Exam 2 (Ch 5-8)

Personality Traits (@ Baseline) Predicting Increased [Frequency of] Stressful Life Events (data from SPAN Study)

"STRESS GENERATION": strong personality characteristics, react strongly->environ events (ie. high neuroticism, low agreeableness & generate interpersonal conflict) ie. stress <=> depression (ie. depressed ppl experience > stressful life events) influences P(exposure->stressful life events, esp interpersonal) Paranoid Personality Disorder inversely related Borderline Personality Disorder: score higher? upper quartiles of stressful life events

Misleading, Pejorative Suicide-Adjacent Terms

"committed suicide" "suicide threat" (implications: person is intending to scare other) "self-mutilation" "parasuicide"

Health Behaviors

+: healthy eating (ie. taking vitamins, watching weight), exercise, seeing doctor/dentist regularly for check-ups, 1st aid kit, sleeping, sanitation (avoiding germs), relaxing, safe driving -: smoking, heavy consumption of alc/drugs, risky sex, reckless driving

Suicide & Mental Disorders

-George Brown: there's no follow up interview to identify the onset major depressive episode for those who die by suicide, just analyzing the notes/words->therapists, fam that they left behind (if they did) how to make decisions on whether someone died by suicide? (ie. did they fall off a bridge or jump off? did they mean to crash the car or was it an accident?) -ppl who die by suicide may experience depression/other mental disorders (ie. substance use, schizophrenia, eating disorders, PTSD) prior—higher suicide risk, but vast majority DO NOT end lives @ least 50% suicides happen in context of clinical depression 15-20% depressed patients eventually commit suicide -2nd leading cause of death among adolescents (15-29) -suicide rates have increased from 1999-2016 (up 25%); sociodemographic & stressful life experiences predict risk more strongly than mental disorder

Background Issues for PTSD

-Vietnam War: traumatic combat experiences (considered weak if develop emotional probs) resilience after a loss is seen as cold/uncaring -introduced->DSM-III instead of "combat fatigue" -DSM-IV considered anxiety disorder -DSM-5's NEW CHAPTER: TRAUMA & STRESS DISORDERS (includes Acute Stress & Adjustment Disorder) -"bracket creep": seems that this diagnostic category is maybe too permissive/lacks precision; increased breadth (lumping grandpa's death w/combat trauma (ie. seeing friends die))—how horrific does the traumatic event have to be until considered PTSD inducing?; subjective response->threat -community research (nonclinical samples) by ECA/NCSR=>expand symptoms "have you ever been in combat" "when you were, were others killed near you" "have you ever been unarmed robbery" "have you ever unexpectedly learned about death of fam member? -now, focus on rape/violent sexual assault (Edna Foa)

Major Depressive Disorder (MDD)

-becoming leading cause of disease burden (Global Burden of Disease by WHO) -co-morbidity w/anxiety disorders @ LEAST 1 major depressive episode euthymic (recovering) between episodes NO manic/unequivocally hypomanic (not full blown mania bc not same severity/duration but still symptoms) episodes -DROPPED "BEREAVEMENT EXCLUSION" OF DSM-IV (diagnostic criteria for episode of major depression): no diagnosis until 2 months after loss of relative/close friend justification for the bereavement exclusion: after loss events, supposed/expected to be sad research evidence for singling out loss (not the only kind of stressful life event after all!) and not things like job, reputation, marriage, health ie: compare and see if difference between (met criteria) depressed but not bereaved vs. depressed AND bereaved (ie. duration of depression, response->immediate treatment, family history; would not qualify for diagnosis w/bereavement exclusion) why should there be a difference between the depression we normally see and then the kind after a loss? possible difference: expected that grieving people would have later age of onset, fewer/shorter duration previous episodes, fewer recurrent episodes in future implication: if actually had depression post-loss, access->treatment is delayed bottom line: either expand this exclusion for all types of stressful life events or eliminate Alan Francis (DSM-IV) argued this should be kept bc turning sadness into "medical disease)

Thinking Critically About the DSM-5: Depression vs. Grief

-eliminating turns grief (maybe transient depressive symptoms so minimize false positives—normal but grieving people not diagnosed ) into illness (expand boundaries of mental disorders) will grief be stigmatized? will people be treated w/antidepressants unnecessarily? most grieving do not meet diagnostic criteria for major depression -keeping would mean delay treatment arbitrary, illogical (all kindsa stressful/traumatic events may increase P(onset of major depression), ie. divorce, financial hardships, need to assume familial responsibilities (ie. caring for sick relative), but why don't they have their own exclusion clause? CONSISTENCY means EXPANDING to include all stressful life events or wiping out the exclusion clause) -leave medication/treatment decisions up->discretion/judgment of mental health pros based on clinical experience! ie: active intervention if suicidal thoughts treatment=joint agreement of therapist and patient!

Problems w/Emotional Response Systems

-emotion: state of arousal described by subjective states of feeling accompanied by physiological changes -affect: pattern of observable behaviors associated w/subjective feelings (ie. facial expressions, pitch of voice, body movements) -mood: pervasive, sustained emotional response that influences perception of the world

Mania

-euphoria: extreme happiness, elated mood, exhilaration, ecstatic for no apparent reason; exaggerated feeling of physical/emotional well-being NOTE! Some feel anger -grandiosity & ambition & inflated self-esteem -hyper energy, no need to sleep for 2-3 days (may be productive), then collapse from exhaustion

Case Study: Bipolar Disorder (George Lawler)

-hospitalized, rapid, pressured speech, rapid/erratic movements (paced halls/rooms), easily provoked rage in him (threatened to report attendant who blocked his entrance into nursing station->Olympic committee), believed he was US Olympic track team head coach and offered tryouts->other patients (before at school, said was contacting assistant coaches/athletes to organize the tryouts and any interference would be attributed->foreign teams reluctant to compete against a distinguished one) (actually coached track teams @ junior college that were undefeated (only sport w/winning record so school followed closely bc so close to a repeat championship)/favored to win conference), taught sports management), sleepless for 3 nights but excited but near exhaustion (bloodshot eyes, stubble, disheveled hair) -1st episode (untriggered) was back in junior year of college played defensive on football team, fairly popular, good academic standing spring sem: started losing interest in studying/class, didn't enjoy going out (didn't care) and was depressed, avoided and found fault w/gf, impaired concentration (didn't care what he watched on TV bc not entertainment but a distraction), no energy to play football so missed practices (didn't care about team/future in sports, not just lacking motivation put on antidepressants/individual student counseling @ student health clinic until treatment was discontinued when he was back->normal functioning within weeks -hypomanic episodes (periods of increased energy, sleeplessness, inflated self-esteem allowing for productivity but not sufficiently severe to be full blown mania): unusual ambition/endless, internal reserves of energy (even w/o stimulants) temporary tendencies: lack need for sleep, talking mile a minute, ambitious goals (behavioral excesses may be adaptive in competitive environ) -2 episodes of depression, 1 8 months pre-hospitalization and the first 2 years ago brooding/preoccupied/concerned about the team in constant, consuming way—who would replace the star sprinter, high jumper's health? winning streak? constantly tired bc lost sleep and woke up several times in middle of night uh oh...athletic department wouldn't provide travel funds, assistant coach on leave of absence to finish degree=>tension and anxiety into depression (he perceived as disasters even tho wouldn't affect the szn too much) lethargic to the point where almost unresponsive slow, monotone speech alternated between long period of sleep vs. staring vacuously @ ceiling -called athletic director to quit (pointed->minor incidents as proof of incompetence, pervasively blamed self when he was despairing ("assistant coach on leave bc of argument I had w/her 6 months back" even tho really for personal reasons) (apologized for being bad husband/father) -if family left him alone, saw suicide as the only option -lithium carbonate: treat manic episodes + antidepressant for bipolar (both kinds of episodes) Uncle Ralph diagnosed w/BP 3 weeks, then maintenance after better (reduce freq/severity of future mood swings) -1st full blown manic episode: end of next spring track szn 2 days prior->conference (individual at athletes shined), driven quality about his prep (worked longer hours, demanded more) that wife Cheryl took to be bc of pressure—boasted endlessly about his team, the potential for national recognition, strategizing actually losing control over behavior (dramatic quality about disturbance) -on day of conference meet: men's team got dressed as he paced rapidly, gesturing emphatically while talking about virtues of winning, waved mantleplace ceremonial sword as he jumped up on bench singing the school's fight song and everyone joined before shaking fists and screaming on the field (emotional peak, inspirational pregame performance/demonstrated his leadership qualities, given coaching award) after meet, stayed in office all night working for regional meet, approached by reporter next morning and took the opportunity to publicize exciting plans for future in a GRANDIOSE TIRADE of 3 hrs (reporter could not excuse/extract himself embarrassingly/unexpectedly) professional disaster—said would send star female high-jumper->NCAA National meet and would accompany her as chaperone (saw a prospect for genuine romance, "not every year that I can take free trip w/pretty girl", which he asked reporter to quote) and drain the community fundraising drive's proceeds to pay for the trip (DID NOT have authority to redirect funds (angered biz leaders), which were intended to be used to improve track facilities/sponsor running clinics for kids) athletic director demanded an explanation=>shouting match couldn't reason w/him that he needed help so the police took him->psych hospital; 2 days of observation after intake eval *****didn't recognize severity, refused to cooperate (involuntary commitment->hospital through judge & testifying psychiatrist) -father coached HS football -older bro & sisters below him athletic but he excelled and got sports scholarship->state uni (expected to play professionally) -enjoyed leadership role as popular student -mischievous but no disciplinary probs -friends drank but he didn't want to be alcoholic like father, who became sober after Alcoholics Anonymous -uncle on mom's side had adjustment probs & hospitalized 2x after wild behavior due->manic episodes (diagnosis of "acute schizophrenic rxn" but really bipolar) -moderate dosage of haloperidol (Haldol) (antipsychotic for schizo), discontinued after 3 weeks supposed to but didn't take lithium carbonate prior->onset; 900 mg on day 1=>1,800 mg/day over next 2 weeks (blood lithium tests so didn't exceed toxic level of 1.4 milliequivalents/L, which would lead->nausea, gastrointestinal distress, muscular weakness)=>maintenance doses of 2,100 mg/day NOTE! normal sodium intake in diet was stressed so lithium wasn't hazardous -daily group psychotherapy w/patients @ ward, recreational/occupational activities (matched interests) behaviors improved (his excitation was disruptive @ meals, nighttime when he ran around shouting until exhaustion/exertion got to point where he was more subdued and slept for 3 days), not restricted status anymore so could leave ward time->time gave up grandiose notion of Olympic fame, > control of speech/motor behavior discharged after 2 weeks w/maintenance dosage of lithium (blood lithium monitored), regular attendance of outpatient clinic for individual psychotherapy, joint therapy w/Cheryl to improve relationship & find effective ways to interactive w/control kids (INEFFECTIVE (improved interactions but periodic/heated fights)—Cheryl embarrassed by manic episode and his expression of attraction for the student=>insurmountable tension) and filed for divorce 6 months post-discharge, which George talked->friends from work (social support) about+psychotherapy+lithium so avoided depression -residual symptoms (gradual dissipation): still rambling, provocative flirting w/female staff unstable mood (irritation/comical amusement; gregarious/energetic) organized group activities and saw self as hospital aide -voluntary status, recognized severity of previous condition (what was exhilarating/amusing were nightmarish) (racing thoughts about conference meet, concerned about possibly having injured someone w/sword in locker room)

