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Treatment approaches of Borderline Personality Disorder
- Tricyclic antidepressants and lithium.
- Linehan's dialectic behavior therapy(DBT) - helping people cope w/ the stressors that seem to trigger suicidal behaviors.
Cluster A(odd or eccentric)
- tendency to turn inward and away from outside world
- social detachment
- limited range of emotions in interpersonal situations
(Causes & Treatment)
- Biology contribution
- Dopamine hypotheses = lower density of dopamine receptors cause detachment
- Psychological contribution
- "I need plenty of space"
- Overt behavior - isolation
Tx - would not follow
Cluster A(odd& eccentric)
- socially isolated
- behave in unusual ways
- have odd beliefs
- engage in magical thinking
- milder symptoms than schizophrenia
(Causes & Treatment)
- among relatives of people with schizophrenia
- Brain abnormalities
- influenza during pregnancy =increased risk
- Treatment important some will develop schizophrenia
- medication = low doses of antipsychotic meds
- social skills training
Cluster B(dramatic, emotional, or erratic)
- failing to comply with social norms
- violating the rights of others
- aggressive b/c they take what they want
- indifferent to concern of other people
- Shows NO remorse or concern for effects of their actions
- substance abuse common, 83%
Causes & Treatment
- genetic influence on antisocial PD and criminality
- criminality may require environmental factors
- underarousal hypothesis ->low levels of cortical arousal = primary cause of AS and risktaking behaviors
- come from homes with shitty parents
- trauma w/combat = increased likelihood of AS PD
- rarely identify themselves as needin treatment
- can be very manipulative w/ therapists
- clinicians encourage identification of high-risk children
- lead tumultuous lives
- moods and relationships are unstable
- usually have poor self-image/often feel empty
- frequently engage in suicidal and/or self mutilative behaviors
- comorbidity w/ eating d/o & substance abuse
- connection to mood d/os
Causes & treatment
- more prevalent in families w/ this d/o & somehow linked to mood disorders
- early trauma ex. sexual/physical abuse or neglect
- respond positively to tricyclic antidepressants and lithium
- Linehan's dialectic behavior therapy(DBT)
- Definition = theatrical in manner
- over dramatic/seem almost to be acting
- inclined to express emotion in exaggerated fashion
- tend to be vain and self-centered
- uncomfortable when not in the limelight
- comorbidity w/ antisocial PD
Causes & treatment
- remains to be examined
- therapy focuses on problematic interpersonal relationships. Ex CBT
- think highly of themselves
- consider themselves different than others and deserving of special treatment
- Freud's definition-people who show an unreasonable sense of self-importance and are so preoccupied with themselves that they lack sensitivity and compassion for other people
Causes and Treatment
- Parents did not meet the child’s unfulfilled empathic needs. Consequently, the child remains fixated at a self-centered, grandiose stage of development
- limited in success(ex. CBT)
Cluster C(anxious or fearful d/os)
- are extremely sensitive to the opinions of others
- avoid most relationships
- extremely low self-esteem
- chronic fear of rejection
- limited in friendships/dependent on those they feel comfortable w/
- interpersonally anxious
Causes & treatment
- limited support
- Millon suggested that people w/ avoidant PD may be born w/ a difficult temperament -> their parents may reject them or not provide them w/ enough, early uncritical love -> this rejection may result in low self-esteem and social alienation which persist into adulthood.
- Therapy -Have had some success using behavioral techniques to improve anxiety and social skills. ex. behavioral rehearsal and systematic desensitization.
- rely on others to make ordinary decisions as well as important ones
- resulting in an unreasonable fear of abandonment.
Causes & Treatment
- Children learn to bond with their parents and other people who are important in their lives. If early bonding is interrupted, the individuals may be constantly anxious that they will lose people close to them or may grow up fearing abandonment.
- Treatment -use CBT. Because of their attentiveness and eagerness to give responsibility for their problems to the therapist, people with this d/o can appear to be ideal patients.
- fixation on things being done "the right way"
- Preoccupation w/ details prevents them from actually completing much of anything.
- Because of rigidity, tend to have poor interpersonal relationships.
Causes & treatment
- weak genetic contribution
- parental reinforcement of conformity and neatness may predispose people to favor structure in their lives.
- Treatment - not much info on successful treatment
- Therapists often treat the fears that seem to
- underlie orderliness.
