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1

Abnormal

Psychological dysregulation associated with distress or impairment in functioning that is not typical nor culturally expected/accepted.
Behavior that is unusual along w/
Social deviance:
-faulty perceptions of reality
-significant personal distress
-maladaptive/self-defeating behavior
-dangerousness

2

Supernatural Tradition (Late 15th-17th century)

Deviant Behavior = Battle of "good vs. evil"
--demonic possession, witchcraft, sorcery, movement of moon/stars, lunacy.
Treatments inc: exorcism, torture, beatings, crude surgeries (trephination).
---Witches voluntarily work w/ devil (women, poor/unmarried/disobedient. Attempt at diagnosis: death either way.

3

Reform Movement (Late 18th-Early 19th)

1450-1550- horrible asylum conditions so Rise of Moral Therapy (Pinel/Pussin)
--Benjamin Rush (reforms in US), Dorothea Dix (mental hygiene movement).
Moral Therapy declines in 1880s: MI not curable - lifelong institutionalization and little/poor care

4

Early Medical Models

Hippocrates (~400bc) said Abnormal behavior as Physical Disease (first break from Demonology)
Fluids=humors: black bile is depression, yellow bile is quick-tempered, blood is cheerful/confident/optimistic, phlegm is lethargic.
Galen: Discovered arteries carry blood not air.
Galenic-Hippocratic Tradition: linked abnormality w/ brain chemical imbalances and foreshadowed modern views.

5

Impact of Biological Tradition

Mentall Illness ~ Physical Illness
1930s Biological treatment standard: insulin shock therapy, ECT, brain surgery
1950s medications increasingly available: anti-psychotics, major tranquilizers. many released from institutions.

6

Community Mental Health Movement

Communities can better meet its members needs: Congress est. nationwide Community Mental Health Centers (CMHCs) and anti-psychotic drugs widely available. Deinstitutionalization

7

Psychoanalytic Theory

From Moral Therapy & Charcot's use of hypnosis to treat hysteria-- Freud's theory that intrapsychic forces in subconscious are MI
1st major theory of abnormal behavior
Conflict within - blocked emotions - physical manifestations
Treatment: discharge of blocked emotions (catharsis), restored physical functioning. - Modern Psychodynamic Theory

8

Sociocultural Perspective

Society fails the person so abnormal behavior occurs. Mental illness is a myth.
Labels harm/stigmatize/reify abnormality (Thomas Szasz) - pathologies those that threaten the establishment, permits denial of societal injustices.

9

Biopsychosocial Perspective

Interactionist model: Abnormal Behavior too complicated for simple models; must consider biological/psychological/sociocultural factors.
Current trend in the field - behavioral genetics.

10

Multidimensional Models of Abnormal Behavior

Biological, Environmental/Psychological, Developmental
Etiology: Cause/source
Multidimensional: system of multiple influences

11

Biological Influences: Genetic

GENES: (DNA) molecules on chromosomes that contribute to physical/behavioral similarities among biological relatives. Polygenesis: influenced by many genes (genius).
Behavioral Genetics: Discipline concerned w/ genetic and environmental influences on behavior (examine patterns of familial relationships for heritability estimates)
Heritability: proportion of variability in trait/disorder due to genes.
30-70% heritability, Schizophrenia, anorexia Nervosa, Autism are among most heritable of psych disorders (>60%)
IQ 62%, Personality (50%)

12

Concordance

2 ppl have/not a disorder.

13

Discordance

One person has and other does not

14

Diathesis-Stress Model

Diathesis: predisposition/vulneraility
+
Stress: environmental Stressors
=
Development of disorder (stronger diathesis, the less stress necessary to produce disorder).

15

Reciprocal gene-environment model

When genes increase likelihood that individual will encounter environmental rigger: children w/ genes for musical talent drawn to musical environments.

16

Neurobiological

Genes code for proteins: genes for psychopathology likely code for proteins operating in brain.
Frontal lobe is most important for psychopathology.