Anxiety Classification

-in mid 19th cent, anxiety was NOT the focus of psychiatry—focus was on severely disturbed, psychotic, schizo (maybe BD) patients, termed "manic depressive psychosis" -expansion into working w/outpatients instead of being only @ psychiatric hospital (Freud&Pierre Janet (1859-1947)) 20th century: "lumpers" lump anxiety disorders bc it's not about the overt symptoms (don't let these misle you!) but about the unconscious/stuff you're not aware of/childhood -DSM-III->IV began "splitters" movement (subdivide anxiety disorders into categories (ie. PANDAS) -now, > lumping

Case Study: Panic Disorder, GAD, Agoraphobia (Dennis Holt)

-intermittent panic attacks for last 10 years, never > 2/3 times per year 1st panic attack @ 24 y/o, @ dinner theatre w/3 couples (including Mary's boss & wife); he consistently rejected this plan bc self-conscious about eating in public and didn't care for Mary's colleagues but gave in bc important for her advancement @ firm & looked forward->play uncomfortable throughout dinner, concerned if gastrointestinal attack would be imminent (didn't want to explain why he would be holed up in bathroom) so took antispasmodic meds/ate sparingly choking sensation in throat and chest at dessert, stopped being able to breath and felt like fainting couldn't speak/move and was terrified Mary thought he was choking and pounded back between shoulder blades => sharp chest pain, heart palpitations, wheezed out "I think I'm having heart attack" symptoms passed in < 30 min somehow still convinced self that he was in good physical condition, attributed attack->food/interaction of food & meds refused to go->lunch w/Mary & friends but continued to eat business lunches w/own colleagues 2nd panic attack 6 months later while driving alone in rush hour traffic: sudden sensation of smothering,inexplicable, intense fear pulled off road and lied down on seat until over -tense/anxious before attacks, generally could not relax, chronic muscle tension, occasional insomnia (wound up, on edge after work where he had to visit clients in homes), headaches lasting several hours (steady, diffuse pain across head) -self-conscious, worried what others thought of him after each session, felt need to joke loudly so ppl waiting outside could hear laughter—would open the door chuckling "that was fun, let's get together again soon!" b4 appointments/calls w/prospective insurance clients and b4 he got to their house, "would they like him? could he make the sale?", where his concerns reached max as he drove over made 45-min audio recording that he played for himself in car (pep talk where he reassured/encouraged self)—"go out there and charm 'em!you're the best damn salesman this company's ever had! flash that smile, they'll love you!"—actually increased tension still effectively made sales—seemed confident but really miserable -last panic attack during Christmas shopping @ department store (always uneasy in large crowds, suddenly felt sick 10 min in/body felt weak, hands trembled uncontrollably, vision blurred, pressure in chest & gasped for breath bc felt like being smothered; apart from physical symptoms, sensation of apprehension & terror) sought refuge in car after fleeing, rolled down windows to let in air, felt dizzy/short of breath for 10 min -1st psychological clinic appointment: dressed neatly in expensive suit (posture, hair all neat), 5 min early, preferred to stand & leaned casually against corridor wall even tho large/comfortably furnished waiting room he portrayed confidence and success even tho overwhelming sense of dread (@ others thinking he's crazy/emotionally unstable) -1st interview was unproductive and Dennis was trying to crack witty small jokes/chatting superficially (ie. "do you have adequate life insurance coverage", being an insurance salesman) reluctant to admit he had any serious problems and intent on convincing psychologist of it, evaded queries about current adjustment -b4 4th treatment session: met psychologist @ location that required them to walk thru waiting room w/clients to reach office reached middle of room & Dennis suddenly clasped right hand around psychologist's shoulders, smiled, said too loudly "Well, Alicia, what's up? How can I help you today?" visibly shaken, over by wall gulping for air w/hand on heart after inside office apologized profusely, didn't know what came over him—afraid that people in clinic/clients would know he's a client and think he's crazy, was uncomfortable so unable to resists the urge to divert attention from himself by seeming like the therapist (PREOCCUPATION W/SOCIAL EVALUATION) -social history timid/shy esp around girls in adolescence, socialized as child but still shy uncomfortable public speaking/social situations but tried to meet new people and overcome by joining drama club in high school and performing (could speak in front of others w/o making fool of self) academic probs (probation after year 1, gastrointestinal probs after year 2) in liberal arts 2-year college—"test anxiety", choked on exams and once he entered testing room, sweaty palms, shallow/rapid breathing, dry mouth; sensitive stomach (avoided rich/fried foods=>nausea, farting), intermittent constipation, diarrhea, cramping married Mary, licensed realtor (long time freshman gf during sophomore year who dropped out when he did bc classes were boring & continuous parental pressure to do well) after living together for 2 years after he landed job position in sales w/insurance company :) for first 3 years but then promotions=>less time for eo; even when free time, spent diff (Mary liked restaurants/parties, Dennis, home/TV) divorced after 3 years of marriage & 2 years after 1st panic attack—Dennis super reluctant to go out w/Mary due to staying home and resting nerves, apprehensive of crowded public places, avoided heavy rush hour traffic or if he must, stayed in right lane to pull out, steered clear of long bridges bc no opportunities to pull over restrictions => tension, irritability, didn't enjoy eo's presence Dennis entered treatment 5 years post-divorce -internal medicine didn't see any evidence of cardiovascular/gastrointestinal pathology nerve problem=>alprazolam/Xanax (high potency benzodiazepine usually for insomnia, anxiety disorders); 2 mg 3x daily for 4 months; =>relax, <gastrointestinal distress but side effects of light-headedness/drowsiness; decreased dosage daily to discontinue it eventually -forced self to meet new people/drive long distances for work -chronic anxiety, panic attacks, headaches, gastrointestinal probs persisted unchanged thru treatment but varied in severity saw friends but avoided large crowds quiet evenings watching TV or playing cards w/1-2 couples w/less social Elaine (met 4 years post-divorce) -came into treatment wanting to control generalized anxiety (esp when it reached excessive heights in infrequent panic attacks) medication seemed like "artificial crutch" and wanted cognitive-behavioral approach therapist saw problems as interaction between vulnerability->stress + cog/behavioral responses that maintained/exacerbated that stress ie. perceived theatre dinner to be stressful, traumatic event=>avoided/feared chance of another panic attack, where the avoidance was maintained by cognitive distortions about future events/interactions w/others; communicated this conception and Dennis became less defensive & dropped annoying, superficial displays of bravado maladaptive self statements: "I gotta be the best salesperson at the firm so catastrophe/I would be a failure if someone doesn't like me" taught appropriate ways to think about/cope w/ environ applied relaxation training (not to eliminate panic attacks bc controlling still wouldn't improve his adjustment, so wanted to find area of potentially rapid improvement for future motivation; focus on inability to relax when back @ apartment after work; coping skill to control muscular tension; practice @ home for weeks bc developing relaxation skills takes time; began during 6th treatment session—tense/relax muscle groups (ie. fists, then hold for 5s) in recliner, attend->breathing patterns (deep, slow); felt awkward/self-conscious but overcame the apprehension, felt more relaxed and looked forward to practicing this procedure), cognitive restructuring (emotions/feelings influenced/mediated by what people say->self and not just->objective situation; challenged catastrophic thoughts, substituted realistic/evidence-based reasoning)=> situational exposure so didn't avoid situations in which he feared another panic attack (hadn't experienced in 3 months bc refused to accompany Elaine->movies, restaurants, department stores; in vivo (natural environ) by purposefully entering apprehensive/dreaded situations and remain there until proved->self that would not have panic attack; he now had the skills and could cope!) 10-point subjective rating scale for the relaxation training (1: completely relaxed, like quietly drifting off to sleep, 10: max tension, like when client won't buy policy); avg self-rating 6-7 b4 practice, 3-4 @ end and eventually->1-2, hopeful outlook not most effective when severe levels of stress/headaches, and also intended to let Dennis be aware of muscle tension b4 it progressed->advanced level (PREVENTATIVE PROCEDURE, not coping) anxiety-inducing cognitive distortions like "probability overestimation": tendency to overestimate probability of negative event occurring; "catastrophic thinking": tendency to exaggerate consequences of negative events (ie. some event will be devastating instead of just unpleasant but tolerable) Dennis didn't realize/unaware that he was engaging in cognitive distortions bc deeply instilled, overlearned => automatic examined audio recording pep-talk related->anxiety w/clients—statements set unrealistic expectations/demands that exacerbated problem (ie. reassurance that client will like him bc he's the best there is) realize that success/failure if career isn't dependent on 1 client interaction eventually recognized that negative events like being turned down by client was manageable/short-lived practice the generalized skill of adaptive self-statements as coping response b4/during stressful experiences by jotting down in daily diary entry an anxiety-provoking situation & distorted thought/self-statements @ time of experience; after 4-weeks, less anxious in social situations/sales visits Elaine present to make him feel < vulnerable, go->department store & browse men's section on early weekday morning hierarchy of stressful situations for exposure for increasing amounts of time (eventually attending play & sitting in the middle of the center row so no access->exits/aisles) -lots of progress in the 6 months of treatment! Mastered all situations in hierarchy, no panic attacks, decreased general anxiety levels, no insomnia (used tension-relaxation technique as distraction too!) -tension headaches after busy day but less frequent (2-3/month)/severe, intermittent constipation/diarrhea that needed meds on ad hoc basis