- Obsessions->Four features •Recurrent and persistent thoughts, impulses, or images that produce significant anxiety and are experienced by the individual as intrusive and inappropriate •Thoughts, impulses, or images are not simply excessive worries about real-life problems •The sufferer attempts to ignore, replace, o neutralize the obsessive thoughts with another thought or action •Persons with obsessions realize that their obsessive thinking arises from their own disturbed thought processes
- Compulsion •a repetitive behavior or mental act that the person is driven to perform in response to an obsession or according to a rigid set of rules •behavior or mental act (e.g., counting, checking, ordering, arranging, washing, or cleaning) rituals. Same every time. The purpose of the compulsion is to reduce the anxiety or prevent an imagined disaster or catastrophe, but they are clearly excessive or not realistically connected to what they are intended to neutralize
Features of OCD: Incidence->2 - 3% of the population. More common in women. Onset->OCD generally begins by early adulthood. Early onset (onset in childhood or adolescence) is more common in males->6 to 15 years old. Later onset is more common in females->20 to 29 years old. Many children who develop compulsive rituals do not retain them into adolescence. Children with OCD -- sex ratio reversed->more likely to be male. Comorbidity->OCD is frequently comorbid with other anxiety disorders (e.g., GAD; recurrent panic attacks; specific phobia; debilitating avoidance; major depression)->all could occur simultaneously. ->highly correlated w/ Tic d/os and Tourette Syndrome. Post-beta-hemolytic streptococcal infection– antineuronal bodies to these bacteria are found in individuals w/ OCD and Tourette.
Most effective Pharmacological Treatment of OCD
Clomipramine -tricyclic antidepressant
Behavioral Approaches used in treatment of OCD
- Ritual(response prevention)
- Exposure w/ ritual(response) prevention
Acute Stress Disorder
Characteristics and Clinical Symptoms
- Greater than two days but less than one month (2 –30 days). Trauma->Response of intense fear, helplessness, or horror. Dissociative Sxs->precursors for PTSD. During or after the trauma (3 or more): •Detachment, numbing, or reduced emotional responsiveness
- •Reduced awareness of surroundings (e.g., in a daze) •Feelings of Unreality (Derealization) •Feelings of being detached from oneself or from one’s experience (Depersonalization) •Inability to recall an important aspect of the trauma (dissociative amnesia) •Recurrent reexperiencing (dreams, flashbacks, thoughts) Or intense distress when exposed to event-related stimuli •Avoidance of stimuli that elicit memories of the trauma •Sxs of anxiety and increased arousal/hyperarousal (e.g., sleep disturbance, irritability; agitation; hypervigilance, exaggerated startle response)
- Features of ASD and PTSD: Incidence -> ASD: •over 90 % of rape victims meet criteria for ASD; about 15% of people in injurious motor vehicle accidents meet criteria for ASD
Clinical description and concept of PTSD
- Duration criteria: One month or greater -- Persistent Rexperiencing of traumatic event (1 or more) •Distressing recollections/ memories • Dreams
- •Acting or feeling as if event is reoccuring (e.g., flashbacks, illusions, hallucinations) •Distress at internal or external cues symbolic of the event •Physiological activity due to cues -- Avoidance of associated stimuli and Lack of Resonsiveness (3 or more)
- •Active avoidance of thoughts, feelings, or conversations regarding the traumatic event •Avoidance of activities, places, or people associated with the trauma •Inability to recal important aspects of the trauma (dissociative amnesia) •Significant Diminished interest or involvement in activities
- •Feelings of detachment from others (can’t get close) •Restricted range in affect •Sense of foreshortened future -- Persistently Increased Arousal (2 or more)
- •Difficulty falling or staying asleep •Irritablity or angry outburst (overreactive hostility) •Concentration problems •Hypervigilance (watching the perimeter) •Exaggerated startle response
Biological Factors of PTSD
Biological Theories->Primed Nervous System. a. Neuroendocrine alterations in PTSD: ->hypothalamic-pituitary-adrenal (HPA) axis is hypersensitive to stress. Chronic activation of HPA ->increased flow of cortisol (stress hormones). Elevated corticotropin-releasing factor (CRF) b. Brain Structures->damage to the hippocampus has appeared in groups of pts w/ war-related PTSD and adult survivors of childhood sexual abuse. This damage to the hippocampus may cause some disruptions in learning and memory (e.g., short-term memory; recalling of events) demonstrated in pts w/ PTSD. Damage in hippocampus may be reversible->tx may increase hippocampal volume. c. Neurotransmitters (Sxs of arousal and Sxs of emotional flattening). Alterations in serotonin, dopamine in the prefrontal area. Also, alterations of catecholamine->increased norepinephrine
PTSD Risk Factors
- Risk Factors associated with PTSD: •more severe trauma •perceived threat to life •low intelligence: may be associated with low coping skills •lack of social support early separation from parents
- •history of prior stress, abuse, or trauma •family history of psychiatric disorders •personal history of prior mood or anxiety disorders
Course of Mental Retardation
- chronic and less amenable to tx. People do not recover. Prognosis for
- people w this d/o varies considerably. Less severe forms can live relatively independent and productive lives. More severe – requires more assistance to participate in work and community life.