17

Neurotransmitters important in mental illness

Dopamine
GABA
Norepinephrine
Serotonin

18

Serotonin:

Influences processing of info/aggressiveness/eating/sexual behavior.
-At low levels: increased impulsivity/overreactivity/decreased inhibition
Disorders affected: depression/anxiety/eating disorders
--Prozac: selective serotonin reuptake inhibitor (SSRI)

19

GABA

Inhibits emotions and behavior:
-reduces anxiety
-regulated by Benzodiazepines

20

Dopamine

"Switch" that inhibits/facilitates emotions/behavior
-balances serotonin
-schizophrenia/aggression may = excess dope
-ADHD/Parkinsons = low dopamine

21

Neurotransmitters in Different parts of the brain

-May affect functioning of other NTs
-may affect membrane of receptor cell and activate/inhibit that cell's functioning
--Excess/deficit itself can occur for many reasons (presynaptic neuron releases or reuptakes too much or too little, receptor site more/less sensitive to NT, may be reacting to excess/deficit of another NT).

22

Meds and Neurotransmitters

-Agonist drugs activate receptor neuron to produce desired response (increases action of NT)
-Antagonist drugs block receptor neuron from activation
-Reuptake inhibitors (SSRIs) increase action of NT by decreasing pre-synaptic neuron's ability to reabsorb NT in order to reuse/destroy it.

23

Family Factors

-Shared: environmental factors shared by siblings growing up in same family
-Non-shared: influences not shared by siblings in same family (different treatment from siblings/parents)

24

Sociocultural Influences

Gender, ethnicity, mental health (SES and RACE are confounded).
Influences of population projections on mental health:
-treatment needs

25

Cultural Influences

Prevalence/Expression of MI
-prevalence: westernized vs eastern countries, urban vs rural areas w/in country.
-symptom expression: types of symptoms may vary.

26

Gender

Differences in prevalence rates:
-alcoholism -- men
-depression and eating disorders -- women
Social expectations may influence:
-symptom expression
-acceptable 'types' of psychopathology
Biological influences remain

27

Social Supports

Physical Health: more social contacts - longer, healthier life
Mental Health: Protection against development of certain disorders (depression/alcoholism), particularly true in elderly. Lower depression associated w/ more social contacts and support in men/women over 55.

28

Developmental Perspective

Biological: Genetic influences increase in adolescence and adulthood.
Environmental: Shared environment has influence in childhood, afterward non-shared predominates.

29

Classification/Assessment of Abnormal Behavior

DEF: assign ppl to groups/categories constructed on basis of shared attributes or relationships.
Why?
-communication/prediction, comparisons to determine (prognosis/treatment/etiology)

30

DSM (Diagnostic/Statistical Manual for Mental Disorders

Psychology's current classification system. Published by American Psychiatric Association (APA)
History:
-7 versions to date
-first 1952
-latest is DSM-V (2013)

31

DSM-I, DSM-II

DSM-I: 1952, clinical descriptions in paragraph form, resulted in unreliable diagnosis.
DSM-II: 1968, clinical descriptions, criteria still to broad, unreliability, differing systems in US/Europe (schizophrenia in uS, manic depression in Great Britain
--Concordance of diagnoses 55%> among experienced clinicians (bc patient changed (5), clinicians asked different questions (32.5), problematic classification system (62.5)

32

DSM-III, DSM-III-R

1980, specific criteria developed, more reliable, (less valid, added 100 new disorders some very controversial like learning disorders)
DSM-III-R: No major changes in structure, minor changes in criteria.

33

DSM-IV, DSM-IV-TR (text revision)

1994-May 2013: Major change: how criteria established/evaluated:
-task forces of experts: review literature, reanalyze data, conduct new studies
-decisions based on empirical data
-collaboration with World Health Organization
-multidimensional perspective (multi-axial system (5 axes)

34

DSM-5

2013, reevaluation based on panels of experts, eliminated multi axial system due to implementation difficulties, cultural formulation, compatible with ICD and can code diagnoses in both DSM/ICD, still based on medical model, still categorical model of classification, greater emphasis on dimensional assessment
-added many new diagnoses: some formerly in DSM-IV appendix as diagnoses for further study (binge eating), some new
-changed classification of some disorders: added new categories (obsessive-compulsive, etc), some folded into broader categories (aspergers - autism spectrum), some moved into new categories (body dysmorphic disorder - obsessive-compulsive/related)
-Changed criteria for some disorders - change in prevalence rates.

35

Critiques of DSM and Diagnosis

Negative effects of labeling - stigmatization, self-fulfilling prophecy.
Benefits outweigh negatives - research, treatment, prevention.