Evolutionary Perspective of Emotion

-is there an evolutionary/adaptive advantage to these decapacitating levels of sadness/anxiety/negative emotions? -sadness: response->loss of "reproductive resource" (partner, relative—we are social animals and this is the cost/risk; health, job, reputation), separation; protecting us from further losses -generally, negative emotions (esp anxiety) are response/anticipation->threats to protect us from danger/further harm/pain (ie. exclusion from group, submission after losing struggle for dominance) -defense or dysfunction? -continuous mood distribution -consider diff levels of analysis (systems approach) and overlap of symptoms -consider influence of stressful life events, biology/genetics, psychological factors (bio psychosocial)

Case Study: Schizophrenia w/Paranoid Delusions (Bill McClary)

-peculiar behavior (daydreaming, talking to self in nonsensical way), social isolation noticed by sister Colleen; Colleen's husband actually worried about Bill's influence on their kids -Bill was resistant against getting psychological help even tho acknowledged that he needed to have better hours and be more responsible -1st interview w/therapist: talked quietly, hesitated, blinked/shook head as if re-concentrating or clearing his thoughts; when these twitches were brought->his attention, he denied them but apologized -wanted to fit into Colleen's fam's routine better by stopping daydreaming and be more organized -guarded -concern about sexual orientation (gay?)—few close friends but limited/fleeting sex life questioned his motivations to have sex w/men—desire to be closer->father? goal is the quality of the sexual relationship and not preventing future sex w/men (arbitrary choice bc of sexual norms) -concern about daydreams and how they interfered w/daily life -irregular but frequent intrusive/repetitive thoughts that went against his value system (ie. "Damn God"); recognized that these were unacceptable => compelled to repeat self-statements/incantations ("scruples") designed to be corrective (heard as mumbles) (associated w/blinking/headshaking) -extensive, pervasive, intricate delusional belief system brought to notice by brother in law Roger (which Bill was reluctant to share): after moving in w/Colleen, noticed that people took an interest in him and were talking about him behind his back; not able to be refuted (ie. no coincidences) anxious/suspicious flash of insight in front of TV: belief that group of conspirators secretly produced/distributed documentary film about his sexual encounters w/other men (HS friends/relatives had hidden cameras/mics), which appeared on the cover of Time, and which engrossed $250 million @ box office that was sent->Irish Republican Army to buy arms/ammunition so he was responsible for the deaths of ppl in bombings (=>guilty) (parents were 1st gen Irish Americans, relatives mostly in Ireland, Irish heritage was important esp in childhood) believed that conspirators agreed to kill him if found out about the movie (imagined threat=>feared for life) so could not confess imagination (met cousin (who must have been continuous surveillance put in place by conspirators) on Brooklyn subway 2 years ago and why would this happen if not making film about his private life?) (elevator operator in mom's apartment gave him a prolonged, puzzled glance and asked if they knew eo—insistence that the only logical explanation was that he had seen the film) & reality (said the secret film was called same name, Honor Thy Father, as the organized crime novel (which he insisted he was unaware of) written by Gay Talese, who was his character name)—alluded->disrespect for father, reputation as "gay tease" lived in fear/brooding about the plot, felt helpless to prevent distribution of his shameful sex life -heard frequent but unpredictable voices (males discussing his sexual behaviors, arguing how to punish) alone in bedroom but overheard argument in next room about how he's gay and needed to be killed (2 others asked about what he'd done and were against violence)=>he was motionless and terrified; when Roger came, he thought he was going to be taken away; only 2 children were asleep in next room -parents frequently fought and had no signs of wanting to repair relationship (esp since harsh/distant father had extended affair; closer w/mom) guilty about hating his father instead of respecting, emulating his father ambivalence & regret about wishing his sick father would die when he was 12 -clumsy, few friends, preferred to be alone child (hung out w/mom, cousins, neices/nephews) -graduated top of HS class but became bank clerk instead of college bc choosing profession=ominous task and needed time to ponder but quit after 2 years bc not enough time to make a career decision superiors said he was reliable but eccentric (polite but quiet/reserved to the point of being socially withdrawn and didn't speak/associate w/other employees other than pleasantries so could not advance up/get promoted) 1st sexual experience a year into working at bank—primarily anxiety provoking, w/40 y/o man who did biz @ bank continued to have, only 1 relationship lasted beyond days, always his partner took initiative casual fling w/Patty (divorced, 3 y/o daughter, spent time watching TV/drinking wine @ her apartment) -elevator operator aloof, disorganized but appeared neat/clean, peculiar according->residents @ apartment (seemed preoccupied and forgot floor numbers, mumbled) fired after a year, moved in w/mom which made him anxious/tense and daydream in front of TV, which made mom prompt him to sigh up for job-training programs and not be so socially isolated -schizotypal personality disorder (delusional beliefs, hallucinations, peculiarity (anhedonia: inability to experience pleasure (ie. detached, intellectual sex "I performed well"), interpersonal aversive ness (withdrew->room when Colleen threw party), ambivalence (punctual and dependent on therapist but guarded/fearful of imagined consequences/distrustful) w/o psychosis) schizophrenia-thought insertion & cognitive distraction -cognitive-behavioral therapy w/o meds bc didn't confirm the severity of his psychosis developing skills for social/sexual relationships -beginning therapy: tense, reserved, suspicious so therapist needed to est. trustful relationship thru passive/non-directedness eventually actively identified problems, like daily schedule (w/Colleen's help, integrated his daily activities (on a more regular schedule, more helpful around house)->her family's routine (reinforce appropriate behavior, ignore inappropriate)), mumbling (functional assessment revealed that most frequent when thought he was/actually was alone, where he would excuse himself to reduce anxiety if distracted by disturbing/irreverent thought; unlikely maintained by social reinforcement bc Colleen reminded/scolded him; stimulus-control procedure to restrict environmental stimuli for these asocial behaviors->secluded laundry room location in house for scruples/daydreams so reduce freq (did not eliminate his scruples entirely)), lack of social contacts (rehearse/practice phone calls/convos so can reconnect w/NYC friends & Patty nonanxiously by exposing him->anxiety-provoking stimuli; possible sources of friends (tavern, Colleen's parties); moderate success (called Patty and visited her when stayed @ mom's apartment=>animated, optimistic)) atypical/2nd gen antipsychotic meds: Risperdal (risperidone) (this is literally schizo) upon hearing about auditory hallucinations & movie (behaviors supervised by Colleen and not dangerous)=>reduced self-talk over 4 weeks (intrusive thoughts disappeared), delusions despite encouragement to consider rational evidence ie: dispel belief that his movie was on cover of Time go->public library, check all issues of Time in last 8 months convinced self that conspirators saw him going->library and switched magazine covers b4 he could see the og (stubborn resistance) became < adamant, possibility that this was his imagination (admitted that evidence was lacking)—still suspicious but the fear of surveillance & threat of death < imminent

Interpersonal Factors & Depression

-poor interpersonal conflict resolution/problem-solving may make tough situations worse -do depressed people have a negative effect on others?

