aspect they do not have in common is likely to be
the cause of the effect
– For example
• If two people spent the day eating exactly the same foods except
one had potato salad and the other didn’t…
• And one gets food poisoning and the other is not sick…
• Then the potato salad is the cause of the food poisoning
John Stuart Mill: Five Methods of Induction
• 3. Combination of the methods of
agreement and difference…
– Not much else to say here :/
John Stuart Mill: Five Methods of Induction
• 4. Method of Residue
– If many conditions cause many
outcomes…
– And we have matched the
conditions to the outcomes on all
factors except one…
– Then the remaining condition must
cause the remaining outcome
John Stuart Mill: Five Methods of Induction
• 4. Method of Residue
– For example
• A patient goes to the doctor complaining of indigestion,
rash, and a headache…
• And he had eaten pizza, coleslaw, and iced tea for
lunch…
• And we’ve established that
– The pizza caused the rash
– The iced tea cased the headache
• Then we can deduce that the coleslaw must cause
indigestion
John Stuart Mill: Five Methods of Induction
• 5. Method of Concomitant Variation
– If one property of a phenomenon varies in tandem
with some property of the circumstance of interest,
then that property most likely causes the
circumstance
– Example
• If samples of water contain the same ratio of salt and water
and the level of toxicity varies in tandem with the ratio of
lead…
• We can assume that the toxicity level is related to the ratio
of lead, not salt
Austin Bradford Hill – Nine Criteria for Causal
Inference
1. Strength – the larger the
association, the more likely it is
causal
2. Consistency – consistent
observations of suspected cause and
effect in various times and places
raise the likelihood of causality
3. Specificity – the proposed cause
results in a specific effect in a
specific population
Austin Bradford Hill – Nine Criteria for Causal
Inference
4. Temporality –the cause precedes
the effect in time
5. Biological gradient – greater
exposure to the cause leads to
greater effect
6. Plausibility – the relationship
between cause and effect is
biologically and scientifically
plausible
Austin Bradford Hill – Nine Criteria for Causal
Inference
7. Coherence – epidemiological
observation and laboratory
findings confirm each other
8. Experiment – when possible,
experimental manipulation can
establish cause and effect
9. Analogy – cause-and-effect
relationships have been
established for similar
phenomena
Karl Popper – Empirical Falsification
• “In so far as a scientific statement speaks about
reality, it must be falsifiable, and in so far as it is
not falsifiable, it doesn’t not speak about reality.”
If It Can Be Falsified It Might Be True
• Popper is seen as the forefather of empirical
falsification
– For Popper, proving causality was the wrong goal
– Induction should proceed not by proving, but by
disproving
• This idea is often difficult for non-scientists to
grasp
If It Can Be Falsified It Might Be True
• This is why the statement “There is a God” is not a
scientific hypothesis
– It is impossible to disprove
• The goal of scientific experimentation:
– To try to disprove a hypothesis by a process that resembles
experience or empirical observation
• This is why we are always trying to disprove/reject a null
hypothesis in statistics
• A scientific finding:
– Always a matter of rejecting the null hypothesis
– Never a matter of accepting the alternative hypothesis
If It Can Be Falsified It Might Be True
• The Church of the Flying Spaghetti Monster
exemplifies this point
– The point isn’t just that the idea is crazy, but that this crazy
idea can’t be disproven
If It Can Be Falsified It Might Be True
• This explains a lot…
– A scientist doesn’t frame a question: “Can we prove
that this new drug works?”
– It’s always: “With how much certainty can we disprove
the idea that this drug does not work?”
– For this reason
• Scientists are hesitant to make declarative statements such
as “Vaccines do not cause autism”
• Much more comfortable saying “There is no difference in
incidence of autism between vaccinated and non-vaccinated
individuals
The Counterfactual
• The Counterfactual Condition
– This refers to what would have happened in a
different world
– This is the very condition that would establish
causality once and for all
– Unfortunately, it is impossible to observe
• This doesn’t stop us from trying to approximate it
– Using scientific methodologies like random designs,
replication, etc.
The Counterfactual
• Example
– Say I am trying to figure out whether drinking
orange juice caused me to break out in hives
– The precise way to determine this would be to go
back in time and see what would have happened
had I not drank the orange juice
– All would be the same aside from the orange juice
• A perfectly controlled condition
The Counterfactual
• Scientists will always be reluctant to say the
magic word (i.e. “cause”)
– Until someone develops a time machine to allow
us to observe actual counterfactual situations
• Laypeople, on the other hand, are primed to
look for causality and never feel secure until
they have established it
Sufficient Component Cause Model
• Ken Rothman (1976)
– Notoriously complex and
sometimes counterintuitive
• Model imagines the
causes of phenomena
as a series of “causal
pies”
Sufficient Component Cause Model
• Component causes – individual factors that
contribute to a disease
– Shown below as individual “slices” of the pie
– After all of the pieces of a pie fall into place
• The pie is complete
• The disease occurs
Sufficient Component Cause Model
• Sufficient cause – the complete pie
– May be considered a causal pathway
• A disease may have more than one sufficient cause
– Each sufficient cause can be composed of several component causes that may
or may not overlap
• Below
– Component causes B and C
• Either one, the other, or both can contribute to the disease
• Neither are… (see next slide)
Sufficient Component Cause Model
• Necessary cause – a component cause that appears
in every pie or pathway
– Without it, the disease does not occur
• Below
– Component cause A is necessary because it exists within
each pie
• Assuming that these three represent the only “causal pies”
Sufficient Component Cause Model – Lung
Cancer
• Suppose component B is smoking
• Suppose component C is asbestos
• Sufficient cause I
– Includes both smoking and asbestos
• Sufficient cause II
– Includes smoking without asbestos
• Sufficient cause III
– Includes asbestos without smoking
Sufficient Component Cause Model
• Causes can come in four varieties
– Necessary and sufficient
– Necessary but not sufficient
– Sufficient but not necessary
– Neither sufficient nor necessary
Sufficient Component Cause Model
• Examples
– The presence of a third copy of chromosome 21 is a
necessary and sufficient cause of Down Syndrome
• It’s all that is needed to cause Down Syndrome
• One can’t have down syndrome without it
– Alcohol consumption is a necessary, but not sufficient
cause of alcoholism
• In order to be classified as an alcoholic, one must drink
alcohol
• Drinking alcohol, but itself, is not enough to cause
alcoholism
Sufficient Component Cause Model
• More examples
– Exposure to high doses of ionizing radiation is a
sufficient, but not necessary cause of sterility in men
• This factor can cause sterility on it own
• It is not the only cause of sterility and sterility can exist
without it
– A sedentary lifestyle is neither sufficient nor
necessary to cause coronary heart disease
• A sedentary lifestyle on its own will not cause heart disease
• Heart disease can certainly occur in the absence of a
sedentary lifestyle
Sufficient Component Cause Model
• “But Ian, my aunt is 90 years old, smoked
every day of her life, and she does not have
lung cancer. Therefore, cigarettes cannot
possibly cause lung cancer.”