36

Clinical Assessment

Two Factors: reliability = consistency, validity = accuracy.
Assessment tools/Psychological Testing: clinical interview, projective tests (Rorschach), personality inventories (MMPI).

37

Psychological Testing

Clinical interview almost always used and tests often supplement - unstructured, structured (clinical interview for the DSM).
Types of tests: projective tests, personality inventories.

38

Projective Tests

Present ambiguous stimuli and have person describe.
Rationale: personality and unconscious fears 'projected' onto stimuli w/out patient being conscious.
80 yrs ago
Based on Psychoanalytic theory

39

Rorschach Projective Tests

Inkblot tests: Swiss psychiatrist - Hermann Rorschach
10 ambiguous inkblots
Controversial
Early use: unstandardized administration/interpretation (one sentence vs. two, unreliable), standardized version developed.
John Exner: comprehensive system for scoring Rorschach (specifies presenation/administration/response recording/interpretation)
Limitations: continues to be controversial, can be useful for assessing world view, ice breaker, etc.

40

Personality Inventories

Empirically-driven (depressed clients say yes to an item, irrelevant if item linked to depression or not, importance is what it predicts.
Most widely used in Minnesota
Multiphasic Personality Inventory (MMPI)

41

MMPI

Published 1943
Development: Compare item responses between psychiatric and non-psychiatric groups (if more depressed clients say yes to "I hate my mother" then item added to Depression scale.

42

MMPI-2

Inventory Structure: T/F (I cry easily, I believe I am being followed)
Interpretation: based on pattern of responses on clinical scales (hypochondriac, depression, schizophrenia)
Validity Scales: info regarding clients' tendency to: downplay problems/be defensive, answer randomly, may not use if scales are very high.
Psychometrics: computer scored - get profile and an interpretation, helps inc reliability.
Current version: MMPI-2, one of most widely-used test in clinical and research settings.
Problems: Some clinicians still interpret their own way (length 567 items, reading level)

43

Stress-related disorders:

Physical disorders either caused or exacerbated by stress and traumatic events.

44

Stress:

both physiological/psychological reaction to situations that demand adaptation (adaptation includes physical and psychological changes)

45

Stressor/Stresses

pressures/demands requiring one to adapt/adjust.

46

General Adaptation Syndrome

Alarm/shock stage: organism recognizes stress/begins to respond
Adaptation or resistance: mobilizes body's resources for coping
Exhaustion stage: succumbs to fatigue

47

Coping

Styles:
emotion-focused: reduces emotional impact of situation - denial/avoidance/withdrawal
Problem-focused: changes problem: actively addressing the issue (confrontation)
Social support
Ethnic identity
Acculturative stress
Excess death rate
What can we do: self-medicate, identify stressors, exercise, meditation, social contacts, stress management, talking/therapy.

48

Adjustment Disorder

maladaptive reaction to identified stressor (starts within 3 months of stressor's onset).
Symptoms: clinically significant: distress exceeds what is typical for that stressor, significant impairment in social/occupational/important domains of functioning
Does not meet criteria for another disorder nor is it simply exacerbation of preexisting condition.
Not normal bereavement
Symptoms remit within 6 months after stressor or its consequences have ended (lasts less than 6 months).

49

Post-traumatic Stress Disorder

Anyone over 6 yrs old
Development related to severity/duration/proximity of exposure to traumatic event
Prevalence: lifetime (8.7), 12month (3.5), higher rates following interpersonal crimes, highest rates (33-50) following rape/military combat and captivity/ethnically or politically motivated internment/genocide.
Women>Men prevalence and symptom duration; attributed to women's higher rates of interpersonal violence and rape.
--Exposure to actual/threatened death/serious injury/sexual violence in 1+ ways: directly experiencing traumatic event, witnessing in person event, learning event happened to beloved, experiencing repeated/extreme exposure to adverse details of event.
--1+ intrusion symptoms that began after the traumatic event: intrusive memories of the event (<6yrs = trauma-specific reenactment in play), intense/prolonged distress at exposure to internal/external cues that symbolize/resemble event, marked physiological reactions to internal/external cues that symbolize/resemble the event.
--Avoidance of stimuli associated w/ event: memories/thoughts/feelings, external reminders that arouse memories/feelings.
--Negative changes in thoughts/mood associated w/ event (2+): inability to remember an important aspect of event (due to dissociative amnesia), persistent/exaggerated negative beliefs or expectations about self/others/world (no one can be trusted, I am worthless, I am permanently ruined), persistent distorted thoughts about cause/outcome that results in inappropriate blaming (of self/others), persistent negative emotional state (horror/fear/anger/guilt/shame), diminished interest/participation in activities, detachment or estrangement from others, inability to experience positive emotions (love/happiness, satisfaction)
--Marked alterations in arousal and reactivity associated w/ onset of event
--Duration longer than a month
--Clinically significant impairment
--Not due to effects of a substance/medical condition
--Specifiers: w/dissociative symptoms, w/ delayed expression (full criteria meet 6+months after event).