Treatment of Depression

-short-term: psychotherapy/psychological intervention Cognitive-Behavioral Therapy (CBT) & Interpersonal Therapy (IPT) equally effective—65% (2/3) recovered after 11 weeks treatment in primary care facility Social Rhythms Therapy (Cognitive Therapy & encouraging bipolar patients to regulate patterns of behavior across weeks) ie. don't fly->Hong Kong bc fly over time zones and disrupt sleep schedule (check travel schedules) -Meds (ie. SSRIs for MDD, lithium/anticonvulsants bipolar disorder) -combine psychotherapy & meds for anxiety disorders -Electroconvulsive Therapy (ECT) if don't respond -> psychotherapy or meds; treatment refractory period

Case Study: Major Depressive Disorder (Janet & her 5 y/o Adam)

-sleep pattern difficulties 1 week after Janet withdrew: irregular bedtimes, waking up @ irregular intervals throughout night and went downstairs to be w/Janet, who=>argumentative as her tolerance wore down, still gave in to his demands to sleep in her room -when discussing Adam, Janet was overwhelmed (teary-eyed, voice breaking) felt that she was NOT in control -depressed mood, sad, lonely, discouraged since divorce and esp in morning when she thought she couldn't make it thru day; preoccupied/spent considerate time brooding over events leading up->divorce; blamed self (her selfishly returning->school strained relationship, but she was illogical when cited examples of her misconduct as wife, which were out of proportion and attributable->diff interests/personalities and not failures (which were common/expected diffs between men/women—efforts to point out imperfections in marital relationship (ie. personal habits) to work on them, not the same enthusiasm for sports, spending on clothes) but resented David generalized marital failures->failures in all other social relationships ("what is my value as a friend/mom?" "how will I ever have a satisfactory relationship w/another man?"—bleak perspective) severified after withdrawing from uni 1 month post-divorce bc trouble concentrating on lectures/assigned readings; grew pessimistic when no longer on student-aid, had to pay student loans in a month going for walks/playing w/kids no longer relieved her—she was desperate, cried frequently and for long times lost interest in friends (neighbor was aloof/didn't enjoy her company, found excuses to hang up), children were a burden, causal reading=chore, no hobbies bc no time -Janet & parent training group: applicants routinely screened thru interview when Adam was 2, Janet did part-time college so that she could finish her Bachelor's at the end of next sem and go into law school—had to withdraw 1 month before Adam's appointment so her plans were indefinite financial concerns but supplemented w/student loans, grant-in-aid from uni, divorce settlement, child-support payments from divorced husband David -not optimistic but still wanted to be effective parent -socially reserved as child/HS (1-2 close friends but felt awk/self-conscious otherwise) (dated but did not settle on long-term til jr. year of HS, which broke the first year of college—did she marry David hastily to fill this vacuum?) she withdrew from uni the 1st time bc of pregnancy, resorted to being housekeeper/mom for next 7 years -when Adam could go->daycare, she returned-> school so David had > household responsibilities (on top of already unstable relationship) couldn't adjust/communicate=>escalating hostility (then David met the other woman, an alternative) -shaken by divorce and openly confided in neighbor for support (more enduring than the 2 couples she socialized w/w/David, who weren't as close) gained weight middle child sick b4 her midterms=>mood worsened bc worried about health of child, lost studying time/missed classes (had to withdraw so not failing) -Problem-Solving Approach to correct her passive, ruminative responses: relationship w/David did not meet needs but was important way in which she thought about herself (her role as wife) enduring improvement in mood depended on success in forming relationships/expanding herself, learning parenting skills to foster maternal role encouraged to ACTIVELY engage w/environ 1) list all activities she enjoyed (attention shift from unpleasant things she was preoccupied with) mostly things she stopped doing when re-continued school, things she didn't think she would enjoy now: riding horses ($$$, time-consuming) talking->friend over coffee (Susan unavail) listening->music late @ night after children were asleep walking in woods behind house ambivalent but prodded to choose something to do @ least twice, chose walk in woods found part-time job @ local riding stable when asked about campus riding club (ride w/o charge/time limitations, as long as fed/exercised the horses)=>improved mood (still depressed when home but looked forward to work) bc could send Adam->part time daycare again 2) social interactions: choose situations where she could meet someone she would be interested in becoming friends w/, initiate/maintain convo by asking ?s consecutively practiced/role-played social interactions -setback: discontinued financial aid=>can't cover monthly mortgage payments (bank notice threatening to foreclose her mortgage & sell house) apathetic, lethargic, cried, pessimistic outlook suicidal ideation but not lethal (DIDN'T want to die, no plan (after suggestive "that's a good way to kill yourself" from mechanic @ service station when she was getting gas and exhaust fumes were from cracked muffler)—frightened by intrusive thoughts, looked for distractions -fluoxetine/Prozac (antidepressant), 3x/week appointments improved mood after 3 weeks, no suicidal ideation, > talkative, resumed normal activities solved finances when her father provided assistance (surprised and dismayed that she didn't ask before) re-est. friendship w/Susan after social skills, widened socials w/riding stable -set firm limits on Adam's sleep schedule/manipulative behavior (she was inconsistent w/responses->his demands, which reinforced his inappropriate behavior offer drink, tuck him in own bed, leave immediately => Adam slept w/o interruptions, a rapid success that made Janet feel in control and she enrolled for parent training program, improved children-relationship -therapy discontinued after 9 months, planned to return->school, date w/man from work, kids were healthy, kept house, kept taking meds

Stress & Physical Health

-specialized related fields: Health Psychology, Behavioral Medicine (not just clinical psych) -causal models from stress->physical health/illness has mediator of health behaviors in middle NOTE! stress can directly (suppress immune functioning) or indirectly (poor health behavior) cause physical illness

Martha (Filipino Immigrant) w/Major Depressive Disorder

-stressful life event of moving->US -symptoms? trouble sleeping fatigue, lack of energy weak, trembling arms/bones walking in street feels EMPTY, felt lost and didn't know what to do no appetite (sour, can't taste food) shout in pillow bc if not, going crazy -cross cultural differences: aspect of shame in seeking mental health help doctor said to go->psychiatrist but didn't go, just asked for sleeping pills

Common Elements of Suicide (Edwin Schneiderman 1996)

1) intent on ending life (feeling ceaseless psychological pain so they see it as a solution->a helpless problem; can be frustrating but this is not being irrational) PURPOSE: seek solution GOAL: cessation of consciousness STIMULUS: unbearable psychological pain EMOTION: hopelessness COGNITIVE STATE: ambivalence PERCEPTUAL STATE: constriction *"blinders": the only thing that makes sense; can't see self the way outsider does gotta keep talking->them, keep them working on solution until blinder come off

Methodological Difficulty w/ Childhood Abuse/Neglect

1/3 African American, 2/3 Caucasian, minuscule Asian/Latina = representative of St. Louis pop. okay "just check city/court/treatment facilities (ie. where abused child may be placed)/medical (ie. physicians checking child for bruises) records" OK ACCESSING IS HARD ENOUGH BC NOT NATIONALLY PUBLIC LIKE NEW ZEALAND; still good to see if match up w/self-reports (records/self-reports DON'T always agree—MOST FREQUENT DISCREPANCY IS UNDERREPORTING THINGS OF THE PAST, NOT REPORTING SOMETHING NOT IN RECORD) -Demeeden Study in New Zealand is government funded, large representative sample (w/age cohorts), complete national records (school, court, family reports from birth) racial bias in reporting->authorities ie. neighbor witnesses but biased against fam so report as abuse racial bias in convicting even if you get ahold of records, just as flawed as self-reports! 60 y/os taking the Childhood Trauma Questionnaire what can we believe? memory&cognitive decline w/age (forgetting/false memories => over/underreporting) (ie. early onset dementia) maybe reluctant to report abuse if parent died maybe report/not based on current relationship w/parents if alive or align w/how they view their parents now (ie. report adverse events if relationship declined/maintain @ bad state but steer clear if relationship improved/maintain @ good state) Personality: high neuroticism/low agreeableness— > sad/depressed, resentful/angry so likelier to report abuse

Epidemiology of Suicide

10-12 in 10,000 in US (stable rate for many decades), recently 15/10,000 in US (CDC), 10.5/10,000 (WHO; worldwide) highest rate of 22/10,000 in US during 1930s Gr8 Depression 2016: 10th leading cause of death in US, part of the third that's increasing w/Alzheimer's & drug overdose highest rates among those experiencing crisis, violence, abuse, loss/isolation, discrimation ie. Robin Williams (1951-2014) diagnosed w/Bipolar Disorder & Parkinson's (weeks b4 death; last straw)

Panic Disorder

4+ panic attacks, w/symptom onset that MUST PEAK IN 10 MIN: palpitations, sweating, trembling/shaking, sensations of shortness of breath, feeling of choking, chest pain, nausea, dizziness, fear of losing control/going crazy, numbness/tingling, fear of dying, derealization/depersonalization, chills/flushes

George Brown's Prospective Study: Stress & Depression

400 Camberwell, London working class women in the community, not currently clinically treated (18-50 y/o) Structured Diagnostic Interview @ baseline then 1-year later about work life, family life, neighborhood life why women? higher rates of depression find women through Census records cover story: "we're doing women's health study and will pay you" experiences w/symptoms can help diagnosis @ baseline: 303 not depressed 1 year @ follow-up, 130/303 previous experienced major stressful event in previous year, 22% of which became depressed 173/303 did not experience stressful life event, 2% depressed -Conclusion: experiencing major stressful life event increases risk for depression nature of stressful events that => greater risk for depression: EVENTS THAT MATCHED PRIOR DIFFICULTIES/COMMITMENTS WERE LIKELIER TO => DEPRESSION counterex of NOT matching: @ baseline, "I hate my job but have to work to get by" @ T2, lost job, considered less important vs. "my husband and I aren't getting along" (previous difficulty that is matched)=> "my husband and I are divorced" 29/32 women who became depressed experienced stressful life event but 78% who didn't experience stressful life event DID NOT become depressed