Sufficient Component Cause Model
• This statement represents a misunderstanding
of the sufficient component cause model
– And in a potentially dangerous form…
• Smoking is neither a necessary nor sufficient
cause of lung cancer
– People who smoke may not develop lung cancer
– People who do not smoke may develop lung cancer
– This does not mean that smoking is not a cause of
lung cancer
Sufficient Component Cause Model
• Smoking is part of the “causal pie” of lung
cancer
– It is not part of every “causal pie” (i.e. it’s not
necessary)
– It cannot constitute its own causal pie (i.e. it’s not
sufficient)
• Because smoking by itself does not produce lung cancer
• Smoking causes lung cancer, even if we do not
observe cancer in every case of smoking
Conducting Research in the Field
of Psychopathology
… ok, now back to psychopathology
in specific
Paul Meehl: Causes
• Paul Meehl (1977)
– Described several meanings of
causation within psychopathology
– They differ in strength
– We’ll discuss 4 here
Paul Meehl: Causes
• Specific etiology
– A categorical (all-or-none) variable that is both
necessary and sufficient for a disorder to emerge
• Example: Huntington’s Disease
– A single dominant gene is both necessary and
sufficient to produce the disease
• This is rare in psychopathology
Paul Meehl: Causes
• Threshold effect
– A dimensional variable
– When the threshold is exceeded, the individual is at risk for
the disorder
– Below the threshold, there is no risk for the disorder
• Step function
– A dimensional variable
– The individual’s risk for the disorder increases sharply once
past the threshold
– The individual’s risk for the disorder is low below the
threshold, but not zero
Paul Meehl: Causes
• Diathesis-stress
– These variables are necessary, but not sufficient for
a disorder
– Elevated levels of certain variables create a
diathesis (i.e., vulnerability)
• This vulnerability is often
– Genetically influenced
– Actualized only when one encounters a stressor
– Both vulnerability factors and stressors are
necessary for a disorder to emerge
• Neither is sufficient
Paul Meehl: Cause
• A causal factor can also be neither necessary
nor sufficient for psychopathology
– Example
• Hyperreactivity to negative emotions (e.g. neuroticism)
fits this model
Basic Research Designs
Case Study Methodology
• Case Study – the detailed examination of a
single individual
– Good for the context of discovery
• Hypothesis generation
– Poor for the context of justification
• That is, hypothesis testing
• Lack the controls found in systematic research
• Impossible to generalize findings
Case Study Methodology
• Example: Imagine a case study of an individual
with bipolar disorder who reports her parents
were extremely critical while she was young
– We cannot make any conclusions about bipolar
disorder and critical parents
• The experience may be unique to the individual
– No matter how meticulous the case study is, it can
never justify a generalization
Case Study Methodology
• Positives
– Can demonstrate the existence of rare phenomenon
not previously recognized
• For example, H.M. had a surgically removed hippocampus
and was unable for form new memories
– Can function as existence proofs by negating a
general proposition
• For example, many psychologists thought that individuals
with severe mental retardation were incapable of learning
• Only one exception is needed to disprove this rule
Quasi-Experimental Designs
• Experimental design – when researchers
randomly assign participants to one of two
conditions
– Experimental group – received the experimental
manipulation
– Control group – does not receive the experimental
manipulation
• It’s rarely possible to randomly assign conditions
in psychopathology research
– Even if it was, it’d be super unethical!
Quasi-Experimental Designs
• Quasi-experimental design – a comparison of
two or more groups defined by pre-existing
characteristics (e.g., depressed vs. nondepressed individuals)
– “Mother Nature” has already assigned these
groups
– These are technically correlational studies
• Thus, they suffer from the same design limitations
Quasi-Experimental Designs
• Should not draw causal inferences from quasiexperimental studies
– Researchers do not randomly assign groups
• Thus, participants may also differ on numerous potential
confounding variables
• Example
– Say we are comparing individuals with and without
schizophrenia
– The two groups will likely also differ on
• Socioeconomic status (SES), IQ, hygiene, quality of diet, etc.
– It’d be impossible to isolate these confounding variables
Quasi-Experimental Designs
• Matching – equating the quasi-experimental groups
on potentially confounding variables
– For example, a researcher could match the schizophrenic
and non-schizophrenic groups on SES and IQ
• Several difficulties with matching
– There could always be a confounding variable we haven’t
thought of
– It rests on causal assumptions that may be incorrect
• What if SES is a crucial piece of the picture of schizophrenia?
Matching would then cloud the experimental results
– Matching on a variable can create additional systematic
differences
Experimental Designs
• Analogue Experiment – an attempt to produce
variants of psychopathology in either humans or
animals
– For example, rather than study clinical depression, a
research might use a mood induction paradigm
• Two pitfalls
– We assume that the analogue provides an adequate
model of the condition
– May be unethically unacceptable or impractical to
create symptoms
Experimental Designs
• Animal Models of Psychopathology
– Involves attempts to produce a simulated form of a
mental disorder in non-humans
– Example
• Learned Helplessness (Seligman, 1975)
– Exposing animals to uncontrollable aversive stimuli produced
common symptoms of human depression
» i.e. apathy, passivity, and loss of appetite
– Pitfalls
• Researchers must be cautious in generalizing findings to
humans
• Using animals does not sidestep ethical issues
Experimental Designs
• Challenge Paradigm – when researchers
present participants with stimuli thought to
trigger a pathological response
– Example
• Researchers have used biological challenges, such as
CO2 inhalation, with panic patients to test panic
responses
– Pitfalls
• Ethical concerns
Experimental Designs
• Single-Subject Experimental Designs
– Each subject serves as his or her own control
– ABA or Reversal design
• A researcher might measure baseline behavior (e.g.
nail-biting, then after introducing an intervention, then
again after withdrawing the intervention
– Pitfalls
• Some interventions can’t be withdrawn/reversed
Epidemiological Studies: Gathering Clues to
Etiology
• Epidemiology is the study of
– The distribution of disorders in a given population
– The variables associated with this distribution
• Answers
– How common is a psychological disorder?
– What characteristics are associated with the
disorder?
– How often do cases of this disorder arise and
disappear?