50

Acute Stress Disorder

Same criteria as PTSD
Duration: 3days-1month following event
If symptoms continue past 1 month, diagnosis then changes to PTSD (50% those w/ PTSD, initially had ASD)
Interpersonal trauma (20-50), non-interpersonal (<20), assault (19), car accidents (13-21).

51

Anxiety

Generalized state of apprehension/foreboding, is out of proportion to actual threats in environment, associated w/ anticipation of problem rather than responding to actual problem, anxious mood/diagnosable condition.

52

Fear vs. Anxiety

Fear: response to real/immediate danger (surges of autonomic arousal needed for fight/flight, thoughts of immediate danger, escape behaviors)
Anxiety: reaction to anticipated event (muscle tension, vigilance in preparation for future danger, cautious or avoidant behaviors).
Avoiding reduces fear and anxiety temporarily but worsen anxiety over time.

53

Anxiety Disorders

Excessive anxiety/anxiety beyond developmentally appropriate timeframes (excessiveness: determined by clinician, not client, accounting for cultural contextual factors).
Thoughts/situations provoke anxiety.
Preoccupation w/ anxiety-provoking object(s) or persistent avoidance of them.
Persistent = lasting +6months, many start in childhood and persist if untreated.
Clinically significant distress
Impairment (social/work/education)
Commonly comorbid with other anxiety disorders, substance abuse disorders, depressive disorders.
Differ based on: types of objects/situations that provoke fear/anxiety/avoidance behavior, associated thoughts/beliefs.
Most are more common in women than men (2:1).
Physical features: jumpy/jittery/trembling/shaking/sweating/faint/light-headed/dry mouth/heart racing/difficulty breathing/numbness/nausea/pit in stomach
Behavioral features: avoidance/clinginess/dependance/agitation
Cognitive features: worry/nagging sense of dread and apprehension about the future/disturbing recurrent thoughts/difficulty concentrating/overly attentive to bodily sensations.

54

Panic Attack:

sudden surge of intense fear/discomfort, peaks w/in 10 minutes, includes 4+ following: pounding heart/palpitations, sweating, trembing/shaking/shortness of breath/smothering/feelings of choking/chest pain/discomfort/nausea/abdominal distress/fear of dying/dizziness, unsteady, light-headed, faint/chills or heat/paresthesias (numbing tingling sensations)/derealization/depersonalization/fear of losing control or going crazy.

55

Panic Disorder

Recurrent/unexpected panic attacks (at least 2 had no obvious cue), at least one followed by 1month+ of: persistent concern over having additional attacks or consequences, significant maladaptive change in behavior related to attacks (attempts to avoid having them, such as avoiding certain places/situations/exercise)
World: 12-month prevalence: .1-.8
U: 2-3, lifetime = 5
.4% children under 14, inc following puberty, peak in adulthood, down to .7% in older adults, clinical features similar across gender, women more than men.