DSM-5 Criteria: Major Depressive Episode

5 or more symptoms in a set in the same 2-week period, must include one of first two NOTE! pervasive, persistent -depressed mood for most of the day, nearly everyday -markedly diminished interest/pleasure in all/almost all activities (anhedonia) -feelings of worthlessness, excessive/inappropriate guilt -diminished ability to think/concentrate, indecisiveness -recurrent thoughts of death/suicide, suicide attempt, suicidal ideation (specific plan to take one's life) ———cognitive symptoms -significant weight loss w/o dieting, weight gain, persistent change in eating habits -in/hypersomnia nearly every day -psychomotor agitation (can't sit still, pacing)/retardation (sitting w/o moving, SLOWED SPEECH, can't tell if paying attention->you) that is observable by OTHERS -fatigue/loss of energy nearly every day -if ONLY experience depressive episodes, depressive disorder if depressive episodes AND mania, bipolar disorders

Genetic Factors of Anxiety Disorders

8-20% across studies, 1st-degree relative had high rate of panic disorder, and if this is so, those related have high risk of panic disorder but NOT GAD relatives of GAD patients @ risk for GAD and NOT panic disorder GAD is influenced by genetic factors, familial, but nongeneralized GAD is not very influenced by genetic factors relatives of OCD patients @ risk for ALL anxiety disorders, esp GAD

General Symptoms of Panic Attacks (NOT the disorder)

> focused than anxiety sudden, overwhelming experience of terror/fright escalates AND dissipates quickly "false alarm" (Dave Barlow): normal major/intense fear response triggered @ inappropriate time ie. pedestrian crossing busy street in middle of traffic and giant bus bearing down on you/animal chasing you/about to fall off cliff=>fear Evolutionary POV

Cross-Cultural Diffs in Expression of Symptoms of Depression (Universal)

Arthur Kleinman East Asia (Taiwan): somatic symptoms Western: cognitive/emotional

Harkness & Monroe's Diagram of Stress Exposure & Stress Response (Conceptual Model, 2016)

Assessing & Measuring [Occurrence of] Adult Life Stress (major life events or daily hassles) Stress Response in center, affected by Stress Exposure (affected by major life events, daily hassles, chronic difficulties), Neurobiological (Sympathetic Nervous System, HPA Axis, Genetics, Immune System), Psychological (Personality, Coping, Cognitive Style), Behavioral (sleep/wake, diet, activity), Environmental (prior/other stress exposures) Stress Response <->Illness Outcome

Etiology/Causes of Specific Phobias

Behaviorists attribute->learning processes (ie. Pavlov's Classical Conditioning where CS (ringing bell) paired repeatedly w/UCS (meat powder) for eventual CR=UCR (salivation) alone; objects not naturally the source of fear can be learned due->negative experiences Little Albert (John B. Watson in 30s): supposed to show learning a phobia of white fluffy/furry things due->classical conditioning pair CS (holding white furry) w/UCS (loud sound like a hammer smashing) => CR (generalized fear/phobia of white furry) soo exaggerated—not replicable SHOWS NOT PHOBIA BUT A STARTLE RESPONSE->LOUD NOISE analog study can be developed but Albert's crying in presence of white furry doesn't show phobia bc no avoidance! okay obvious human subjects committees MIA

Biopsychosocial (diff levels of analysis) Etiology of MDD (development/maintenance)

Bio: HPA axis Genetic Vulnerability Brain Function/Neurochemicals Psycho: Info-processing Bias Rumination Personality COGNITIVE DISTORTIONS Environmental: stressful life events lack of social support

Conceptual Model Linking Personality->Health (SPAN Study)

Biological/Psychosocial Pathways (Integrative Framework) (Change in) Personality can be due->Early Adversity, can lead -> Health Behaviors, On-going Stress, Social Integration, which each => Health Outcomes (Subjective Health, Self-Report of Medical Disorders) On-going Stress=>Cortisol, Inflammation, Telomere Length

Danish Twin Study (one of firsts for Mood Disorders) by Axel Bertelson (1977)

Bipolar Probands: higher discrepancy of concordance rates between MZ/DZ pairs—GENETIC factors are more SALIENT in BIPOLAR? (50% vs. 30%) MZ 69% > DZ 19% Unipolar (major depression w/o manic episodes) Probands: MZ 54% DZ 24% NOTE! these are concordance rates, ie. this type of twin pair is concordance (proband & his co-twin both have disorder) for this disorder -Why Denmark? genetic homogeneity in pop., generally happier (eliminate environmental factor maybe) so mood disorder rate should be lower, PSYCHIATRIC RECORDS NATIONALLY AVAIL (go->birth registry, ask for MZ/DZ births between certain dates, approved for research, cross-reference these records so that if sought psychiatric help and received treatment for mood disorder, you'll know!) wb those who meet criteria but don't receive treatment? if we stray from these health records, would the rates look diff? NOTE! zygosity depends on blood samples

Treatment for GAD

CBT meds: SSRIs, benzodiazepines new one to target avoidance of emotion: interpersonal/emotional processing therapy, mindfulness based CBT for GAD emotion regulation

Treatment of Social Anxiety Disorder

CBT: cognitive restructuring, social exposures (like how in fear-hierarchy, move toward more feared situations) w/pre-exposure planning

Causal Factors for the Development of OCD

David Barlow's Conceptual Model: genetic predisposition toward negative emotional experiences (ie. sadness, anxiety, anger) or personality psychology (neuroticism) learning experiences where a belief is formed when a thought is associated w/being bad, unacceptable ie. religious family teaches you that thoughts about violence, sex, religion are bad (ie. eternal damnation) EFFORTS TO SUPPRESS THOUGHT (STRUGGLE AGAINST) ACTUALLY EXACERBATE (stronger, harder to avoid bc bringing->mind) Dan Wegner & Ironic Effects of Mental Control "try not to think of a white bear" bogus questionnaires bell on table that you ring when you think of white bear

TABLE 8-2 IN OE8

Different Reactions->Same Life Event serious physical illness => 47.2% large amount of change, 27.8% moderate, 8.3% little. 16.7% none relations w/mate worsened => 41.2% large change, 47.1% moderate, 0% little, 11.8% none

Ch 5 Research Method: Analogue Studies

Does prolonged exposure->uncontrollable stress CAUSE anxiety disorders? in controlled lab setting w/human subjects, ethics committee boards will come after u unless correlational study w/anxiety disorder patients ie. no random assignment to endure stress/conditions hypothesized to produce fullblown disorders CAN ONLY STUDY ANALOGUE CONDITIONS/BEHAVIORS SIMILAR->/RESEMBLING CLINICAL DISORDER/isolated features of mental disorders in the natural environ animal models (of etiology) of psychopathology ie. Harry Harlow & rhesus monkey infants (develop despair response upon social separation from mom) somatic symptoms: facial/vocal displays of sadness/anxiety, social withdrawal, changes in appetite/sleep, psychomotor retardation (like clinical depression) w/> extensive experience w/peers/adults, < likely depression upon separation (skills learnt through social exploration allow coping) use social separation model to find neurochemicals affected by antidepressants ie: rats subjected->uncontrollable, inescapable stress (ie. swimming through cold water) demonstrate somatic symptoms/behavioral features of our clinical depression (ie. withdrawal, trouble sleeping, loss of appetite) maybe these behaviors are rat, not human depression -cognitive symptoms (ie. Beck's depressive triad) can't be measured/modeled w/animals ie. guilt? hopelessness? suicidal ideas? -successful modeling hinges on degree of similarity between animal analogue & actual clinical disorder/how well results generalize beyond the lab (do similar mechanisms produce maladaptive behaviors/clinical disorder in the natural environ? USE CONVERGING EVIDENVE FROM MULTIPLE RESEARCH DESIGNS) -ADVANTAGE: CAN EMPLOY EXPERIMEMTAL PROCEDURE!!!!! (infer about cause/effect)

Specific Phobia Treatments

Exposure Therapy makes use of Fear Hierarchies (starting w/least threatening exposure (ie. think about spider)->most ito fear ratings (ie. let tarantula crawl on arm)) Behavior Therapy (desensitization) -imagination, VR -observation/viewing -touching/experiencing

Intergenerational Similarities in Abuse/Neglect (SPAN Study)

Gen 1: participants of SPAN study (65-74; 55-84 when started study) Gen 2: children (now YA) Gen 3: grandchildren of G1 used CTQ (Childhood Trauma Questionnaire) scores of G1, comparing -> G2, where both gens filled out questionnaires independently (months/years apart) & no consultation between what was reported G1 reported their experience w/G0, G2 reported w/G1 parents G2 scores for emotional abuse (ie. verbally berated, harshly punished)—G1 reported physical abuse, likelier for sexual abuse, emotional/physical neglect INTERGENERATIONAL TRANSMISSION OF ABUSE/NEGLECT @ level of self-report @ least (mostly overlap of physical/emotional abuse/neglect than sexual abuse—for sexual abuse, G2 who were sexually abused had G1 parents sexually abused but not emotionally abused/neglected, for ex.)

DSM-5 Anxiety Disorders

Generalized Anxiety Disorder (GAD) Panic Disorder Agoraphobia Social Anxiety Disorder Specific Phobia NOTE! OCD/PTSD split into own chapters (considered anxiety disorders in DSM-III/IV!