Epidemiological Studies: Gathering Clues to
Etiology
• Research on the rate of a disorder can provide
a baseline comparison
– Example
• The prevalence of schizophrenia is 1% of the general
population
• Identical twins of individuals with schizophrenia have a
50% chance of developing schizophrenia
– This number is only meaningful in comparison to the baseline
rate
Epidemiological Studies: Gathering Clues to
Etiology
• Characteristics covarying with the frequency
of a disorder can provide clues to etiology
– Example
• Antisocial Personality Disorder is more common among
– Males than females
– Those in lower social classes
– Those with a family history of ASPD and criminality
– This suggests that maybe some biological or
socialization (not likely*) variables increase risk in
men
Epidemiological Studies: Gathering Clues to
Etiology
• Cholera
– Snow (1955) traced the source of a cholera
epidemic in London to a specific water pump by
constructing a detailed map of the distribution of
affected cases
Studying Genetic and Environmental
Influences
• Behavior genetics – the study of genetic and
environmental influences on behavior
– Biological parents contribute the following to their
offspring
• Genetic influences
• Environmental influences
• Interaction between genetic and environmental influences
– These can’t be distinguished using family studies
– Adoption and twin studies can determine their
specific effects
Biological Studies
• Psychophysiology – the study of involuntary
physiological responses that may be affected by
psychological processes
– Measures include:
•
•
•
•
•
•
•
•
Skin conductance
Heart rate
Blood pressure
Brain waves (EEG)
Muscle activity (EMG)
Eye movements (EOG)
Respiration
Pupil dilation
Biological Studies
• Brain Imaging Technology
– Observing Brain Structure
• CAT (computerized axial tomography) scans
• MRI (magnetic resonance imaging)
– Observing Brain Functioning
• EEG (electroencephalography)
– Measures brain waves
• fMRI (functional MRI)
– Examines changes in the magnetic properties of brain regions
• PET (positron emission tomography) scan
– Uses radioactive isotopes
Posttraumatic Stress Disorder
and Dissociative Disorders
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion A: stressor
– The person was exposed to: death, threatened death, actual or
threatened serious injury, or actual or threatened sexual
violence as follows: (one required)
1. Direct exposure
2. Witnessing, in person
3. Indirectly, by learning that a close relative or close friend was exposed
to trauma. If the event involved actual or threatened death, it must
have been violent or accidental
4. Repeated or extreme indirect exposure to aversive details of the
events(s), usually in the course of professional duties (e.g., first
responders, collecting body parts; professionals repeatedly exposed
to details of child abuse). This does not include indirect nonprofessional exposure through electronic media, television, movies, or
pictures.
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion B: intrusion symptoms
– The traumatic event is persistently re-experienced in the
following way(s): (one required)
1. Recurrent, involuntary, and intrusive memories
Note: children older than six may express this symptom in repetitive play
2. Traumatic nightmares
Note: children may have frightening dreams without content related to the
trauma(s)
3. Dissociative reactions (e.g. flashbacks) which may occur on a
continuum from brief episodes to complete loss of consciousness
Note: children may reenact the event in play
4. Intense or prolonged distress after exposure to traumatic reminders
5. Marked physiologic reactivity after exposure to trauma-related
stimuli
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion C: avoidance
– Persistent effortful avoidance of distressing
trauma-related stimuli after the event: (one
required)
1. Trauma-related thoughts or feelings
2. Trauma-related external reminders (e.g., people,
places, conversations, activities, objects, or
situations)
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion D: negative alterations in cognitions and
mood
– Negative alterations in cognitions and mood that began
or worsened after the traumatic event: (two required)
1. Inability to recall key features of the traumatic event
(usually dissociative amnesia; not due to head injury,
alcohol, or drugs)
2. Persistent (and often distorted) negative beliefs and
expectations about oneself or the world (e.g., “I am bad,”
The world is completely dangerous”)
3. Persistent distorted blame of self or others for causing the
traumatic event or for resulting consequences
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion D cont.
– Negative alterations in cognitions and mood that
began or worsened after the traumatic event: (two
required)
4. Persistent negative trauma-related emotions (e.g., fear,
horror, anger, guilt, or shame)
5. Markedly diminished interest in (pre-traumatic)
significant activities
6. Feeling alienated from others (e.g., detachment or
estrangement)
7. Constricted affect: persistent inability to experience
positive emotions
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion E: alterations in arousal and reactivity
– Trauma-related alterations in arousal and reactivity
that began or worsened after the traumatic event:
(two required)
1.
2.
3.
4.
5.
6.
Irritable or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance
Posttraumatic Stress Disorder:
Diagnostic Criteria
• Criterion F: duration
– Persistence of symptoms (in Criteria B, C, D, and E)
for more than one month
• Criterion G: functional significance
– Significant symptom-related distress or functional
impairment
• Criterion H: exclusion
– Disturbance is not due to medication, substance
use, or other illness
Posttraumatic Stress Disorder
• Now clear that traumatic events can produce
psychiatric symptoms
– Used to be held that
• Stress-induced symptoms were transient
• Persistent symptoms implied the presence of another
neurotic or characterological disturbance
Posttraumatic Stress Disorder
• The Vietnam War
– Psychiatric sequelae of the war altered the
prevailing view
– Clinicians became convinced that the war itself
could cause chronic psychiatric disability
• Rather than seeing them as having pre-existing conditions
exacerbated by the war
Posttraumatic Stress Disorder
• Veterans Administration (VA)
– Would not provide treatment and psychiatric
disability compensation unless veterans’ problems
were a direct consequence of the war
• Not simply exacerbated pre-existing conditions
• “Post-Vietnam syndrome”
– Antiwar psychiatrists and leaders of the Vietnam
veterans’ organizations began lobbying to include
this in the then-forthcoming DSM-III
Posttraumatic Stress Disorder
• Leaders of the DSM-III revision process initially
opposed this proposal for two reasons:
– Combinations of several traditional diagnoses could
cover the problems of these veterans
– Atheoretical DSM aimed to be explicitly defined by
signs and symptoms, rather than debated etiology
Posttraumatic Stress Disorder
• Similarities in the symptoms of Vietnam
veterans were similar to those who survived
other traumatic experiences
– e.g. rape, disaster, and concentration camps
• This resulted in the consensus that any
terrifying, life-threatening event could cause a
chronic syndrome
• PTSD was added to DSM-III and classified as an
anxiety disorder
Posttraumatic Stress Disorder
• Central idea
– A traumatic event establishes a memory that gives rise
to a characteristic profile of signs and symptoms
• Natural selection ensures that people remember potentially
life-threatening experiences
– Forgetting them would court disaster
• Stress hormones released during the trauma render the
central features of the trauma highly memorable
– Psychopathology
• When people continue to recall traumas involuntarily with
the full emotional force of the original experience
• Failure of stress symptoms to abate despite the absence of
danger justifies PTSD as a mental disorder
Posttraumatic Stress Disorder
Four Symptomatic Clusters
• Intrusion cluster
– Includes reexperiencing symptoms such as
• Traumatic nightmares
• Intrusive sensory images of the trauma
• Physiological reactivity to reminders of the trauma
• Avoidance cluster
– Includes efforts to avoid feelings, thoughts, and
reminders of the trauma
Posttraumatic Stress Disorder
Four Symptomatic Clusters
• Negative alterations in cognitions and mood
– Includes symptoms such as
• Emotional numbing
• Distorted blame of self or others
• Pervasive negative emotional states
• Alterations in arousal and reactivity
– Includes symptoms such as
•
•
•
•
Exaggerated startle
Aggression
Reckless behavior
Hypervigilance
What Counts as a Traumatic Stressor?