Biological Theories of Mental Retardation
- •Genetic Influence->researchers believe that people w/ MR probably are affected by multiple gene d/os in addition to environmental influences. People w/ MR have identifiable single-gene d/os involving genes that are: dominant – expresses itself when paired w/ a normal gene or recessive – expresses itself only when paired with another copy of the same kind. People w/ milder MR do marry and have children, thus passing on their genes.
- •Chromosome influences->People w/ Down Syndrome has an additional small chromosome -- an extra 21st chromosome and is referred to as trisomy 21. All have Mental Retardation-> generally in the mild to moderate range. Have been tied to maternal age. E.g., at age of 45, 1 in 18 births.
- •Fragile X syndrome->cause moderate to severe MR, especially in males. An abnormality on the X chromosome -> mutation that makes the tip of the chromosome looks as though it is hanging from a thread. 1 of every 2,000 males is born w/ fragile X syndrome. Primarily affects males because they do not have a second X chromosome w/ a normal gene to balance out the mutation.
Treatment of Mental Retardation
- no cure. •Education -- special classes/schools vs. mainstreaming (persons with cognitive and physical
- limitations are integrated into the classrooms of their normal peers) •Behavioral Treatment – targets. E.g., increase motor development, language development,
- social development, and cognitive development. Strategies->reinforce desired behavior
- immediately. •Parent Training->train parents to reinforce and punish. Positive reinforcement. Negative
Characteristics of Autism
- •Incidence of MR -- prevalence is from 2% to 5%. 4x males to 1x female. Higher IQ range
- more common in males. IQ of below 35->more prevalent among females. •Onset -- most people w/ autism develop symptoms before the age of 36 months. •Course of Autism -- Language abilities and IQ scores are reliable predictors of how children
- w/ autism will fare later in life. •Comorbity->epilepsy, with bimodal peak of onset in early childhood and adolescence.
Clinical Symptoms of Autism
- TOTAL OF 6 OR MORE ITEMS FROM A, B, AND C. ->A. Severe Impairments in social interaction (2 or more):
- •impaired use of nonverbal behaviors (facial expression, eye contact, posture); absence of reciprocal facial gestures; avoidance of eye contact
- •failure to develop normal peer relationships->not able to enjoy meaningful relationships with others.
- •lack of spontaneous sharing ofenjoyment, interests, achievements
- •lack of social and emotional reciprocity
- B. Severe Impairments in Communication (1 or more):
- •Delayed language or no language (e.g., use gestures or mime) •Impaired ability to initiate and sustain a conversation •Stereotyped and repetitive use of language or idiosyncratic • language
- C. Restricted, repetitive, and stereotyped patterns of behavior, activities, and interests (1 or more):
- •Preoccupation with stereotyped or restricted patterns of interest •Inflexible adherence to nonfunctional routines or rituals. Intense need for sameness->
- extremely upset even if small change is introduced •Stereotyped and repetitive motor movements. E.g., hand flapping; hand gazing;
- grimacing; self stimulation Associated features->aggression (comm); self-injury (comm); self-stimulatory behavior; delayed toileting.
Major Difference between Asperger's d/o and Autism
people w/ Asperger's can be quite verbal.Obsessed with arcane facts over people. Very formal and pedantic style of speech (e.g., Little professor syndrome). Often exhibit clumsiness and poor coordination.
Biological theories of autism
Autism is a neurodevelopmental disorder. Deficits in neural development during the 2nd semester of gestation that may not be expressed until the second year of life. A small percentage of mothers exposed to rubella virus have children w/ autism. -- Genetics ->92% concordance between monozygotic twins. Families have one child w/ autism have a 3 to 5% risk of having another child w/ the d/o. Relatives of person with autism have higher rates of deficits in communication and social functioning. Possible abnormalities on chromosome 15. -- Brain Structures ->abnormalities of the cerebellum among people w/ autism. Reduced size. ->reduced cell size and densities in amygdala – hypoactivation ->brain may be enlarged by as much as 10% in volume in toddlers with autism.