Help for OCD

International OCD Foundation founded by OCD patients + Wayne Goodman (1986) behavioral therapists Behavioral Medical Institute in STL is leading treatment facility for OCD (intensive daily treatment for 2 weeks but not institutionalized)

Treatments for Panic Disorder

Interoceptive Exposure: deliberate exposure->feared internal situations CBT: targeting catastrophic thoughts which have become automatic Psychoeducation Benzodiazepines but relapse is frequent after discontinuing 70-90% recover

Childhood Abuse/Neglect => Poor Health/Subsequent Illness

LIFETIME ADVERSITY, 1 DOMAIN OF STRESSFUL LIFE EVENTS -categories: parental separation (divorce, depression) family poverty witnessing domestic violence bullying emotional/physical abuse, sexual abuse emotional/physical neglect

Measuring Stressful Life Events: Social Readjustment Rating Scale

List of potentially stressful life events... ie. death of one's spouse (100 life change units—how potentially stressful), divorce, marital separation, jail term, death of close family member, personal injury/illness, marriage, fired @ work, marital reconciliation, retirement, change in health of fam member, etc. change in recreation (19 life change units), change in church activities, change in social activities, mortgage/loan of <$10K, change in sleeping habits, etc. which events are checked/how were they rated? individual diffs in ratings (ie. if rough marriage, divorce might be relieving instead of stressful)

MDD vs. Bipolar Disorder (Same continuum?)

MDD: later onset (mid/late 30s), more prevalent in women (2-3x), responds->tricyclic antidepressant drugs, SSRIs no manic episodes BD: earlier onset (20s for first episode), equally prevalent, responds->lithium carbonate (for the mania) general consensus: different, own chapters under mood disorders, respond->diff pharmacology bc diff substrates, twin studies/genetics In Twin Study... 21/27 concordant (proband w/bipolar+co-twin too) MZ pairs 19 concordant MZ pairs for unipolar general pop: major depression > bipolar (~2%) if BD=MDD, then expect most of the concordant pairs w/bipolar proband diagnosis would have co-twin w/MDD diagnosis but not what's found! co-twin has bipolar too! if you really wanna make sure these are separate disorders, gotta follow twin pairs over lifetime to ensure than the major depression ones don't even develop manic episodes Conclusion: genetic factors distinguish BD from MDD

"Normal Obsessions" (Rachman 1978)

Modsley Hospital in London: 100 OCD OutPatients, 100 staff/orderlies from 16-50 y/o, 1/2 women asked about presence of intrusive, unacceptable thoughts/impulses (ie. violence, sex, religion for normal ppl too) ie. wow this person is making me angry I have an impulse to shove them but doesn't mean you will total: 84% yes—NO DIFF BETWEEN GROUPS, minimal content differences CLINICAL SAMPLE JUST HAD THEN > FREQUENTLY, LONGER DURATION, STRUGGLED HARDER AGAINST THEM (associated w/corrective efforts)

Lifetime Prevalence of Mood Disorders

NCS-R: large, representative sample of community residents (not just clinical) MDD: 16%; 25% for women Persistent Depressive Disorder: 3% Bipolar I&II: 4% a little more than 20% who met criteria for mood disorder received treatment in past year -mood disorders more common young/middle aged adults & avg age of onset might be getting YOUNGER Birth-Cohort Trend: born post-WWII in recent gens at greater risk to develop depression -risk for mood disorders across lifespan 18-20 y/o: MDD 15% 30-34: MDD 20% 45-59: MDD less than 20% 60+: MDD 10% dysthymia risk is lowest across lifespan BD has decreasing risk

Anxiety/Depression Co-Morbidity (Trans-Diagnostic Emphasis)

NCSR/ECA epidemiology—qualify for 1, likely to qualify for other -defined ito negative moods that you DO have self-knowledge/insight about -triggered/precipitated by stressful life experiences recall that anxiety=response->danger/threat events; depression->loss events (ie. people, job, reputation, home) -respond->similar evidence-based treatments (ie. meds like SSRIs, CBT) Dave Barlow trying to find evidence-based psychological treatments for anxiety

Genetic Risk + Sensitivity-> Stress (Genes/Environ Interact!)

NOT A DICHOTOMY OF 2 TYPES OF DEPRESSION (ie. one caused purely by genes/environ) -Caspi et al. (2003): Figure 5-2 NOTE! not everyone could replicate this finding follow participants over time, interview about stressful life events, genotype 'em based on serotonin transporter 2 gene (short s allele associated w/REDUCED EFFICIENCY FOR NEURAL TRANSMISSION) serotonin=neurochemical transmitter associated w/depression as # stressful life events increases, so does risk of depression (by like 1/2) highest risk for depression if experienced stressful life event is ss, ll risk lowest and doesn't change much, sl medium and increases w/stressful life events 40% of depression onset means 4+ stressful life events in a year -RISK FOR DEPRESSION COMBINES GENETIC PREDISPOSITION & STRESSFUL LIFE EVENTS (ofc genetic factors increase risk but there's no gene for depression) -map of world tells about energy consumption per location but does it explain the phenomenon of global warming? map of brain shows which areas light up but does it tell us about depression?

DSM-5 & Stress

New chapter: Somatic Symptoms & Related Disorders -Somatic Symptom Disorder: no hurry physical explanation for pain, fatigue -Illness Anxiety Disorder (aka Hypochondriasis): preoccupation w/having or acquiring serious illness -Conversion Disorder: altered voluntary motor/sensory function ie. hand paralysis w/o neurological explanation -Factitious Disorder: falsification of physical/psychological signs/symptoms New chapter: Trauma & Stressor-Related Disorders -PTSD: b4 diagnosis, need @ least 1 month of symptoms -Acute Stress Disorder: PTSD symptoms between trauma & 1 month -Adjustment Disorder: "development of emotional/behavioral symptoms in response->identifiable stressor occurring within 3 months of onset of stressor" why are these categories so broad? whatever is self-reported/described by patients is up->practicing therapist's discretion, this acts as guide

Deliberate Self-Harm

Nonsuicidal self-injury, w/o intent to die ie. cutting, burning

DSM-5 Criteria for Panic Disorder

RECURRENT, unexpected panic attacks (sudden, overwhelming experience of fright/terror @ least 1 attack followed by 1 month+ or more than 1 of the following: PERSISTENT CONCERN about having additional panic attacks worry about implications of attack significant change in behavior related->attack

Childhood Trauma Questionnaire

Self-Report, 28-item, 5 scores (childhood emotional/physical abuse, sexual abuse, emotional/physical neglect) Example item: "when I was growing up...I didn't get enough to eat [poverty]; my parents parents were too drunk or high to take care of the family [parental separation]; I felt loved; I felt that someone in my family hated me; someone molested me"

Epidemiology/Prevalence of Anxiety Disorder (NCS Study)

Specific Phobia (most common out of anxiety orders): 1-year prevalence: 9% varying age of onset 3x more common in women than men blood injection injury phobia in ~3-4% of pop. Social Phobia: 1-year prevalence: 8% Agoraphobia w/o Panic Disorder: 1-year prevalence: 3% GAD: 1-year prevalence: 3% Panic Disorder: 1-year prevalence: 2% OCD 1-year prevalence: 2%

DSM-5 Criteria for Hoarding Disorder

Used to be symptom but now own disorder persistent difficulty discarding/parting w/possessions regardless of actual value (perceived need to save/accumulate => congestion/clutter/crowding or else distress) NOTE! compromise intended use of the possession causes clinically significant distress 80% hoarders don't have other OCD symptoms

Disease Burden in Economically Developed Countries (% of Total)

WHO's Global Burden of Disease MDD: 6.8% Schizo: 2.3% Bipolar Disorder: 1.7% OCD: 1.5% Panic Disorder: 0.7% PTSD: 0.3%

DSM-5 Criteria for Agoraphobia

anxiety about being in situations from which escape may be difficult 2+ of the following: using public transportation, being in open spaces (ie. parking lots, bridges), being in enclosed spaces (ie. shops, theatres), standing in line/being in a crowd, being outside the home alone related->situations where he'll might not be available if you develop panic-symptoms AVOIDANCE of such situations (ie. restricted travel) or endured w/distress 80-90% female

Compulsive Hoarding (No longer just a symptom) vs. OCD

are these reluctancies to part w/items similar->obsessions? nah, hoarding thoughts NOT experienced as intrusive or distressing—clutter is distressing hoarding thoughts do NOT => compulsions saving/acquisition associated w/positive emotions when forced to discard possession, experience NOT anxiety but GRIEF

Gender Diffs in 12-Month Prevalence of Anxiety Disorders (NCS Study)

blue: men green: women ANXIETY DISORDERS MORE COMMON IN WOMEN specific/social phobia are the most common anxiety disorders panic disorder/OCD are the least common OCD prevalence: about same in men/women

Ben David (Ozark) & Bipolar Disorder

cab ride in midst of manic episode pressured speech pattern (talking a mile a minute, change topics using "clang" association—words that rhyme, repeating phrases) "you serve in the military?" "you ever have scary thoughts at night?" (ie. killing kid on scooter) "I wake up and think about the guy @ the corner store", repeats "he's just a guy" "much like yourself" "cause he can't" "I would imagine there are days when it's close" "I remember what my mind was before the things happened that ruined my mind" "I remember who I am now" "I'm losing it" "I gotta sleep in the sidewalk by the gun store so I don't kill myself or my wife"

Stress is Challenging Conceptually & Methodologically (Measurement)

challenging event requiring physiological, cognitive, behavioral adaptation activates fight-or-flight response (arousal of sympathetic nervous system)

% of Clinical & Community Samples in CTQ Severity Quartiles (Self-Report Data)

clinical samples: distress=>seeking professional help @ community mental health centers -none: 40% -low: 30% -moderate: 20% -high: 12% community sample: no clinical problems -none: 60% -low: 25% -moderate: 10% -high: 5% STILL HIGH PROPORTION IN COMMUNITY REPORTING CHILDHOOD ABUSE/NEGLECT none (reported [severity of] abuse/neglect), low, moderate, severe