• To qualify for PTSD, one must have exposure to a
stressor
– This is essential to the concept of PTSD for 2 reasons:
• Core symptoms of PTSD possess intentionality
– Symptoms possess intentional content or “aboutness”
– Key symptoms are not merely “caused” by a trauma; they are about the
trauma
» e.g. to have intrusive images is to have intrusive images about
something, namely the trauma
• Many symptoms of PTSD overlap with other disorders (e.g., loss
of pleasure in activities, insomnia, etc.)
– It’s the memory of the trauma that unites them into a coherent
syndrome
What Counts as a Traumatic Stressor?
• DSM-III
– Presupposed that only traumatic stressors falling
outside the boundary of everyday experience
could produce PTSD
• e.g. rape, torture, natural disasters
• Events that would produce intense distress in anyone
– Conversely, ordinary stressors falling outside this
boundary could not cause PTSD
– However…
What Counts as a Traumatic Stressor?
• Two findings complicated the DSM-III framework
– First, epidemiological studies documented that most
people exposed to Criterion A traumatic stressors
don’t develop PTSD
• This implies that risk factors influence who develops the
disorder
– Diathesis stress?
– Second, other studies found that those who didn’t
meet the DSM-III Criterion A could still meet criteria
for PTSD
What Counts as a Traumatic Stressor?
• Cont.
– Some people met criteria for PTSD with no direct
traumatic experience
• Some met criteria after learning of the violent death of
a loved one
– In response, DSM-IV broadened the concept of trauma
exposure to include
» Being “confronted with” information about a threat to
the “physical integrity” of another person
• Other examples of reportedly meeting PTSD criteria…
– People encountering obnoxious jokes in the workplace
– Giving birth to a healthy baby after an uncomplicated delivery
– Having a wisdom tooth removed
What Counts as a Traumatic Stressor?
• A delicate balance in broadening criteria
– On one hand…
• Concern that suffering people would be denied the diagnosis and
reimbursable treatment
– On the other hand…
• It means that nearly everyone qualifies as a trauma survivor
• A study of residents of southeastern Michigan
– Found that 89.% of adults had been exposed to a DSM-IV
Criterion A stressor
• A study of American adults living far from the scenes of
September 11th terrorist attacks
– 4% developed apparent PTSD seemingly from watching the
events on television
What Counts as a Traumatic Stressor?
• DSM-5 committee tightened the Criterion A
– People who learn of physical threats to others
must be a close friend or relative of the
threatened person
– Trauma exposure via the media has also been
excluded
• Except for those whom such exposure is part of their
vocational role
Epidemiology and Sex Ratio
• National Comorbidity Survey Replication
– Life-time prevalence is 6.8%
• Women – 9.7%
• Men – 3.6%
• Men are exposed to traumatic events more often
than women are, yet the rate of PTSD is more than
twice as great in women as in men
– These differences remain even when controlling for type of
trauma
– Suggests that men and women differ in ways that influence
their risk of developing PTSD following exposure to trauma
Epidemiology and Sex Ratio
• Military personnel are at a
heightened risk for exposure to
trauma
• Vietnam Veterans Readjustment
Study (NVVRS)
– 30.9% of all men who served in
Vietnam developed DSM-III-R PTSD
– 22.5% had partial PTSD
• So, 53.4% of all men who served in
Vietnam had either the full-blown or
partial diagnosis
– 15% still had the diagnosis in the
1980’s
Longitudinal Course of PTSD
• Acute stress symptoms are common following
exposure to traumatic events
• Rothbaum and Foa (1993)
– Study on help-seeking rape victims
• Found that 95% met PTSD criteria within 2 weeks
– 63.3% met criteria after 1 month
– 45.9% met criteria after 3 months
– 41.7% met criteria after 6 months
– Study on victims of nonsexual assault
• Found that 64.7% met PTSD criteria after 1 week
–
–
–
–
36.7% met criteria after 1 month
14.6% met criteria after 3 months
11.5% met criteria after 6 months
0% met criteria after 9 months
Longitudinal Course of PTSD
• Symptoms of PTSD usually emerge within hours or
days after the trauma
– Delayed-onset PTSD is extremely rare
• Jones & Wessely, 2005
– Only 1 person among the 93 diagnosed with PTSD
appeared to have a delayed onset
Comorbidity of PTSD
• Pure PTSD is unusual, and comorbidity is common
– Vietnam Veterans Readjustment Study (NVVRS)
• 98.8% of veterans who had a lifetime diagnosis of PTSD had
one other mental disorder
– This is in contrast to the 40.6% of those without PTSD
– Most common comorbid disorders
• Men and women
– Alcohol use and depression
• Men
– Generalized anxiety disorder
• Women
– Panic disorder
Risk Factors for PTSD
• Risk factors for PTSD
– Female sex
– Neuroticism
– Lower social support
– Preexisting psychiatric illness
• Especially anxiety and mood disorders
– Family history of anxiety, mood, or substance abuse
disorders
– Neurological soft signs
• e.g. nonspecific abnormalities in central nervous function
– Small hippocampi
Cognitive Aspects of PTSD
Phenomenology of Traumatic Memory
• Two types of thoughts in PTSD patients
– Ruminative and intrusive thoughts about the trauma
• e.g. “Why did this have to happen to me?”
– Repetitive and intrusive thoughts of the trauma
• e.g. vivid sensory flashbacks of the event
• A DSM-5 distinction
– Only intrusive sensory memories qualify as
reexperiencing symptoms
– Ruminative thoughts about the trauma no longer
qualify
Cognitive Aspects of PTSD
Phenomenology of Traumatic Memory
• Memories of trauma differ in content and
emotional qualities
– Are the memories processed differently?
• Porter and Peace (2007)
– Compared to traumatic memories, memories of positive events
» Fade in terms of vividness and emotional intensity
» Decrease in accuracy over the course of several years
– Are the memories more fragmented?