56

Agoraphobia

Fear/anxiety about 2+ public transport, open spaces, enclosed places, standing in line/being in crowd, being outside of home alone.
Fears/avoids due to thoughts that escape may be hard/help unavailable if panic symptoms start, become incapacitated or something embarrassing happens (fall/incontinence).
Actively avoid.
Disproportionate fear/anxiety
Not confined to specific/social phobia, obsessive thoughts, beliefs about flaws in appearance, trauma/fear of separation.
World 12-month: .1-.8
US:1.7, lifetime <2
Women more than men
Mean age onset = 17, w/ no history of panic attacks = 25-29, rare in childhood and after 40.
Course typically persistent and chronic. Complete remission rare (10) if untreated.
Comorbid with panic disorder (30-50)

57

Specific Phobia

Marked fear/anxiety about specific object/situation (flying/blood)
Phobic object/situation
almost always provokes immediate fear/anxiety
actively avoided/endured w/ intense fear/anxiety
provoked fear/anxiety out of proportion to actual danger
75% diagnosed have 2+ specific phobias
often recognize overreaction, but still overestimate danger
Asian, African, Latin American countries - 2-4
US - 12-month 7-9, life - 12
5 children, 16 13-17yrolds, 3-5 in older adults
Women higher rates animal/natural environment/situational specific phobias than men
Equal rates blood-injection-inury phobia (vasovagal fainting/near-fainting response)

58

Social Anxiety Disorder

Marked fear/anxiety about social situations where scrutiny by others possible
Some performance only
World 12-month: .5-2
US 12-month: 7, life - 12
Rates decrease with age ~7 children and adults, 2-5 in older adults.
Women more than men, esp in adolescence/young adulthood
equal/slightly more men in clinical samples.
Women: more social fears/comorbid depressive/bipolar/anxiety disorders.
Men: more oppositional defiance and conduct disorder, use of alcohol and drugs, fears of dating and initiating romantic relationships, more likely to never partner or have children.

59

OCD

Obsessions: recurrent/persistent thoughts/urges/images that are intrusive/unwanted, and cause marked anxiety or distress (not simply worry about real-life problems)
Attmepts to ignore/suppress/neutralize thoughts/urges/images w/another thought or action
COmmon: contamination, aggressivve impulses, sexual content, somatic concerns, need for symmetry
Typically have multiple obsessions
Compulsions: repetitive behaviors/mental acts that person driven to perform in response to obsession or according to rules that must be rigidly applied.
Aimed at preventing/reducing distress or preventing some dreaded event/ Behaviors not connected in realistic way or are excessive.
Common: checking, ordering/arranging, washing/cleaning
Obsessions/Compulsions cause clinically significant distress/impairment, or are time-consuming (more than 1hr/day)
Content of obsessions not limited to content of another disorder (preoccupation in presence of food in Anorexia Nervosa)
Not due to general medical condition/substance

WOrld: 12-month: 1.2, lifetime 2-3
25 start by age 14, rare after 35, women slightly higher rates than men, men earlier onset-nearly 25% of men began before 10 (worse outcomes)
Gendered presentations (women: symptoms related to cleaning)(men: symptoms related to forbidden thoughts and symmetry; more likely to have comorbid tic disorders)

Chronic course: childhood onset often predicts lifelong symptoms, symptoms increase during stress, can have debilitating effects on relationships
Treatment: exposure/response prevention (expose patients to feared object/prevent them from engaging in compulsions, more effective than meds, around 60-70 get better.

60

Hoarding Disorder

Persistent difficulty discarding/parting with possessions, regardless of value
Difficulty due to perceived need to save/distress with discarding
Results in accumulation of possessions that congest/clutter living areas and compromises intended use (specify: with excessive acquisition.
Prevalence is not known, community surveys estimate 2-6%
Epidemiological studies report significantly higher rates in men, whereas clinical studies show higher rates in women
3x higher rates in older adults (55-94) compared to 33-34
First emerges 11-15, interferes with functioning by mid-20s, clinically significant impairment by mid-30s. Course is chronic and progressively worse over time.

61

Body Dysmorphic Disorder

Preoccupation w/ imagined defects of flaws in physical appearance that are not observable (nose deformed...)
Perfrm repetitive behaviors (mirror checking...) or mental acts (comparing appearance to others) in response to appearance concerns
Not better accounted for by another disorder (anorexia nervosa/preoccupation w/ body fat)
US - 2.4%
women slightly higher than men
Childhood onset assd w/ suicide attempts, more comorbid disorders. greater severity

Gendered presentations: women more comorbid eating disorder
Men: more genital preoccupation and muscle dysmorphia (idea that body too lean w/ insufficient muscle)
Culturally influenced, but not culture-bound
Treatments: behavioral-exposure and response prevention: drug therapy-SSRIs.