Suicide

death resulting from self-inflicted injury w/some intent to die -immediate predictors: stressful life events (esp interpersonal loss) previous history of suicidal ideation (esp w/mental disorders like depression, bipolar, PTSD) CONNECTEDNESS: -> others (fam, religious communities) or -> purpose/meaning in life (ie. employment, social roles) -motivations social isolation, belongingness physical/1) overwhelming psychological pain 2) hopelessness [that pain can be stopped] perceived burdensomeness (sense that you're a burden->others)

Mood Disorders

defined by EPISODES (distinct periods of time where behavior is dominated by depressed/manic mood)

Bipolar Disorders

depressive + manic episodes unipolar disorder: ONLY manic episodes w/o depressive rapid cycling: cycle right from depressive->manic episode mixed episode: flip flopping -BP-1: @ least 1 manic/mixed episode (usually w/depressive episode) -BP-2: @ least 1 depressive episode w/@ least 1 HYPOmanic episode (***intoxicating how confident/unanxious/productive you are, which is a DISINCENTIVE to keep taking meds) -"BP-III" for research purposes: met criteria for @ least 1 depressive episode (unipolar) but never manic/hypomanic BUT 1st-degree relative w/Bipolar -Cyclothymic Disorder: Persistent Depressive Disorder of Bipolar numerous periods w/hypomanic symptoms, depressed mood for @ least 2 years never w/o these symptoms for more than two months in the 2 years: no major depressive episodes no manic episodes

Preparedness Version of Learning Theory (Phobias)

developing phobias requires learning but NOT thru classical conditioning (conditioned fear responses easily extinguished) humans evolved to fear certain objects/situations (only associate fear w/certain types of stimuli) BIOLOGICAL CONSTRAINTS ON LEARNING (ie. teach pigeon to peck key to get food, flap wings to avoid electric shock, they will NOT learn to flap wings to get food bc wing flapping evolved to avoid dangers @ feet & pecking evolved to get food from ground) *****organisms are biologically prepared (biological constraints due->evolutionary pressures) to learn certain kindsa associations quickly; not any neutral stimulus can be used as the CS prepared associations (ie. phobia after trauma) are learned in 1 trial's time & extinguished quickly ie. Sue Mineka's observational learning of fear in Rhesus Monkeys

Thomas Joiner's Approach->Suicide in "Why People Die by Suicide" (2005)

empirical evidence & personal experience (ie. factors increasing risk for suicide in professional life) cumulative risk! 1) being a burden->individual/group ("perceived burdensomeness") 2) social isolation ("thwarted belongingness") 3) history of acquired ability to inflict lethal self-injury Nonsuicidal self-injury: loosely conceived predisposition to avoid harming self=barrier if you are thinking about ending life but this self-I jury history is like practice to get around feeling the need to protect yourself

DSM-5 Criteria for GAD

excessive anxiety, WORRY (apprehensive expectation) occurring > days than not for at least 6 months about a number of events/activities ie. work, school performance difficulty controlling the worry anxiety/worry associated w/3 or more of the follow 6 symptoms, some symptoms at least present > days that not for the past 6 months: restlessness, feeling on edge being easily fatigued difficulty concentrating, mind goes blank irritability muscle tension sleep disturbance (difficulty falling/staying asleep where it's not satisfying) clinically significant distress/impairment in social & occupational & other areas of functioning

Kendler's Twin Study (Twin Concordance for Anxiety)

genetic risk factors for anxiety disorders neither highly specific nor nonspecific GAD/MDD highly influenced by genetic factors panic disorder & phobias too environmental risk factors specific->individual too disorder-specific environmental factors found for phobias

Clark & Watson's Model (Anxiety/Depression Relationship allowing for distinction/overlap)

global personality dimensions -2 Dimensions of Mood/Affect: (+) high=energetic low=tired descriptive adjs: delighted, interested, enthusiastic, proud (-) high=upset low=relaxed descriptive adjs: sad, angry, guilty, afraid, disgusted, worried maybe related->high neuroticism orthogonal dimensions) (not continuum from negative->positive affect) *****depression (LOW POSITIVE AFFECT: loss of interest, fatigue) & anxiety (ANYWHERE ALONG POSITIVE AFFECT AXIS: could have high levels of physiological arousal (ie. heart racing, sweating, respiration rate increases)) BOTH have HIGH NEGATIVE AFFECT, difference in positive affect

Cognitive Factors Maintaining Panic Disorder (Sanderson & Barlow)

hypothesis: ppl who believe/perceive that they're in control are less anxious/less CO2-induced panic directly against biological reductionism, which denies psychological factors in panic disorder in lab, induce panic attack by breathing in CO2-enriched air through mask (pre-IRB/ethics committees) take 20 people (small sample) who've already experienced panic attack, random-assignment, get them comfortable & alone in lab room, amp up the CO2 to increase P(another panic attack) (dependent measure) MANIPULATE PERCEPTION/ILLUSIONOF CONTROL! control knob/dial on wall w/wire (did nothing) that can control amount of CO2 air mixture when green light was on EVERYONE breaths the CO2-enriched air for the same duration control group: 8/10 panic attack experimental group w/illusion of control: 2/10 had panic attack BIOLOGICAL FACTORS STILL MATTER (all breathing the same mixture of air so panic attack was due in part to what they're breathing; CO2 passes blood-brain barrier) BUT INTERACT W/PSYCHOLOGICAL FACTORS

Stress Exposure (->EXTERNAL life event that MIGHT elicit stress response) vs. Stress Response (INTERNAL response)

ie. major life events like lived thru flood, car accident, death of soloists, divorce, getting fired vs. ie. anxiety, neuroendocrine responses, overall arousal ie. fearing public speaking isn't due->physical danger usually but self-talk like "they'll think I'm dumb and won't like me"

Stress & Discrimination (LIFETIME ADVERSITY, CHRONIC STRESS)

ie. racial health disparities (onset/maintenance) James Jackson (Director of Institute for Social Research @ UMich) & Everyday Discrimination Scale: broadly based questionnaire Lists 7 areas/domains in life of discrimination: "think of experience ito access->the below, have you experienced discrimination in any/all of these areas?" -basis of sex, race, gender identity (ie. women), sexual orientation, religion, age (ie. forced to leave job early), weight etc. (MOST COMMON REPORT OF DISCRIMINATION ON BASIS OF RACE) -domains: education, housing, healthcare, employment, service @ restaurants/stores, treatment by police

Inappropriate Guilt

ie: delivery man hospitalized for depression dropped out of HS but faked to land/get hired for the job 15-years valued employee w/spotless performance but thought should be fired bc lied->company—"I should go-> front desk and turn myself in"

DSM-5 Criteria: Manic Episode

kinda opposite of symptoms of depressive episode -distinct period of elevated, expansive, irritable mood; abnormally/persistently increased goal-directed activity and energy -lasts at least 1 week, present most of the day, nearly everyday -at least 3 of the following (4 if mood=irritable) inflated self-esteem, grandiosity (grandiose delusions possible) "flight of ideas" (subjective experience that thoughts are whizzing by/racing that your speech can't catch up) increase in goal-directed activity (socially, work-wise, sexually) or psychomotor agitation excessive involvement in activities w/high potential for painful consequences (ie. sexual indiscretion, unrestrained buying sprees, risky business investments) ie: taking out all of life savings @ bank (poor judgment) for gambling in Vegas decreased need for sleep pressured speech (very talkative) distractible (attention easily drawn->irrelevant external stimuli; disrupting flow of thought/speech) significant distress/impairment

Prevalence of Anxiety Disorders

life prevalence 12.1% like 1/10 in general pop. 12-month prevalence: 6.8% higher rates in women: 15.5%, 11% men early age of onset: childhood->mid-adolescence

Epidemiology of OCD (NCSR Data)

lifetime prevalence: 2.3% 1-year: 1% (like schizo) AFFECTS BOTH GENDERS EQUALLY co-occurs w/anxiety disorders, mood disorders accounts for significant portion of total disease burden worldwide (4th leading cause after depression, schizo, bipolar) Onset: adolescence, early adulthood (ie. hoarding in elderly)

Prevalence of GAD

lifetime prevalence: 5.7% median age of onset: 31/33 GAD & MDD correlation: 0.59-0.70

Persistent Depressive Disorder (Dysthymia)

longer duration, less severity/intensity, chronic lifetime prevalence: 3% depressed mood for AT LEAST 2 years, never w/o these symptoms for more than 2 months in those 2 years: NO manic/hypomanic episodes -two or more of these symptoms low self-esteem poor concentration, difficulty making decisions feelings of hopelessness poor appetite in/hypersomnia low energy/fatigue

DSM-5 Criteria for Social Anxiety Disorder

marked/persistent fear of one or more social situations where person is exposed->possible scrutiny (social interactions, being observed, performing in front of others) fear of acting in a way/showing anxiety symptoms that will be NEGATIVELY EVALUATED (ie. humiliated, embarrassed, rejected) social situation almost always provoked anxiety/fear =>avoidance or endure w/distress fear OUT OF PROPORTION w/actual threat posed, persistent (6+ months) interfere significantly w/social & occupational functioning, social activities OR marked distress about having a phobia

Diagnostic Criteria for Specific Phobia

marked/persistent fear that's excessive/unreasonable cues by presence/anticipation of an object or situation exposure->phobic stimulus => immediate anxiety/possible panic attack PHOBIA SITUATION = AVOIDED or endured w/intense anxiety/distress peristent avoidance, fear, anxiety should be 6+ months, interfere w/social/occupational functioning, everyday routine

lifestyle disease

most of the leading causes of death = affected by stress & health behavior -psychological/behavioral factors for medical conditions