• Memory fragmentation in PTSD patients is seen in
patients’ subjective ratings, but not in objective ratercoded or computer assessed measures of fragmentation
Dissociative Disorders
Dissociative Disorders
• These disorders have the chief feature of “dissociation”
– Dissociation – Spiegel et al. (2011)
• “A disruption of and/or discontinuity in the normal, subjective
integration of one or more aspects of psychological functioning,
including – but not limited to – memory, identity, consciousness,
perception, and motor control.”
• Broad definition that includes diverse phenomena that
may not have a common source
– For example, one self-report measure includes
• Mundane occurrences
– e.g. staring off into space and being unaware of time passing
• Eerie occurrences
– e.g. failing to recognize oneself in a mirror
Dissociative Disorders
• Other phenomena dubbed “dissociative”
– Feelings of unreality (depersonalization and derealization)
– Emotional numbing
– A sense of time slowing down
– Reported inability to recall encoded autobiographical
information too excessive to count as ordinary forgetting
• Some clinicians regard seemingly opposing phenomena
as the same dissociative process
– Vivid sensory recollection of traumatic events
• e.g. “dissociative flashbacks”
– Reports of inability to recall traumatic events
• i.e. “dissociative amnesia”
Dissociative Disorders
• McHugh (2008) on dissociation
– Calling phenomena dissociative “is merely a
description with a professional ring masquerading as
an explanation. One really knows no more about a
case of amnesia or fugue by saying the patient
‘dissociates’ than by saying the patient behaved as
though he or she couldn’t remember.”
DSM-5 Dissociative Disorders
• Dissociative amnesia
• Dissociative identity disorder (DID)
– Formerly, multiple personality disorder (MPD)
• Depersonalization/derealization disorder
• Other specified dissociative disorder
– e.g. dissociative trance
• Unspecified dissociative disorder
DSM-5 Dissociative Disorders
• Dissociative disorders have been omitted from
major epidemiological surveys, such as the NCS-R
– Due to
• Their presumed rarity
• Controversial nosological status
• Clinicians specializing in dissociative disorders
hold that “dissociative disorders are common in
general population samples and psychiatric
samples” (van der Hart & Nijenhuis, 2009)
DSM-5 Dissociative Disorders
• Why include dissociative disorders within a
lecture on PTSD?
– Many experts who study dissociative disorders
believe that “trauma causes dissociation”
(Dalenberg et al., 2012)
– However…
• Many other scholars, after examining the same studies,
argue that the hypothesis that trauma causes
dissociation is far from convincingly confirmed (Lynn et
al., 2014)
Dissociative Amnesia
• DSM-5 definition
– “… an inability to recall important autobiographical information,
usually of a traumatic or stressful nature, that is inconsistent with
ordinary forgetting.”
• Spiegel (1997)
– “… that it is not subject to the same rules of ordinary forgetting; it is
more, rather than less, common after repeated episodes; involved
strong affect; and is resistant to retrieval through salient cues.”
• So,…
– The more often trauma occurs and the more emotionally distressing it
is for the victims
• The more likely it supposedly is that they will not remember having suffered
any trauma
• Encoded, but dissociated, memories of trauma will not be accessible by
ordinary means (e.g. interviewing people ordinarily)
Dissociative Amnesia
• Dissociative fugue
– Previously a distinct syndrome in DSM
– Now a subtype of Dissociative Amnesia in DSM-5
– Characterized by
• Aimless wandering often coupled with amnesia for parts of
the journey
Dissociative Identity Disorder
• Those diagnosed with DID act as if different
personalities (a.k.a. alters, identities) seize control of
the person at various times
• The personalities vary in their behavior, thoughts, and
feelings, and each has its own name, history, and
memories
Dissociative Identity Disorder
• Specialists interpretation
– The syndrome arises from chronic, severe sexual
and physical abuse during childhood
– Victim’s sense of self dissociates into multiple
identities
• Some of these harbor the memories of trauma too
horrific for the host personality to entertain consciously
Dissociative Identity Disorder
• In many cases of DID, patients had no memories
of childhood abuse until therapists (using
hypnosis, guided imagery, etc.) helped them
recall presumably dissociated traumatic
memories
• Authentication of these memories is
questionable
– Traumatic memories are seldom, if ever, inaccessible
to awareness
– Many patients retracted their recovered memories,
especially of satanic ritual abuse
Dissociative Identity Disorder
• Problem/paradox inherent in this
interpretation
– Many patients with DID report histories of
childhood trauma that they have never forgotten
• The motivation for the emergence of dissociation in
general (and in DID in particular) is to quarantine
memories of trauma
• Yet, if these patients have remembered their trauma all
too well, why, then, are they dissociative?
Dissociative Identity Disorder
• Case reports of MPD were rare in the
literature before the 1980s
– One review cited only 76 cases that had
appeared in the past 128 years
• Sybil (Schrieber, 1973)
– Bestselling book about a case of MPD
• Became a made-for-TV movie
– After its publication, an epidemic
erupted
– Putname, Guroff, Silberman, Barban,
and Post (1986)
• “… more cases of MPD have been reported
within the last 5 years than in the preceding
two centuries.”
Depersonalization/Derealization Disorder
• During a depersonalization episode
– People feel emotionally numb and disconnected
from their body
– Experience the world as an unreal dream (i.e.
derealization)
• Many people experience brief episodes of
depersonalization or derealization
– e.g. when exhausted, during marijuana
intoxication, when encountering sudden danger
Depersonalization/Derealization Disorder
• People with depersonalization/derealization
disorder
– Some experience the state unremittingly,
sometimes for months or years
– Others experience recurrent episodes interspersed
with periods of normal consciousness
– Onset is usually sudden
– Many fear for their sanity
Generalized Anxiety Disorder, Panic Disorder,
Social Anxiety Disorder, and Specific Phobias
Generalized Anxiety Disorder
DSM-5 Criteria
A. Excessive anxiety and worry (apprehension
expectation), occurring more days than not
for at least 6 months, about a number of
events or activities (such as work or school
performance)
B. The individual finds it difficult to control the
worry
Generalized Anxiety Disorder
DSM-5 Criteria
C. The anxiety and worry are associated with three (or
more) of the following six symptoms (with at least some
symptoms having been present for more days than not
for the past 6 months):
1.
2.
3.
4.
5.
6.
Restlessness, feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or
restless, unsatisfying sleep).