Psychological theories of Autism and Aspergers
autism was seen as the result of failed parenting. Mothers and fathers of children w/ autism were characterized as perfectionistic, cold, and aloof with relatively high SES and higher IQs than the general population. Imagine being accused of such coldness toward your own child as to cause serious and permanent disabilities. Not backed by the scientific community since 1960s. ->social cognitive domains – Theory Of Mind->most influential framework emerging in 1990s. Has been studied extensively by Simon Barron-Cohen at University of Cambridge. According to this theory, individuals with autism have difficulty in making attributions of mental states to others and to themselves, which result in an inability to construct a social world that is guided by intentions, desires, and beliefs. By the age of 4 or so, most children have the ability to understand other people as having feelings, intentions, and pictures of the world that are not the same as their own. A TOM is also a basic requirement for empathy or deceit. Baron-Cohen coined word, “mindblind.”
Findings of Baron-Cohen's Research
a proclivity for systemizing – for understanding and constructing rules-based systems to explain our experience. Baron-Cohen et al. found some evidence of a link between autism in children and a propensity for engineering in their parents. ->12% of the parents of children w/ autism are engineers.
Three term contingency of Operant Conditioning
- Discrete Trials Training (Ivar Lovaas)->based on Operant Conditioning. E.g., teaching
- communication; toileting; dressing; hygiene; socialization
Most widely abused illegal drug in U.S.
Opiates->e.g., morphine, codeine, and heroin (most highly abused and most addictive opioid). Positive effects include an elevation of mood (“a high”), a sense of euphoria, a decrease in anxiety and pain (analgesic properties), and an increase in self-esteem. Withdrawal symptoms include dysphoric mood, nausea, vomiting, muscle aches, diarrhea, and insomnia. Abrupt withdrawal from opiates can be life threatening.
- from alcohol after prolonged heavy drinking may cause hand tremors, nausea or vomiting, insomnia, psychomotor agitation, anxiety, autonomic hyperactivity (sweating), and headaches. May also cause convulsive activity (grand mal seizures) and eventually hallucinations, delusions, or confusion accompanied by high temperature and rapid heartbeat.
- Amphetamines & Cocaine -depression, fatigue, vivid/unpleasant dreams, insomnia/hypersomnia, psychomotor retardation/agitation, and increased appetite.
Reasons for initial drug experimentation
Sociocultural factors->Initial experimentation – e.g., opportunity; curiosity; sensation seeking; peer pressure; availability.
Biological factors associated with substance use, abuse, and dependence
- changes in the brain. Drugs motivate the brain through their actions on neurotransmitters, particularly dopamine and endorphins.
- •Dopamine is used by neurons located in brain structures such as those in the limbic system (center for pleasure and rewards).Pleasure and euphoria result from the release of dopamine in the limbic system.
- •Endorphins (opioids/internal morphine) appear in the brain’s pathway (e.g., thalamus, sensory cortex, and the limbic system) and the spinal cord. Endorphins serve as analgesics (pain reducers) because they have pain-reducing properties.
- Drugs operate at the synapses where these neurotransmitters are located in two ways: •They can prevent the reuptake of a neurotransmitter associated with pleasure. The
- neurotransmitter remains available to repeatedly stimulate the pleasure centers. •Some drug molecules fit into receptor sites much like the real neurotransmitter would. They
- stimulate the neurons responsible for producing pleasure.
- For example: •Alcohol stimulates the central nervous system and dopamine, thus leading to a disinhibition
- effect. •Amphetamine stimulates the additional release of dopamine from synaptic vesicle storage
- points. •Cocaine blocks the reuptake of dopamine. •Cannabis blocks the reuptake of dopamine and serotonin (disinhibits activities of neurons in the
- sensory perceptual and limbic systems). •Hallucinogenics (e.g., LSD) block the reuptake of dopamine and prevent normal reuptake of
- serotonin (disinhibits activities of neurons in the sensory perceptual and limbic systems). •Opiates stimulate the output of large amounts of dopamine. Also produce pleasure because
- they bind directly with endorphin receptor sites. •Nicotine activates dopamine, opioid production system, and acetylcholine (neurotransmitter
- that signals your muscles to become active and allow you to move).
Social learning model of alcohol abuse and dependence
- developed by Cooper et al. (1988). According to this model, people use alcohol for two distinct reasons:
- •drinking to socialize or enhance positive emotion
- •drinking to cope People who use alcohol/drugs to escape from aversive situation or to cope are more likely to become addicted (alcohol dependence) compared to those who use alcohol/drugs for socialization or pleasure enhancement.
•12-step program treating alcoholism as disease. •Spiritually based, providing social support.