Cognitive Vulnerability->Depression

of course, what happens->you objectively in the environ matters but it's what you make of it/how you interpret or react to it/what you tell yourself Cognitive Distortions, Errors, Biases (Aaron Beck, founder of cognitive therapy) -latent, NEGATIVE cognitive schemas activated by stressful life events (environmental) -overreaction (perception problem) -maybe overgeneralization conclusions about yourself when negative experiences happen: tendency to assign global, personal meaning->failures -"sticky thoughts" (Yorman), persistent & pervasive -problems controlling attention to/memory for negative emotional experiences -pessimistic view of environ ie. bombed test, can either think "that's disappointing, I wish I did better than we get to drop an exam and I'm doing well on quizzes"/"what a tough week I had! I was also distracted while studying" OR CATASTROPHIZE, MALADAPTIVE THINKING "omg I'll score the same on all the rest of the exams and I'll get a low grade and I'll flunk out of my other courses and I might as well drop out" -rumination: the way/style someone responds->onset of a depressed mood determines its duration—RUMINATION PROLONGS DEPRESSION; DISTRACTION SHORTENS women are likelier to ruminate

Clark's Catastrophic Misinterpretation Model of Panic

panic attacks = triggered by internal stimuli (body sensations, thoughts) anxious mood => physiological sensations (ie. heart rate, dizziness), since your attention is narrowed and you focus on bodily sensations MISINTERPRET BODILY SENSATIONS AS CATASTROPHIC EVENT & spiral "omg I'm about to have a panic attack" Treatment: exposure->physiological arousal symptoms, amp up the symptoms (ie. heart/breathing rate by doing exercises, drink caffeine, for ex.), think through/become aware of what's happening (this is NOT due->panic attack but based on what you're doing); REINTERPRETATION/DECATASTROPHIZE physiological sensations

Panic Attack vs. Panic Disorder

panic attacks usually follow stressful life events/distress first attacks are often reported->primary care physician bc so many physiological symptoms/think they're having heart attack RESPONSE->panic attack determine if they'll develop panic disorder most adults experiencing 1 panic attack do not develop the disorder ~20% (1/5) college students experience panic attack 1-2% general population

General Symptoms of Phobias

persistent, irrational, narrowly defined fear associated w/specific obj or situation => AVOIDANCE ie. can't be "I have a phobia of live hand grenade" bc reasonably dangerous & fear is normally warranted DSM-5 Subtypes: animals (spider) ie. Angela Merkel intimidated by dog (has dog phobia since 1995 attack) during 2007 meeting w/Putin situational: enclosed spaces, airplanes, elevator natural environ: water, storm, heights blood injection injury

Stress & Health Chapter

physical illnesses are due->interactions of the mind/psyche & body/soma; behavioral medicine studies psychological factors in physical illness; psychoneuroimmunology (PNI) studies effects of stress on immune impairment -cardiovascular disease (CVD): heart & circulatory system ie. Coronary Heart Disease Hypertension psychological factors: health behavior, chronic stressor (ie. job strain), depression/anxiety, Type A behavior pattern (competitive, hostile, urgent, impatient achievement-striving); cardiovascular reactivity stress: challenging event requiring physiological, cognitive, behavioral adaptation; fight-or-flight response = activated to =>arousal of sympathetic nervous system (release epinephrine/adrenaline, cortisol hormones) cope through problem-focused coping (change stressor) or emotion-focused coping (change internal distress) engage in PRIMARY PREVENTION like health behaviors (positive actions like exercise, negative like smoking cigs) & SECONDARY PREVENTION like stress management & TERTIARY PREVENTION like modifying Type A behavior

Social Readjustment Rating Scale (SRRS)

rates diff stressors causing life changes for people

STAN Study (Dr. Oltmanns)

recruited 1600 ppl between 55-84 interested in normal/maladaptive personality traits over time, track stressful life experiences/events -used follow-up interviews post-questionnaires (12 major life events); if reported yes->any item, call & double-check experiences so can separate real instances vs. subjective ("hmm this could have counted as stressful life event") bc LOTS OF OVERREPORT ie. death of close relative checked off "I'm sorry for your loss" "What loss" "Maybe I made a mistake"/couldn't remember

Suicide Attempt

self-inflicted injury w/some intent to die but may or may not lead->death suicide attempts:suicide 10:1; 100:1 for adolescents 15-19 y/o: females 3x likelier male attempts > lethal (> destructive methods like firearms) Ayo like how about we decrease the readily available guns (gun control) so less die this way

12-Month Prevalence of OCD-Related Disorder

small sample size Hoarding Disorder 0.06% but highest, then EDD (Excoriation), Body Dysmorphic Disorder, OCD, Trichotillomania

Major Stressful Life Events vs. Minor Daily Hassles

stressful life events: getting laid-off/fired, divorce (marital separation), death/loss of loved one, breakup w/serious partner, natural disasters (ie. Floods) daily hassles=transient: traffic jam, exams, short illnesses -problem measuring daily hassles ONLY stressful life events linked->onset of MDD -consider acute/chronic stress (DURATION of stress, how long exposed->stress) -consider if there are critical periods in development when stress can be esp harmful? sensitive->stressful life events?

Twin Study Method (Table 2.4)

studying the influence of genetic vs. environmental factors Recall: MZ/identical twins share 100% genes/genetically identical vs. DZ/fraternal twins share 50% genes Concordance: in twin pair, do both members have same trait Step 1: PROBAND (1st person you find (ie. @ hospital clinic)w/relevant diagnosis who has twin) Step 2: does other member of twin pair (co-twin) have the disorder? yes? concordant! Step 3: compare concordance rates between MZ & DZ pairs MZ>DZ (MZ 100%, DZ 50% perfect case) genetic factors influence development of trait MZ=DZ, both high, shared environ (ie. reared in same fam w/nurturing parents, adequate diet) MZ=DZ, both low, nonshared environ (separated from birth maybe or like grew up in same fam but not equally treated)

David Klonsky's Framework from Suicidal Ideation->Action (Suicide Attempt) (3-Step Theory; 2015)

thinking about ending life->acting on thoughts (40% w/ideation do NOT attempt) suicide IS NOT SINGLE PHENOMENON W/SINGLE EXPLANATION diff predictors/explanations for the stages

Suicide Ideation

thoughts about suicide or suicide attempts (passive desire for death->active/lethal intent to die by suicide) ie. "sometimes I think I may be better off dead" vs. "I know when I'm going to end my life and I have access->the means" > common than attempts

Measuring Stressful Life Events: LTE (List of Threatening Experiences)

used in SPAN study again! serious illness/injury->close relative, self (challenging reaction) death of close friend/relative, partner/parent/child major problem w/close friend/relative major financial crisis broke off steady relationship something valuable stolen/lost marital separation/divorce fired from job, unemployed/seeking work for 1+ months problem w/police/court appearances 12-item checklist!^^ ask once a year, if checked, phone calls once a year to ask about events—"what happened?" (required to be acute, major, several independent (?) (ie. if major financial crisis AND fires from job AND unemployed & actively seeking work for > 1 month, maybe 1 major event) or else dropped) this is an avg # stressful life events—flawed bc should be tailored->each person

Vulnerability Model

vulnerability factors increased P(woman became depressed iff she experienced a stressful/severe life event) as function of intimate relationships and whether she experienced the event having husband/intimate relationship = no vulnerability factor -vulnerability factors include: no husband/gay relationship/no one to 同居 with (no intimate, confiding relationship), having 4+ children under 10 y/o, losing mother @ early age, having no home-external employment basically if you have no vulnerability factor (have intimate relationship) AND experienced stressful life event, % depressed is lower than having no one and experiencing stressful life event if you have no vulnerability factor and do NOT experience stressful life event, even lower %! RISK FOR DEPRESSION INCREASES AS FXN OF HAVING VULNERABILITY FACTOR/NO INTIMATE RELATIONSHIP AAAAAND EXPERIENCING STRESSFUL LIFE EVENT (ofc stressful Iife event alone but MORE so when you have vulnerability factor) NOTE! if you JUST have a vulnerability factor w/o stressful life event, risk for depression doesn't change by much from those having intimate confiding relationship & no stressful life event (NEED stressful life event in ADDITION/on TOP of vulnerability factor) 1/5 women reporting stressful life event became depressed (some experienced but did NOT become depressed)

Stress & Mental Health

we've seen how stressful life events => onset of mental disorders (ie. MDD (esp loss events, ie. death of parent/romantic partner), Bipolar Disorder (goal-attainment experiences, ie. received a promotion but have > responsibilities so if already @ risk for BD, might just get triggered), anxiety disorders (ongoing threats, representatives of future danger), dissociative disorders (often precipitated by abuse/trauma)

Suicide & DSM-5

workgroups expanded coverage for/consider and include suicide risk for all forms of mental disorders—"cross-cutting issue" considered adding "Suicide Behavior Disorder" as diagnostic category in main book but was rejected & shifted->Appendix in "Conditions for Further Study" -didn't make sense to reify this specific symptom if all disorders are identified by their symptoms (ie. infer someone has this disorder by inferring that they tried to end their own life) -could => funding for brain scan studies in the "chip" causing this disorder "Nonsuicidal Self-Injury" (NSSI) added->Appendix & Bipolar Disorder too! -for Appendix items, are they disorders or symptoms?? (just behaviors w/complex connections->disorders)