Generalized Anxiety Disorder
DSM-5 Criteria
D. The anxiety, worry, or physical symptoms cause clinically significant distress
or impairment in social, occupational, or other important areas of
functioning
E. The disturbance is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hyperthyroidism)
F. The disturbance is not better explained by another medical disorder (e.g.,
anxiety or worry about having panic attacks in panic disorder, negative
evaluation in social anxiety disorder [social phobia], contamination or other
obsessions in obsessive-compulsive disorder, separation from attachment
figures in separation anxiety disorder, reminders of traumatic events in
posttraumatic stress disorder, gaining weight in anorexia nervosa, physical
complaints in somatic symptom disorder, perceived appearance flaws in
body dysmorphic disorder, having a serious illness in illness anxiety disorder,
or the content of delusional beliefs in schizophrenia or delusional disorder
Panic Disorder
DSM-5 Criteria
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of
intense fear or intense discomfort that reaches a peak within minutes, and
during which time four (or more) of the following symptoms occur:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feelings of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, light-headed, or faint
Chills or heat sensations
Paresthesia (numbness or tingling sensations)
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Fear of losing control or “going crazy”
Fear of dying
Panic Disorder
DSM-5 Criteria
B. At least one of the attacks has been followed by 1 month
(or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, “going
crazy”)
2. A significant maladaptive change in behavior related to the attacks
(e.g., behaviors designed to avoid having panic attacks, such as
avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition (e.g., hyperthyroidism,
cardiopulmonary disorders).
Panic Disorder
DSM-5 Criteria
D. The disturbance is not better explained by another
mental disorder (e.g., the panic attacks do not occur
only in response to feared social situations, as in
social anxiety disorder; in response to circumscribed
phobic objects or situations, as in specific phobia; in
response to obsessions, as in obsessive-compulsive
disorder; in response to reminders of traumatic
events, as in posttraumatic stress disorder; or in
response to separation from attachment figures, as
in separation anxiety disorder)
Social Anxiety Disorder
DSM-5 Criteria
A. Marked fear or anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
Examples include social interactions (e.g., having a conversation,
meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a speech).
B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated (i.e., will be
humiliating or embarrassing; will lead to rejection or offend
others)
C. The social situations almost always provoke fear or anxiety
D. The social situations are avoided or endured with intense fear or
anxiety
Social Anxiety Disorder
DSM-5 Criteria
E. The fear or anxiety is out of proportion to the actual threat posed by the
social situation and to the sociocultural context
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or
more
G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning
H. The fear, anxiety, or avoidance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition
I. The fear, anxiety, or avoidance is not better explained by the symptoms of
another mental disorder, such as panic disorder, body dysmorphic disorder,
or autism spectrum disorder
J. If another medical condition (e.g., Parkinson’s disease, obesity,
disfigurement from burns or injury) is present, the fear, anxiety, or
avoidance is clearly unrelated or is excessive
Specific Phobia
DSM-5 Criteria
A. Marked fear or anxiety about a specific object or situation (e.g.,
flying, heights, animals, receiving an injection, seeing blood)
B. The phobic object or situation almost always provokes
immediate fear or anxiety
C. The phobic object or situation is actively avoided or endured
with intense fear or anxiety
D. The fear or anxiety is out of proportion to the actual danger
posed by the specific object or situation and the sociocultural
context
E. The fear, anxiety, or avoidance is persistent, typically lasting for
6 months or more
Specific Phobia
DSM-5 Criteria
F. The fear, anxiety, or avoidance causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning
G. The disturbance is not better explained by the symptoms of
another mental disorder, including fear, anxiety and avoidance
of situations associated with panic-like symptoms or other
incapacitating symptoms (as in agoraphobia); objects of
situations related to obsessions (as in obsessive-compulsive
disorder); reminders of traumatic events (as in posttraumatic
stress disorder); separation from home or attachment figures
(as in separation anxiety disorder); or social situations (as in
social anxiety disorder)
Fear and Anxiety
• The constructs of fear and anxiety are central
in defining and differentiating these diagnoses
– Fear (or panic) – an alarm response when danger
is perceived to be present
• Involves a triggering of the fight-flight-freeze (FFF)
– Anxiety – a future-oriented mood state associated
with preparation for possible harm
• Involves a priming (simultaneous excitatory and
inhibitory input to) the FFF mechanism when danger is
perceived to be possible at a later point in time
Fear and Anxiety
• Overlapping features
– Both involve the perception of danger
– Both involve excitatory input to the FFF mechanism
• Distinctive features
– Temporal aspects
• Fear (panic) is more immediate
• Anxiety is longer lasting and future oriented
– Fear (panic)
• Purely excitatory input to the FFF mechanism
– Anxiety
• Simultaneous excitatory and inhibitory input to the FFF
mechanism
Panic Attacks
• Two types of panic attacks
– Expected – the individual is aware of a cue or
trigger at the time of the attack
– Unexpected – the individual is not aware of a cue
or trigger at the time of the attack
Panic Attacks
• Panic Attacks
– Seen across all anxiety disorders (and even in major
depression)
• Anxiety
– Central to the definition of each of the anxiety disorders
• Panic Disorder, Social Anxiety Disorder, and Specific Phobias
• Non-clinical panic vs. Panic Disorder
– Non-clinical panic
• Do not experience anticipatory anxiety about their attacks
– Panic Disorder
• Do experience anticipatory anxiety about their attacks
Panic Disorder
• Central Features in DSM-5
– Recurrent, unexpected panic attacks
– One of the following:
• Persistent worry about having attacks (or about their
consequences)
• The development of significant, maladaptive behavioral
changes designed to avoid having attacks
• Note:
– If all panic attacks are expected, a diagnosis other than
Panic Disorder would be made
• Maybe Social Anxiety Disorder, Specific Phobia, Post-Traumatic
Stress Disorder, or Obsessive Compulsive Disorder
Panic Disorder
• Agoraphobia – the fear and avoidance of
situations in which the individual fears having
a panic attack and from which it would be
difficult to leave or get out
– DSM-5 has reverted to identifying agoraphobia as
an independent diagnosis, as in DSM-III
• Someone with PD who develops agoraphobia would
have two diagnoses instead of one (as in DSM-IV)
Generalized Anxiety Disorder
• Cardinal feature
– Excessive, uncontrollable worry about a number
of different life circumstances
• This worry must be accompanied by at least three
common manifestations of anxiety
– e.g. muscle tension, sleep disturbance, or irritability
Specific Phobia
• Five subtypes:
– Animal – fear cued by animals or insects
• e.g. dogs, snakes, or spiders
– Natural environment – fear cued by an object in the natural
environment
• e.g. heights, thunderstorms, or water
– Blood-injury-injection – fear cued by seeing blood, injury, or
receiving an injection
– Situational – fear cued by specific situations
• e.g. driving, enclosed spaces, or flying
– Other – fear cued by other triggers
• e.g. falling down, costumed characters such as clowns, or
emetophobia (the fear of vomiting)
Specific Phobia
• To receive a DSM-5 diagnosis of specific phobia:
– The cue has to almost invariably provoke an
immediate fear response
– The fear has to be excessive*
– The fear must be associated either with:
• Some avoidance of the phobic cue
• Endurance of exposure to that cue with intense fear
– The fear must be associated either with:
• Some functional impairment
• Significant distress about having the fear
Specific Phobia
• Who judges “excessiveness”?
– DSM-IV – the patient
– DSM-5 – the clinician
Social Anxiety Disorder
• Key feature
– A persistent and marked fear of social situations in which
the individual might be judged or evaluated by others
• Exposure to the feared social situation(s) has to
almost invariably provoke an immediate fear
response
• The fear must be associated with either
– Some avoidance of the phobic cue
– Endurance or exposure to that cue with intense fear or
anxiety
Social Anxiety Disorder
• Who judges
“excessiveness”?
– DSM-IV – the patient
– DSM-5 – the clinician
Distinct Categories?
• Controversy within the field
– Some see these anxiety disorders as distinct
categories
– Others think they represent inconsequential
variations of a broader syndrome
• Differ solely at the descriptive level in terms of the
content of apprehension
• This is why we are discussing them within the
same lecture…
Epidemiology for Anxiety Disorders
Epidemiology for Specific Phobia
• Specific phobia is the most prevalent of the
anxiety disorders
• The mean number of fears reported by an
individual is approximately three
– Most common subtypes
•
•
•
•
Natural environment
Situational
Animal
Blood-injection injury
Epidemiology for Social Anxiety Disorder
• Social anxiety disorder is the second most
prevalent anxiety disorder covered here
• Between-group racial and ethnic differences
– Higher percentage of White Americans diagnosed
than Black/African, Hispanic/Latino, and Asian
Americans
– Higher percentage among Native Americans than
White Americans
Epidemiology for Social Anxiety Disorder
• Most common fears reported are those related to
performance-based situations
– e.g. public speaking, participating in class, performing
in front of others
• Comorbidity
– Highly comorbid with other mood, anxiety, and
personality disorders
• Particularly avoidant personality disorder
– Most common comorbid anxiety disorders are PD, SP,
and GAD
Epidemiology for Generalized Anxiety
Disorder
• Between-group racial and ethnic differences
– White Americans are more likely to be diagnosed
than are Black/African, Hispanic/Latino, and Asian
Americans
• Comorbidity
– Of those with comorbid disorders…
• 71% meet criteria for a mood disorder
• 90% have a comorbid anxiety disorder
– Most common being PD with agoraphobia and SAD
Epidemiology for Panic Disorder with
Agoraphobia
• Prevalence
– Lifetime prevalence of panic attacks (which often
do not warrant a diagnosis) is 23%
– PD (with or without agoraphobia) is less common
• PD with agoraphobia is less common than PD
• Treatment
– Those with PD with agoraphobia are more likely to
seek treatment than those with (just) PD
Conditioning
• J. B. Watson (pictured) and
Rayner (1920)
– Hypothesized that SPs are
intense classically conditioned
fears that develop when a
neutral stimulus is paired with
a traumatic event
• Until the 1970’s this was the
dominant thinking regarding
anxiety disorders
– The approach then became
widely criticized
Conditioning
• Demonstrated this in their
experiment with Little
Albert
– Little Albert acquired an
intense fear of a white rat
after hearing a frightening
gong paired with the
presence of the white rat
– Unconditioned Stimulus (US)
• Gong
– Conditioned Response (CR)
• Fear of the white rat
Criticisms of the Conditioning Model
•
•
•
•
Vicarious conditioning
Selective associations
Uncontrollability and unpredictability
Temperament/Personality and conditioning
Vicarious Conditioning
• Many phobics do not appear to have had any
relevant history of classical conditioning
• In response, clinicians speculated that
vicarious conditioning may play a role
• Vicarious conditioning
– Simply observing others experiencing a trauma or
behaving fearfully can sufficiently induce phobia
Vicarious Conditioning
• Some retrospective studies suggest vicarious
conditioning may play a role in the development of PD,
SAD, and SPs
– Studies including reports from a) mothers of individuals with
SAD and b) the individuals with SAD
• Both mother and individual reports indicate more social avoidance
among families of patients with SAD compared with non-clinical
controls
– Because these are family studies, it is impossible to
determine whether these similarities are due to
environmental or heritable factors (or both)
• That is, the individuals may have either a) learned anxiety through
vicarious conditioning, b) inherited anxiety from parents, or c)
some combination of both
Vicarious Conditioning
• Primate models have shown that strong and
persistent phobic-like fears can be learned
rapidly through observation alone
– This vicarious conditioning has occurred simply
through videotapes of models behaving fearfully
• This suggests that humans may also be susceptible to
acquiring fears vicariously through movies and
television
Vicarious Conditioning
• Direct social reinforcement and verbal instruction
– Patients with PD receive more parental encouragement
for sick-role behavior during childhood experiences of
panic-like symptoms in comparison to non-clinical
controls
• e.g. “Take care of yourself and avoid strenuous activities.”
– Parents of anxious children may be more likely to
reciprocate their children’s proposals of avoidant
solutions
– When anxious children discuss potentially threatening
situations with their parents, such discussions strengthen
the anxious child’s avoidant tendencies
• Anyone see a problem with this conclusion?!
Selective Associations
• Equipotentiality
– Early conditioning models predicted that any
random group of objects could be conditioned to
elicit fears, SPs, and anxiety
Selective Associations
• Prepared fears – those fears that are not truly inborn or
innate, but which are very easily acquired and/or
especially resistant to extinction
– e.g. snakes, water, heights, enclosed spaces, elevated heart
rate, other people, etc.
• People are much more likely to have fears of “prepared”
stimuli than they are of bicycles, guns, or cars
– This is noteworthy, because bicycles, guns, and cars pose a
much greater threat (today) than “prepared” stimuli
– Seligman (1970) suggested that “prepared” fears posed a
greater threat in our species history, thus conferring a
selective advantage to those who fear them
Selective Associations
• Empirical findings
– Ohman and Dimberg (1987) conditioned two
types of stimuli
• Fear-relevant stimuli (snakes, spiders, and angry faces)
• Fear-irrelevant stimuli (flowers, mushrooms, electric
outlets, or neutral or happy faces)
• Found that the fear-relevant stimuli were more easily
conditioned to be fearful than fear-irrelevant stimuli
Uncontrollability and Unpredictability
• Early conditioning models do not explain why
many individuals who undergo traumatic
experiences do not develop an anxiety disorder
– Perceptions of controllability can explain these
individual differences
Uncontrollability and Unpredictability
• Fear is more easily conditioned when the
aversive event is inescapable than when it is
escapable
– Animal research
• Electric shock increases social submissiveness only
when uncontrollable
• “Learned helplessness” results from repeated social
defeat
– This effect is usually seen in response to uncontrollable shock
(and not controllable shock)
• Some suggest that this means that uncontrollable social
stressors may play a role in SAD
Uncontrollability and Unpredictability
• Social Anxiety Disorder
– Cross-sectional evidence documents a strong
association between generalized perceptions of
uncontrollability and SAD
Uncontrollability and Unpredictability
• Study on panic disorder
– Patients with PD underwent a panic provocation procedure
• Breathing of air with higher than normal CO2
– They were told that they could turn down the level of CO2
if and when a light came on
• Two conditions
– One where the light came on (perceived control)
– Another where the light never came on (no perceived control)
– Results
• 80% reported experiencing a panic attack in the no perceived
control condition
• 20% reported experiencing a panic attack in the perceived control
condition
Temperament/Personality and Conditioning
• Individual differences in
temperament/personality could explain why not
all exposed to trauma develop anxiety disorders
• Evidence
– Individuals high on trait anxiety/neuroticism more
rapidly acquire aversive conditioned responses and
expectancies than others
– These traits could serve as nonspecific vulnerability
factors for the development of SPs, SAD, and MDD
Reasons for Believing
SW-3453-75317133
How do we know the things we know?
• How do we know that stars
are huge balls of fire? Like
the sun, but very far away?
– They look like pinpricks in
the sky
• How do we know that the
Earth is a smaller ball
whirling around one of
those stars?
• What if I told you I could
fly?
Good and Bad Reasons for Believing
• There are many more
bad reasons than good
reasons
–
–
–
–
Observation*
Tradition
Authority
Intuition
• Betrand Russell
– “It is not what the man
of science believes that
distinguishes him, but
how and why he believes
it.”
Observation
Observation
Observation
• The trouble with
tradition
Tradition
– No matter how long ago
a story was made up, it
is still exactly as true or
untrue as the original
story was
Tradition
Tradition
Intuition/Common Sense
• Many of the most
important scientific
discoveries have been
counter-intuitive
• Common sense differs
from theoretical sense
Intuition/Common Sense
• “A bat and a ball cost $1.10 in total. The bat
costs $1.00 more than the ball. How much
does the ball cost?”
Intuition/Common Sense
• “A bat and a ball cost $1.10 in total. The bat costs
$1.00 more than the ball. How much does the ball
cost?”
– Many people respond by saying that the ball must cost 10
cents. Is this the answer that you came up with?
Although this response intuitively springs to mind, it is
incorrect. If the ball cost 10 cents and the bat costs $1.00
more than the ball, then the bat would cost $1.10 for a
grand total of $1.20. The correct answer to this problem
is that the ball costs 5 cents and the bat costs — at a
dollar more — $1.05 for a grand total of $1.10.
Intuition/Common Sense
Theoretical Sense
Theory
Authority
• Believing in something
because you are told to
believe it by somebody
important
• Authority figures
disagree
Truth and Knowledge
Truth and Knowledge
• ‘Nullius in verba’ (‘Take no one’s word for it’)
– Prior to the Enlightenment
• Was believed that everything important that was
knowable
– Had already been discovered
– Was enshrined in authoritative sources such as ancient
writings and traditional assumptions
– A tradition of criticism was imperative for the
sustained, rapid growth of knowledge
Truth and Knowledge
• “Here’s another thing I believe: We are
far better equipped to take on the
challenges we face than ever before. I
know that might sound at odds with
what we see and hear these days in the
cacophony of cable news and social
media. But the next time you’re
bombarded with over-the-top claims
about how our country is doomed or
the world is coming apart at the seams,
brush off the cynics and fearmongers.
Because the truth is, if you had to
choose any time in the course of
human history to be alive, you’d
choose this one. Right here in America,
right now.” – Obama
How do we know the things we know?
Dogmatism
• Dogmatism
– The tendency for people to
cling to their assumptions
• Dogma
– A principle or set of principles
laid down by an authority as
incontrovertibly true
Empiricism
• Empiricism
– The belief that accurate
knowledge can be acquired
through observation*
– An essential element of the
scientific method
• Empirical
– Based on, concerned with, or
verifiable by observation or
experience rather than theory
or pure logic
The Scientific Method
• The scientific method – A procedure for finding truth
using empirical evidence
– Simply a way of knowing something
• It’s not a perfect way of knowing something, but it’s the best
that we’ve got
• When better ways come along, science incorporates them
The Scientific Method
• A few more thoughts:
• Any scientific theory that cannot be disproven is worse
than useless*
• In science, we don’t attempt to prove, we attempt to
disprove
• The scientific theories that we adhere to are those that have
withstood many attempts to be disproven
• Not perfect, but the best method we have
• Science is a way of knowing [period]
• Silent regarding what we do with what we know
Science
•
•
•
•
Theory
Hypothesis
Data collection
Examination of
evidence
• Refinement of theory
•
•
•
•
•
Peer review
Replication
Methods
Reliability
Presentation of data
The History of Psychopathology
Well, how did we get here?
The History of Psychopathology
• Efforts to understand and resolve problems of
psychopathology
– Traced throughout many centuries and cultures
• Times and places where mysticism and charlatanism
flourished
– Have unfolded without the care and watchful eye of
scientific methods
• Based largely off of “bad” reasons for believing
• Many current techniques and theories are
connected to these past efforts
The History of Psychopathology
• Historical periods
– Each
• Is dominated by certain beliefs that ultimately won out over
previously existing conceptions
• Retains elements of the previous periods
• Historical Review
– Helps us understand how current conceptualizations
have roots in
•
•
•
•
Chance events
Cultural ideologies
Accidental discoveries
Brilliant and creative innovations
Ancient History
• The Sacred Approach
– Psychopathology was the expression of transcendent
magical action brought about by external forces
– Animistic Phase
• Connection between primitive beings and the forces of
nature
• World is populated by animated entities and forces that
act on the mind and soul
– Mythological Phase
• Every symptom of a disorder was thought to be caused by
a deity who, if appropriately implored, could benevolently
cure
Ancient History
• The sacred Approach cont.
– Demonological Phase
• Two competing forces struggled for superiority
– Creative and positive
» Represented by a good parent or God
– Destructive and negative
» Represented by the willful negation of good in the form of
demonic forces
Early Hindus
• Susruta
– He followed the traditional
beliefs of demonic
possession
– Suggested that passions and
strong emotions of the
mentally disordered brought
about physical ailments
• These were best served by
psychological help
Hindu Medicine
• Proposed the existence of three emotional
inclinations
– Wise and enlightened goodness
• Seated in …
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